Jaundice in newborn

JAUNDICE IN NEWBORN

SACHIN K

G

DEFINITION

YELLOWISH DISCOLORATION OF SKIN AND THE MUCOUS IS CAUSED BY ACCUMULATION OF EXCESS OF BILIRUBIN IN THE TISSUE & PLASMA (SERUM BILIRUBIN LEVEL > 7mg% )

CAUSES OF NEONATAL JAUNDICE

PhysiologicalUsually appears on 2nd and 3rd day and disappears on 7th to 10th dayIn term infant level may be 6-8mg/dlcauses:1)Increased red cell volume and increased red cell destruction2)transient decreased conjugation 3)Increased enterohepatic circulation 4)decreased hepatic excretion of bilirubin5)Decreased liver cell uptake of bilirubin

PATHOLOGICAL

• ABSOLUTE FEATURES:

A) Jaundice appearing within 24 hours of pregnancy

B) Unconjugated bilirubin level > 12.9mg/dl in a term infant

C) Unconjugated bilirubin level >15mg/dl in a preterm infant

D) Bilirubin level increasing at the rate of >5mg/dl/day

E) Conjugated bilirubin > 2mg/dl

F) Clinical jaundice persisting > 1 week in a term infant or

2 weeks in a preterm infant

1)Excessive red cell hemolysis a)Hemolytic disease of newborn b)Sepsis c)Blood extravasation 2)Defective conjugation of bilirubin a)Congenital deficiency of GT3)Breast milk jaundice4)Metabolic and endocrine deficiency5)Increased enterohepatic circulation 6)Substance and disorder that affect binding of bilirubin to albumin7)miscellaneous

CAUSES OF PATHOLOGICAL JAUNDICE

HYPERBILIRUBINEMIA When the bilirubin level rises more than the arbitrary cut-off point of 10 mg%,in a term infant the condition is called “hyperbilirubinemia of the newborn”.

Unconjugated: Hemolytic disease due to Rh (common) or ABO (rare) incompatibility prematurity G6PD deficiency Sepsis iatrogenic drugs cephalhematoma, cretinism, etcConjugated: Neonatal hepatitis bacterial infection TORCH infection Trisomy 18, 21 Galactosemia cystic fibrosis, biliary atresia, etc

DIAGNOSIS OF NEONATAL HYPERBILIRUBINEMIA

A.CLINICAL Sr. bilirubin >5mg/dl

B.LABORATORY STUDIESa)Serum bilirubin level >12mg/dl, requires further investigation1)Total conjugated bilirubin and unconjugated bilirubin 2)complete hemogram including reticulocyte count 3)Blood group (ABO, Rh) status4)Direct Coombs’ test (infant)5)Serum albumin6) Other laboratory tests : Urine Hemoglobin electrophoresis Osmotic fragiltity Thyroid and liver function tests G6PD screeningC) Radiology and Ultrasonography

5mg/dl

10mg/dl

12mg/dl

15mg/dl

>15mg/dl

KERNICTERUS

Is a pathological condition characterized by yellow staining of the brain by unconjugated bilirubin resulting in neural injury.Basal ganglia Cranial nerve nucleiHippocampus Brain stem nucleiAnt horn cell of spinal cord Clinically characterized by lethargy, hypotonia, poor feeding and loss of neonatal reflexesSevere illness-prostration, respiratory distress and finally ohisthotonus, hyperpyrexia, convulsion, enlarged liver and spleenRx double surface phototherapy exchange transfusion use of barbiturate

MANAGEMENT

1)PHOTOTHERAPY: bilirubin level > 12mg% 420-480nm DOUBLE PHOTOTHERAPY bilirubin to lumibilirubin by structural isomerization Complications: watery diarrhea, skin rashes, dehydration, bronze baby syndrome and retinal damage2)PHARMACOLOGIC THERAPY:PHENOBARBITONE 10mg/kg on day 1 5-8mg/kg for next 4 days Prophylaxis: mother for 2 weeks prior to delivery 90mg/kg 3)METALLOPORPHYRINS: Sn MP, Zn MP (-)HEME OXYGENASE

4)EXCHANGE TRANSFUSION :Double vol exchange replaces 85% of circulating red blood cells and reduces bilirubin level; by 50%Indications;Rise in bilirubin level >1mg/dl inspite of phototherapyRise >0.5mg/dl /hr despite phototherapy when Hb is between 11-13g/dlTo improve anemia and CCF The sr. bilirubin is >12mg/dl in first 24 hours and >20 mg/dl in neonatal periodCord blood hemoglobin is <12g/dl and bilirubin level is > mg/dlProgressive anemia Nonimmune hyperbilirubinemia –two vol exchange is done

Air EmbolismThrombosisHypervolemiaRDSHypothermiaAcidosisInfectionHyperkalemiaHypocalcemiaHypoglycemiaCardiac arrhythmiasThrombocytopeniaCoagulopathyNecrotising enteritis

Complications:

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