Neonatal Jaundice By Dr. Nahed Al-Nagger. NJ - 2 Neonatal Jaundice Learning Objectives: Define hyperbilirubinemia. Define hyperbilirubinemia. Differentiate.

Neonatal Jaundice

By Dr. Nahed Al-Nagger

NJ - 2

Neonatal JaundiceLearning Objectives:Learning Objectives:

• Define hyperbilirubinemia.Define hyperbilirubinemia.• Differentiate between physiological and Differentiate between physiological and

pathological jaundice.pathological jaundice.• State causes of hyperbilirubinemia.State causes of hyperbilirubinemia.• Discuss the pathophysiology of Discuss the pathophysiology of

hyperbilirubinemia.hyperbilirubinemia.• Describe the most dangerous complication Describe the most dangerous complication

of hyperbilirubinemia.of hyperbilirubinemia.• List the three elements of therapeutic List the three elements of therapeutic

management.management.• Design plan of care for baby has Design plan of care for baby has

hyperbilirubinemia.hyperbilirubinemia.

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Neonatal Jaundice(Hyperbilirubinemia)

Definition: Definition: Hyperbilirubinemia Hyperbilirubinemia refers to an refers to an excessive level of accumulated bilirubin in excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, yellowish discoloration of the skin, sclerae, mucous membranes and nails. mucous membranes and nails.

UnUnconjugated bilirubin = conjugated bilirubin = InIndirect bilirubin.direct bilirubin.Conjugated bilirubin = Direct bilirubin.Conjugated bilirubin = Direct bilirubin.

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Neonatal Jaundice

Visible form of bilirubinemia Visible form of bilirubinemia

–Newborn skin >5 mg / dlNewborn skin >5 mg / dlOccurs in 60% of term and 80% of preterm Occurs in 60% of term and 80% of preterm neonatesneonates

However, significant jaundice occurs in However, significant jaundice occurs in 6 % of term babies 6 % of term babies

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Bilirubin metabolism

Hb → globin + haem1g Hb = 34mg bilirubin

Non – heme source1 mg / kg

Bilirubin glucuronidase

Bilirubin

Bilirubin

Ligandin(Y - acceptor)

Bil glucuronide

Intestine

Bil glucuronide

Stercobilin

bacteria

β glucuronidase

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Bilirubin Production & Metabolism

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Clinical assessment of jaundice

Area of body Area of body Bilirubin levels Bilirubin levels mg/dl mg/dl

(*17=umol)(*17=umol)

Face Face 4-8 4-8Upper trunkUpper trunk 5-12 5-12Lower trunk & thighsLower trunk & thighs 8-16 8-16Arms and lower legsArms and lower legs 11-18 11-18Palms & solesPalms & soles > 15 > 15

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Physiological jaundice

CharacteristicsCharacteristics

Appears after 24 hoursAppears after 24 hours

Maximum intensity by 4th-5th day in term Maximum intensity by 4th-5th day in term & 7th day in preterm& 7th day in preterm

Serum level less than 15 mg / dlSerum level less than 15 mg / dl

Clinically not detectable after 14 daysClinically not detectable after 14 days

Disappears without any treatmentDisappears without any treatment

Note: Baby should, however, be watched for Note: Baby should, however, be watched for worsening jaundice.worsening jaundice.

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Why does physiological jaundice develop?

Increased bilirubin load.Increased bilirubin load.

Defective uptake from plasma.Defective uptake from plasma.

Defective conjugation.Defective conjugation.

Decreased excretion.Decreased excretion.

Increased entero-hepatic Increased entero-hepatic circulation.circulation.

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Age in Days

TermPreterm

1 2 3 4 5 6 10 11 12 13 14

15

10

5Bil

iru

bin

leve

lm

g/d

l

Course of physiological jaundice

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Pathological jaundice

Appears within 24 hours of ageAppears within 24 hours of age

Increase of bilirubin > 5 mg / dl / dayIncrease of bilirubin > 5 mg / dl / day

Serum bilirubin > 15 mg / dlSerum bilirubin > 15 mg / dl

Jaundice persisting after 14 daysJaundice persisting after 14 days

Stool clay / white colored and urine Stool clay / white colored and urine staining clothes yellowstaining clothes yellow

Direct bilirubin> 2 mg / dlDirect bilirubin> 2 mg / dl

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Causes of jaundice

Appearing within 24 hours of age

Hemolytic disease of NB : Rh, ABOHemolytic disease of NB : Rh, ABO

Infections: TORCH, malaria, Infections: TORCH, malaria,

bacterialbacterial

G6PD deficiencyG6PD deficiency

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Causes of jaundice

Appearing between 24-72 hours of

life

PhysiologicalPhysiological

SepsisSepsis

PolycythemiaPolycythemia

Intraventricular hemorrhageIntraventricular hemorrhage

Increased entero-hepatic circulationIncreased entero-hepatic circulation

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Causes of jaundice

After 72 hours of ageAfter 72 hours of age

SepsisSepsis

CephalhaematomaCephalhaematoma

Neonatal hepatitisNeonatal hepatitis

Extra-hepatic biliary atresiaExtra-hepatic biliary atresia

Breast milk jaundiceBreast milk jaundice

Metabolic disorders (G6PD).Metabolic disorders (G6PD).

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Risk factors for jaundice

JAUNDICEJAUNDICEJJ - jaundice within first 24 hrs of life - jaundice within first 24 hrs of lifeA A - a sibling who was jaundiced as neonate - a sibling who was jaundiced as neonate U U - unrecognized hemolysis- unrecognized hemolysisN N – non-optimal sucking/nursing– non-optimal sucking/nursingDD - deficiency of G6PD - deficiency of G6PDI I - infection- infectionCC – cephalhematoma /bruising – cephalhematoma /bruisingE E - East Asian/North Indian- East Asian/North Indian

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Diagnostic evaluation:

Normal values of unconjugated B. are Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.0.2 to 1.4 mg/dL.

Investigate the cause of jaundice.Investigate the cause of jaundice.

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Therapeutic Management

PurposesPurposes: reduce level of serum bilirubin : reduce level of serum bilirubin and prevent bilirubin toxicityand prevent bilirubin toxicity

Prevention of hyperbilirubinemia: early Prevention of hyperbilirubinemia: early feeds, adequate hydrationfeeds, adequate hydration

Reduction of bilirubin levels: Reduction of bilirubin levels: phototherapy, phototherapy, exchange transfusion, exchange transfusion,

Drugs Drugs Use of Phenobarbital promote Use of Phenobarbital promote liver enzymes and protein synthesis.liver enzymes and protein synthesis.

Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy

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Prognosis

Early recognition and treatment of Early recognition and treatment of hyperbilirubinemiahyperbilirubinemia prevents severe prevents severe brain damage.brain damage.

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Nursing considerations of Hyperbilirubinemia

Assessment:Assessment: observing for evidence ofobserving for evidence of

jaundice at regular intervals.jaundice at regular intervals. Jaundice is common in Jaundice is common in

the first week of life and the first week of life and

may be missed in dark skinned may be missed in dark skinned

babiesbabiesBlanching the tip

of the nose

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Approach to jaundiced baby

Ascertain birth weight, gestation and Ascertain birth weight, gestation and postnatal agepostnatal ageAsk when jaundice was first noticed Ask when jaundice was first noticed Assess clinical condition (well or ill)Assess clinical condition (well or ill)Decide whether jaundice is physiological or Decide whether jaundice is physiological or pathologicalpathologicalLook for evidence of Look for evidence of kernicterus*kernicterus* in deeply in deeply jaundiced NBjaundiced NB

**Lethargy and poor feeding, poor or absent Moro's, or Lethargy and poor feeding, poor or absent Moro's, or convulsionsconvulsions

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Nursing diagnosis

See the high risk infant plan of care. See the high risk infant plan of care. Plus:Plus:

Body T.,Body T., risk for imbalanced T. related risk for imbalanced T. related to use of phototherapy.to use of phototherapy.

Fluid volumeFluid volume, risk for deficient related , risk for deficient related to phototherapy.to phototherapy.

Interrupted family process related to Interrupted family process related to situational crisis, re hospitalization for situational crisis, re hospitalization for the therapy. the therapy.

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The goals of planning

Infant will receive appropriate therapy if Infant will receive appropriate therapy if needed to reduce serum bilirubin needed to reduce serum bilirubin levels.levels.

o Infant will experience no complications Infant will experience no complications from therapy.from therapy.

o Family will receive emotional support.Family will receive emotional support.o Family will be prepared for home Family will be prepared for home

phototherapy (if prescribed).phototherapy (if prescribed).

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QUESTIONS?