NEONATAL JAUNDICE

Caren Chepkirui
 Definition
• The yellow color of the skin,sclerae and mucous
membranes resulting from the deposition of
bilirubin in these easily observable tissues
• Hyperbilirubinemia-↑serum bilirubin [Neonatal
bilirubin production rate 6-8mg/kg/day; Adult 3-
4/kg/day
• Jaundice is as a result of accumulation of
unconjugated bilirubin
• The condition arises when the rate of bilirubin
production exceeds the rate at which bilirubin is
eliminated
 BILIRUBIN FORMATION
• Its the end product of the catabolism of heme
• Major source of bilirubin is from circulating
hemoglobin
• Other sources
 Myoglobin
 Cytochromes
 Catalase
 Peroxidase
 Bilirubin metabolism
Heme
Heme oxygenase

Carbon monoxide Biliverdin

Biliverdin reductase
Bilirubin
Glucuronosyltransferases Glucuronic acid

CarboxyHb Bilirubin mono/diglucuronide ……..conjugation

Exhaled CO2
Stercobilin Gut flora (reduction)

Urobilinogen(oxidation)
 Biliary excretion
Conjugated bilirubin

Active canalicular transporters

Bile
intestinal beta-glucuronidase
Urobilinogen Stercobilin

Unconjugated bilirubin …….. enterohepatic circulation.

 Clinical features
• Jaundice may be present at birth or
may appear at any time during the
neonatal period, depending on
etiology.
• Usually becomes apparent in a
cephalocaudal progression starting
on the face and progressing to the
abdomen and then feet, as serum
levels increase.
Kramer’s Rule
• Dermal pressure may reveal the
anatomic progression of jaundice
(face, = 5 mg/dL;
mid-abdomen, = 15 mg/dL
soles, = 20 mg/dL
• Clinical examination cannot be
depended on to estimate serum
levels
• Whereas jaundice from deposition of indirect
bilirubin in the skin tends to appear bright
yellow or orange
• That of the obstructive type (direct bilirubin)
has a greenish or muddy yellow cast.
• signs of kernicterus rarely appear on the 1st day
• affected infants may present with lethargy and
poor feeding
• without treatment, can progress to acute
bilirubin encephalopathy
 Conjugated Hyperbilirubinemia
Conjugated bilirubin is water soluble and is
measured as direct bilirubin.Its raised due to
• Failure of hepatic excretion of conjugated
bilirubin
• Causes include neonatal hepatitis, congenital
biliary atresia, extrahepatic biliary obstruction,
neonatal sepsis,intrauterine infections,paucity
of bile ducts,galactosemia
 Physiologic jaundice
• Development of mild unconjugated
hyperbilirubinemia in normal newborn
• Usually during 1-2weeks of life
• 5 - 6 mg/dL (86 to 103 µmol/L) but not >17 to
18 mg/dL (291 to 308 µmol/L)
• Develops 72-96hrs after birth
• Newborns have higher rates of bilirubin
production than adults because of increased
RBC mass and shorter RBC life span.
• The decrease in bilirubin elimination relates to
a transiently limited ability of the newborn
liver to conjugate bilirubin.
• Newborns, esp preterm infants, have rate
limitations in hepatic conjugation and biliary
excretion of bilirubin
• Increased enterohepatic circulation
• Diminished bilirubin binding to albumin- and
bilirubin-binding protein
• Physiologic jaundice occurs when bilirubin
normally increases from 1.5 mg/dL in cord
blood to a mean of 6.5 mg/dL on day 3,
followed by a gradual decline to normal adult
levels of 1.5 mg/dL by day 10 or 12 of life
 Maternal risk factors
• Pregnancy complications- diabetis mellitus-large
babies have increased erythropoiesis therefore
high bilirubin
• Maternal drugs - oxytocin,diazepam-drugs may
reduce enzyme activity
• Race/ethnicity-Asian,Native Americans,Greek
Islanders
• Runs in families- with previous risky baby the higher
the risk
 Perinatal risk factors

Birth trauma-SVD have high total

serum bilirubin than C/S
◦Cephalohematoma
◦Delayed cord clamping
◦Forcep delivery
 Neonatal risk factors
• Prematurity
• Breech, lowbirth weight, male,
• Polycythemia
• Drugs-streptomycin,benzyl
alcohol,sulfisoxazole
• Early onset breastmilk jaundice
• Delayed bowel movements
 Pathological jaundice
There is elevated unconjugated bilirubin due to
• ↑bilirubin load metabolized by liver
• Damaged/↓transferase enzyme activity
• Competition and blocking transferase enzyme
Increase of bilirubin > 5 mg / dl / day
 Etiology
Unconjugated Hyperbilirubinemia
• Unconjugated bilirubin is the direct
breakdown product of heme, is water
insoluble, and is measured as indirect bilirubin
• The causes of unconjugated
hyperbilirubinemia can be grouped into two
main categories:
1. overproduction of bilirubin
2. decreased conjugation of bilirubin
 Overproduction of bilirubin
• Increased rate of hemolysis (reticulocyte count
elevated)
– ABO blood group incompatibility
– Rhesus sensitizations
– Abnormal red cell shapes: Spherocytosis
– Red cell enzyme abnormalities: Glucose-6-
phosphate dehydrogenase deficiency
– Sepsis: bacterial, viral, or protozoa
• Nonhemolytic causes of increased bilirubin load (Unconjugated
bilirubin elevated, reticulocyte count normal.)
1. Extravascular hemorrhage
 Cephalohematomas
 Extensive bruising
 Central nervous system hemorrhage
2.Polycythemia
 Due to maternal-fetal transfusion
 Fetal-fetal transfusion
3.Exaggerated enterohepatic circulation of bilirubin
 Gastrointestinal tract obstruction –pyloric
stenosis
 Decreased rate of conjugation
• Unconjugated bilirubin elevated, reticulocyte
count normal,mostly due to enzymatic defects
– Gilbert syndrome (familial partial defect in
glucuronyl transferase activity) is a common
benign condition
– Crigler-Najjar syndrome (congenital absence of
glucuronyl transferase causes lifelong
unconjugated hyperbilirubinemia)
– Lucy-Driscoll syndrome (severe unconjugated
hyperbilirubinemia thought to be due to inhibition
of infant's glucuronyl transferase by unidentified
maternal serum factors)
 Breastfeeding jaundice
• Occur in 1st week of life
• Hyperbilirubinemia (>12 mg/dL) develops in
13% of breast-fed infants in the 1st wk of life .
• may be due to
 decreased milk intake with dehydration
and/or reduced caloric intake.
Giving supplements of glucose water to
breast-fed infants is associated with higher
bilirubin levels, in part because of reduced
caloric intake of the higher density in breast
milk
 Breast-milk jaundice
• Develops in abt 2% of breast-fed term infants
after the 7th day of life, with maximal conc-
10–30 mg/dL reached during the 2nd–3rd
week.
• If breast-feeding is continued, the bilirubin
gradually decreases but may persist for 3–10
wk at lower levels.
• If nursing is stopped levels drop n seldom rise
when breast-feeding is resumed.
 Kernicterus
• Neurologic syndrome due deposition of
unconjugated (indirect) bilirubin in the basal
ganglia and brainstem nuclei.
• Develop at serum levels 21–50 mg/dL
• Onset usually in 1st wk of life, but may be
delayed to 2nd–3rd wk
• Development depends on
gestation……preterms easy
 Pathogenesis
• Multifactorial ,involves an interaction btn
unconjugated bilirubin levels, albumin binding
and unbound bilirubin levels, passage across
the blood-brain barrier, and neuronal
susceptibility to injury.
• Disruption of the BBB by disease, asphyxia, n
maturational changes in BBB permeability
affect risk
 Clinic Manifestations
1.ACUTE FORM
• Phase 1 (1st 1–2 days): poor sucking, stupor,
hypotonia, seizures
• Phase 2 (middle of 1st wk): hypertonia of extensor
muscles, opisthotonos, retrocollis, fever
• Phase 3 (after the 1st wk): hypertonia
2. CHRONIC FORM
• First year: hypotonia, active deep tendon reflexes,
obligatory tonic neck reflexes, delayed motor skills
• After 1st yr: movement disorders (choreoathetosis,
ballismus, tremor), upward gaze, sensorineural hearing
loss
Summary
 PHOTOTHERAPY
• PREPARING THE PHOTOTHERAPY UNIT
• Ensure that a plastic cover or shield is in positio
n. This prevents injury to the baby in case a lam
p breaks and helps to screen out harmful ultravi
olent light.
• Warm the room where the unit is located, if nec
essary, so that the temperature under the lights
is 280C to 300C.
• Switch on the unit, and ensure that all the fluor
escent tubes are working.
• Replace fluorescent tubes every 2000 hou
rs of use or after three moths, whichever c
omes first, even if the tubes are still workin
g.
• Use white linens in the cot, bassinet, or inc
ubator, and place white curtains around th
e area where the unit is located to reflect a
s much light as possible back to the baby.
 GIVING PHTOTHERAPY
• Place the baby under the phototherapy lights.
– If the baby weighs 2 kg or more, place the baby nak
ed in the cot or bassinet. Place or keep smaller babie
s in an incubator.
– Place the baby as close to the lights as the manufactu
rer’s instructions allow.
– Cover the baby’s eyes with patches ensuring that the
patches do not block the baby’s nostrils. Do not secur
e the patches in place with tape.
• Turn the baby every three hours.
• Ensure that the baby is fed:
– During feeding, remove the baby from the phototherapy u
nit and remove the eye patches;
– There is no need to supplement or replace breast milk wit
h any other type of feed or fluid (e.g. breast milk substitut
e, water, sugar water etc.).
– If the baby is receiving Iv fluid or expressed breast mi
lk, increase the volume of fluid and/or milk by 10% of the
total daily volume per day for as long as the baby is unde
r the phototherapy lights.
– If the baby is receiving IV fluid or is being fed by gast
ric tube, do not remove the baby from the phototherapy l
ights.
 Note that the baby’s stool may become loose
and yellow while the baby is receiving phototh
erapy. This does not require specific treatme
nt.
 Continue other prescribed treatment and tests
:
- Remove the baby from the phototherapy unit
only for procedures that cannot be performed
while under the phototherapy lights;
- If the baby is receiving oxygen, briefly turn o
ff the lights when observing the baby for centr
al cyanosis (blue tongue and lips).
– Discontinue phototherapy when the serum bili
rubin level is below the level at which phototh
erapy was started or 15 mg/dl (260μmol/l), wh
ichever is lower;
– If the serum bilirubin is close to the level re
quiring exchange transfusion, organize tran
sfer and urgently refer the baby to a tertiary h
ospital or specialized centre for exchange tran
sfusion, if possible. Send a sample of the mot
her’s and the baby’s blood.
• If the serum bilirubin cannot be measur
ed, discontinue phototherapy after three d
ays
– Bilirubin in the skin rapidly disappears under p
hototherapy. Skin colour cannot be used as a
guide to serum bilirubin level while the baby is
receiving phototherapy and for 24 hours after
discontinuing phototherapy
  After phototherapy has been discontinued:
- Observe the baby for 24 hours, and repeat the serum bilirubin m
easurement, if possible, or estimate jaundice using the clinical m
ethod:
- If jaundice has returned to or is above the level at which phototh
erapy was started, repeat this step each time phototherapy is dis
continued until the measured or estimated bilirubin stays below t
he level requiring phototherapy.
 If phototherapy is no longer required, the baby is fee
ding well, and there are no other problems requiring
hospitalization, discharge the baby.
 Teach the mother to assess jaundice, and advise her
to return if the baby becomes more jaundiced.