Neonatal

Hyperbilirubinemia
Bilirubin physiology
Physiological Jaundice
PHASE 1
Rapid rise in serum bilirubin levels to 12 to 15
mg / dl

Lasts for 5 days in term infants,7 days in pre

term
 PHASE 2
serum bilirubin level ~ 2 mg/ dl
lasts for 2 weeks in term infants,more than a
month in pre term & exclusively breast fed.
Mechanisms of Physiological Jaundice

 Increased bilirubin load on liver cells

 Defective hepatic uptake of bilirubin from

plasma
 Defective bilirubin conjugation
 Defective bilirubin excretion
Pathological jaundice

 Clinical jaundice appearing in first 24 hours

 Increase in total bilirubin by >0.5 mg/dl/hour

or 5 mg/dl/24 hours
 Total bilirubin >15 mg/dl
 Direct bilirubin > 2 mg/dl
Causes of
Unconjugated
Hyperbilirubinemia
INCREASED PRODUCTION
1) Fetomaternal blood group incompatibility :
Rh,ABO
2) Hereditary spherocytosis
3) Non spherocytic hemolytic anemia:G6PD
deficiency,PK deficiency,Vit.k induced
hemolysis
4) Sepsis
5) Increased enterohepatic circulation ,eg large
bowel obstruction
DECREASED CLEARANCE
1) Inborn errors of metabolism : Crigler najjar
syndrome type 1 & 2

2) Drugs & hormones :

hypothyroidism,breastmilk jaundice
Physical examination
 Prematurity
 Small for gestational age
 Bruising,cephalhematoma
 Pallor
 Petechiae
 Hepatosplenomegaly
 Omphalitis
 Hypothyroidism
Dermal Zones & Levels of Jaundice

Dermal zone Body part involved Bilirubin(mg/dl)

1 Face,neck 5
2 Chest,Upper limbs 10
3 Abdomen,thighs 12
4 Legs 15
5 Palms & soles >15
TRANSCUTANEOUS BILIRUBINOMETER
SEQUELAE OF UNCONJUGATED
HYPERBILIRUBINEMIA
 TRANSIENT ENCEPHALOPATHY

 KERNICTERUS
KERNICTERUS
 Yellowish staining & necrosis of neurons in
basal ganglia,hippocampus,subthalamic
nuclei & cerebellum

 CLINICALLY :
I. Phase 1:poor
suck,lethargy,hypotonia,depressed
sensorium
II. Phase 2:fever,hypertonia,opisthotonus
III. Phase 3:high pitched cry,convulsions,death
TREATMENT

2.)EXCHANGE
1.)PHOTOTHERAPY
TRANSFUSION
Phototherapy – Mechanism of Action
OXIDATIO
N

STRUCTUR
AL
ISOMERISA
TION

GEOMETRIC
PHOTOISOMERIS
ATION
Phototherapy
 Indications
 When bilirubin levels may be hazardous to
infant,but not yet reached exchange
transfusin levels.
 Prophylactically in extremely low birth weight
or severely bruised infants.
Phototherapy
 Complications
1. Increased insensible water loss
2. Diarrhoea
3. Retinal damage
4. Bronze baby syndrome
5. Hypocalcemia
Exchange Transfusion
 Indications
1. No response to phototherapy
2. To correct anemia & improve CCF in
hydropic infants
3. To stop hemolysis & production by removing
antibodies & sensitised rbc s
4. Septicemia
Exchange transfusion
 Complications
o Bacterial sepsis
o Thrombocytopenia
o Portal vein thrombosis
o Umblical or portal vein perforation
o Arrythmia,cardiac arrest
o Hypocalcemia,hypoglycemia,hypomagnesemia
o Metabolic acidosis,alkalosis
o HIV,HBV,HCV,GVHD
Conjugated Hyperbilirubinemia
 Directbilirubin > 2mg/dl or >15% of total
bilirubin

 Causes –
 Biliary atresia
 Neonatal hepatitis
 Sepsis
Biliary atresia
 Clay coloured stools from day 4-5 of life
 Gradual decline in liver function
 Anemia & fat soluble vitamin deficiencies set

in

 Types
1) Extra hepatic – good prognosis,CBD or CHD
involved,surgery successful within 60 days
2) Intra hepatic – poor prognosis,orthotopic
liver transplant needed
Neonatal Hepatitis
 Presents at 4-6 weeks of age
 Symptoms are usually intermittent,unlike

biliary atresia
 Presence of cholestatic inflammatory process

with giant cell transformation

 Addition of medium chain TG’s,fat soluble

vitamins & repeated doses of vitamin K are

useful.