Neonatal Jaundice

Sathesh Kumar.p Department of Pediatrics, Hospital Tuanku Fauziah, Kangar, Perlis

Introduction
Yellowish discolouration of: Skin mucous membranes Sclera Due to deposition of excess plasma bilirubin Jaundice is quite common (5mg/dl).

Full term infants: at least 50% Preterm infants: over 80% Elevated blood bilirubin levels: 97%

Introduction continued
When? in the first week of life Where? skin , mucosa and white of eye How many? blood bilirubin concentrations is 80mol/L (5-7mg/dl)

Introduction continued

Why Jaundice occurred?

Producing

Excreting

Bilirubin Metabolism:
1. RBC: Heme bilirubin (UCB) 2. Blood: carried by bound to albumin 3. Liver: uptaken : Y protein, Z protein conjugated: UDPGT excreted to the biliary system 4. Intestine: stercobilins -glucuronidase enterohepatic circulation

The metabolic characteristics of bilirubin in newborns:

1. Bilirubin production

8.8mg/Kg/d
3.8mg/Kg/d a. preterm infant; b. acidosis

in newborns
in adults

2. Bilirubin-albumin complex formation

The metabolic characteristics of bilirubin continued

3. Bilirubin metabolism of hepatocyte

a. Hepatic uptake of bilirubin

b. Bilirubin conjugation: UDPGT (uridine diphosphate

glucoronyl transferase)
c. Defective bilirubin excretion ability to bile system 4. Enterohepatic circulation

Bilirubin toxicity
1. Conjugated bilirubin
water-soluble 2. Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy kernicterus

Clinical Manifestations
Jaundice appears
When: at any time during the neonatal period Where: from face chest feet abdomen

Manifestations continue
Evaluation of jaundice :
1. By eyes: face, 5mg/dl ( 85mol/L ); abdomen, 10-15mg/dl; feet, 15-20mg/dl ; 2. By transcutaneous measurement : used for screening 3. By serum levels : standard

Manifestations continue
Classification: Physiological Jaundice
Pathological Jaundice

Manifestations continue
Physiological jaundice :
1. General state is well 2. Appears 2-3days (>24h of age) peaks < 12.9mg/dl (full term infants) <15mg/dl (preterm infants) fades <2 week (term infants) <4 weeks (preterm infants) 3. Accumulates <5mg/dl/d 4. Direct bilirubin <2mg/dl

Manifestations continue
1. Appears earlier (first 24 hours of life) 2. Peaks >12.9mg/dl (full term infants) >15mg/dl (preterm infants) Fades >2 weeks (term infants) >4 weeks (preterm infants) 3. Accumulates >5mg/dl/d 4. Direct bilirubin >2mg/dl 5.Jaundice recurrent

Pathological Jaundice

Common causes of pathological jaundice

1. Unconjugated bilirubinemia:

a. hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice

Causes of pathological jaundice continue

2. Conjugated bilirubinemia:
a. Neonatal hepatitis b. Biliary obstruction (cholestatic jaundice) biliary atresia,

common bile duct stenosis

c. Congenital metabolic diseases -1 antitrypsin deficiency

Hemolytic disease of newborn

Hemolytic disease: ABO: 85.3% Rh : 14.6% MN : 0.1%

Hemolytic disease of newborn

continued

ABO incompatibility
the mother: type O the infant: type A or B

Rh incompatibility
the mother Rh- the infant: Rh+D,E,C,d,e,c

Pathogenesis

Pathophysiology
Red blood cell breakdown
Hyperbilirubinemia Jaundice Anemia 1. Liver 2. Spleen 3. Heart, other organs Seizures etc. 4. Hydrops

Kernicterus

Clinical Manifestations:
ABO 1.Jaundice : 2.Anemia: 3.Hepatomild 1-2 day mild (3-6 weeks) rare Rh severe 24 h severe heart failure common

splenomegaly

Complication
Kernicterus:
Phase 1: decreased alertness

Hypotonia
Poor feeding Phase 2: Hypertonia, Retrocollis, opisthotonus Phase 3: Hypotonia

Laboratory tests:
1. Blood type incompatibility 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests

1). Hemoglobin level : low

2). Reticulocytes:1015% 3). Nucleated RBC

Laboratory tests continued

Antibody test
1). Direct Coombs test (+) confirm confirm judge

2). Antibody release test (+) 3). Free antibody test (+)

Treatments
1). Phototherapy
2). Exchange transfusion 3). Internal Medicine

Treatments
Phototherapy Principle : photon of light Three photochemical reactions: 1). Structure isomer 2). Geometric isomer 3). Photo-oxidation Photoproducts excretion: w/o conjugation

Treatments continued
Indications of phototherapy :
Unconjugated bilirubinemia Bilirubin level >12mg/dl

Light source:
Spectral outputs 420 to 500nm

Treatments continued
Side effects of phototherapy :
a. diarrhea b. fever c. skin rash d. bronze baby syndrome (conjugated bilirubin>4mg/dl)

Treatments continued
2. Exchange Transfusions:
a. Severe hemolytic disease

b. Refractory to phototherapy

Treatments continued
Aims of transfusions:
a. Remove antibodies b. Remove bilirubin c. Correct anemia

Treatments continued
Indication of transfusions:
one of the follows
a. 20mg/dl (340 mol/L)
b. >4mg/dl,Hgb<120g/L, edema c. 0.7mg/dl/h d. Kernicterus

Treatments exchange transfusions

Source of the blood mother
For Rh: incompatibility
For ABO: incompatibility

newborns
ABO

Rh

AB plasma packed RBC

O cells

Treatments exchange transfusions

Potential complications:
a. Infection b. Necrotizing enterocolitis NEC c. Thromboembolic complications

Treatments continued
3. Pharmacological agents:
a. Phenobarbital Effects: Uptake, Conjugation Excretion b. Albumin c. IVIG

Preventions
For ABO incompatibility: No
For Rh incompatibility 300 g of human anti-D globulin within 72 h of delivery.

1.Unconjugated bilirubinemia:
a. Hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice

1.Unconjugated bilirubinemia:
b. G-6-PD deficiency; male, jaundice, enzyme activity c. Breast milk jaundice causes: unclear, -glucuronidase follows physiologic jaundice: 4-7 d breast feeding persist for several weeks.

Conjugated bilirubinemia:
2.Conjugated bilirubinemia: a. neonatal hepatitis b. biliary obstruction (cholestatic jaundice)

biliary atresia,
common bile duct stenosis c. congenital metabolic diseases -1 antitrypsin deficiency

Case analysis :
24 old male infant, gravida1,para 1. Apgar scores: 8 at 1 min Mother: blood type O PE: icterus appeared on

face and trunk skin

liver edge 1cm palpable spleen tip

Case analysis continued

Lab tests: Hgb:13g/dl, reticulocyte count : 7% Blood smear: nucleated RBC Blood type: A, Rh-positive

Serum bilirubin: 12.9mg/ml

Direct Coombs test: weakly positive Question: whats the risk factor ?

Department of Pediatrics

Thank you! Questions