Neonatal Jaundice/Hyperbilirubinemia

Clinical jaundice in newborn appears at bilirubin level >5mg/dl

Jaundice during 1st week of life is senn in 60% term infants and 80% preterm.

Physiological Jaundice Pathological Jaundice

Never appears in 1st 24hrs May appear in 1st 24 hrs

Does not stain palms and soles May stain palms and soles
Urine does not stain diapers High colored urine and clay colored stool may be
(always unconjugated bilirubin) present
Does not persist beyond 3 weeks May persist beyond 3 weeks

Causes of unconjugated hyperbilirubinemia

Increased production of bilirubin Decreased conjugation of bilirubin
Hemolytic anemia Criggler Najjar syndrome
 ABO or Rh incompatibility
 Hereditary spherocytosis
 G6PD deficiency
Polycythemia Gilbert syndrome
Delayed cord clamping Down syndrome
Cephalhematoma Hypothyroidism
Breast milk jaundice

Causes of conjugated hyperbilirubinemia

 Non obstructive causes

Infections Metabolic
Viral: CMV, Rubella,Herpes Cystic fibrosis
Bacterial: Syphilis, TB Galctosemia
Parasitic: Toxoplasmosis Alpha 1 antitrypsin deficiency
Tyrosinemia
 Obstructive causes

Intrahepatic Extrahepatic
Caroli disease Extrahepatic biliary tree atresia
 Congenital hepatic fibrosis Choledochal cyst
Choledochal cyst Choledocholithiasis
Dubin Johnson syndrome Stricture of CBD
Rotor syndrome

Modified Krammer’s Rule

Clinical Features
 Kernicterus or bilirubin encephalopathy is a neurologic syndrome
resulting from deposition of unconjugated bilirubin
 Lethrgy, poor feeding and loss of Moro reflex
 Diminished tendon reflexes
 Opisthotonus with a bulging fontanel and shrill high pitched cry
 In advanced cases, convulsions, coma and death
Diagnostic evaluation
 Determination of direct and indirect bilirubin
 Hemoglobin with reticulocyte count and peripheral smear
 Blood grouping and coomb’s test
 Treatment
Goal of therapy is to prevent neurotoxicity
 Phototherapy
 Exchange transfusion
 Drugs
Phototherapy
 Most effective wavelength: 450-460nm
 Mechanisms
 Photo isomerization
 Structural isomerization: Bilirubin is converted to
lumirubin which is irreversible structural isomer
excreted by kidneys
 Photo oxidation
 Therapeutic effects of phototherapy depend on
 Types of lamps: LED lamps are better
 Distance between light and infant
 Surface area of exposed skin
 Complications
 Loose stools, dehydration due to increased insensible water
loss
 Hypocalcemia
 Bronze baby syndrome: due to elevated conjugated
bilirubin
 Retinal toxicity
 Gonadal toxicity
 Temperature disturbances

Phototherapy is contraindicated in porphyria

Exchange transfusion
  Double volume exchange transfusion is done if high
bilirubin levels and intensive phototherapy has failed
Drugs
 Intravenous immunoglobulin
Used as adjunctive in hyperbilirubinemia due to hemolytic
disease
Reduces the need for exchange transfusion by reducing
hemolysis

Important points to remember

o Area of brain most commonly involved: Basal ganglia

o Extrapyramidal typer cerebral palsy seen in neonatal jaundice
o Most important mechanism of phototherapy: structural
isomerization
o Effectiveness of phototherapy does not ddepend on pigmentation
of body
o Genitalia and eyes of baby must be covered during phototherapy
o