Neonatal jaundice

Objectives
Definition of jaundice
• Metabolism of bilirubin
• Types of jaundice
• Causes of neonatal jaundices
• Management of neonatal jaundice

Neonatal hyperbilirubinemia
Definition : Jaundice is the yellow color of the skin and
sclerae caused by deposits of bilirubin
When is visible ?
Adult sclera > 2mg / dl
Newborn skin > 5 mg / dl
Incidence of neonatal jaundice
ž Term : Occurs in 60%
ž Preterm : 80% of preterm neonates
ž Jaundice is the most common condition that
requires medical attention in newborns.

Unconjugated bilirubin (Indirect )

Bind to albumen
• Fat soluble
• Can cross blood brain barrier
• Toxic in high level to brain

Conjugated bilirubin (Direct )

Conjugated with glucoronic acid
• Water soluble
• Excreted in urine and stool
• Not toxic
Mechanisms of Neonatal Jaundice
1. Increased Bilirubin Load due to a high hemoglobin
concentration.
• The normal newborn infant
• Hemolysis
• Cephalhematoma or bruising , Polycythemia
2. Decreased Bilirubin Conjugation in the liver
• Decreased uridine glucuronyl transferase Activity
• Glucuronyl Transferase Deficiency Type 1 (Crigler Najar
Syndrome)
3. Defective Bilirubin Excretion

Physiological Jaundice Characteristics

Appears after 24 hours
• Total bilirubin rises by less than 5 mg/dl per day
• Maximum intensity by 4th-5th day in term & 7th day
in preterm
• Serum level less than 15 mg / dl
• Clinically not detectable after 14 days
Why does physiological jaundice develop?
Increased bilirubin load
• Defective conjugation
• Increased entero-hepatic circulation
• Incidence
– Term in 60%
– Preterm 80%

Pathological jaundice
1. Appears age Appears within 24 hours of age
2. Increase of bilirubin > 5 mg / dl / day
3. Serum bilirubin > 15 mg / dl
4. Jaundice days Jaundice persisting after 14 days
5. Stool clay / white colored and urine staining yellow
staining clothes
6. Direct bilirubin > 2 mg / dl

Unconjugated (Indirect) hyperbilirubinemia

1. Hemolysis
• Rh , ABO and other blood group incompatibilities
• spherocytosis , elliptocytosis, Alpha thalassemia
• Sepsis ,DIC
• Hematomas
• Polycythemia
2. Non hemolytic
• Breast milk jaundice
• Crigler-Najjar syndrome, types I and II
• Gilbert syndrome

Conjugated hyperbilirubinemia
1. Hepatic
• Idiopathic neonatal hepatitis
• Infections - TORCH, sepsis
• Inborn errors of metabolism
• Galactosemia
• Tyrosinemia
2. Post hepatic – Biliary atresia, choledochal cyst
Common causes of jaundice
• Physiological
• Blood group incompatibility
• G6PD deficiency
• Breast milk jaundice
• Cephalhaematoma
• Infections

Risk factors for jaundice

• J - jaundice within first 24 hrs of life or premature
• A - a sibling who was jaundiced as neonate
• U - unrecognized hemolysis (ABO)
• N nursing – non-optimal sucking/nursing
• D - deficiency of G6PD , DRUGS , Ceftriaxone,
• I - infection
• C – Cephalhematoma /bruising
• E - East Asian/North Indian
Approach to jaundiced baby
1. Determine birth weight, gestation and postnatal age
2. Assess clinical condition (well or ill) ,degree of
jaundice
3. Decide whether jaundice is physiological or
pathological
4. Look for evidence of kernicterus in deeply jaundiced
NB

Management
1. Phototherapy
2. intravenous immune globulin (IVIG)
3. Exchange transfusion
4. Drugs

Therapy of Indirect Hyperbilirubinemia

Phototherapy is an effective and safe method for
reducing indirect bilirubin levels, particularly when
initiated before serum bilirubin increases to levels
associated with kernicterus. • In term infants,
phototherapy is begun when indirect bilirubin levels are
between 16 and 18 mg/dL.
Phototherapy is initiated in premature infants when
bilirubin is at lower levels, to prevent bilirubin from
reaching the high concentrations necessitating exchange
transfusion
Blue lights and white lights are effective in reducing
bilirubin levels.
Under the effects of phototherapy light with maximal
irradiance in the 425- to 475-nm wavelength band,
bilirubin is transformed into isomers that are water
soluble and easily excreted. • This isomer can be
excreted easily, bypassing the liver's conjugation
system.
Complications of phototherapy include an increased
insensible water loss, diarrhea, and dehydration. •
Additional problems are macular-papular red skin rash,
lethargy, masking of cyanosis, nasal obstruction by eye
pads, and potential for retinal damage. • Skin bronzing
may be noted in infants with directreacting
hyperbilirubinemia.
Infants with mild hemolytic disease of the newborn
occasionally may be managed successfully with
phototherapy for hyperbilirubinemia, but care must be
taken to follow these infants for the late occurrence of
anemia from continued hemolysis.
Therapy of Indirect Hyperbilirubinemia
Exchange transfusion usually is reserved for infants with
dangerously high indirect bilirubin levels who are at risk
for kernicterus. • As a rule of thumb, a level of 20 mg/dL
for indirect-reacting bilirubin is the "exchange number"
for infants with hemolysis who weigh more than 2000 g.
• Asymptomatic infants with physiologic or breast milk
jaundice may not require exchange transfusion, unless
the indirect bilirubin level exceeds 25 mg/dL.
The exchangeable level of indirect bilirubin for other
infants may be estimated by calculating 10% of the birth
weight in grams: ü the level in an infant weighing 1500 g
would be 15 mg/dL. Infants weighing less than 1000 g
usually do not require an exchange transfusion until the
bilirubin level exceeds 10 mg/dL. Therapy of Indirect
Hyperbilirubinemia • Small infusions of whole blood
crossmatched with that of the mother and infant are
alternated with withdrawals of an equivalent quantity of
the infant's blood, which is discarded.
Depending on the size of the infant, aliquots of 5 to 20
mL per cycle are withdrawn and infused, with the total
procedure lasting 45 to 90 minutes.
This volume should remove 85% of the infant's RBCs
(the source of bilirubin), maternal antibodies, and
exchangeable tissue indirect bilirubin.
The exchange transfusion usually is performed through
an umbilical venous catheter placed in the inferior vena
cava or, if free flow is obtained, at the confluence of the
umbilical vein and the portal system. • The level of
serum bilirubin immediately after the exchange
transfusion declines to levels that are about half of
those before the exchange; • levels rebound 6 to 8
hours later as a result of continued hemolysis and
redistribution of bilirubin from tissue stores.

Complications of exchange transfusion include:

problems related to the blood (transfusion reaction,
metabolic instability, or infection), • the catheter (vessel
perforation or hemorrhage), • the procedure
(hypotension or necrotizing enterocolitis). • Unusual
complications include thrombocytopenia and graft-
versus-host disease. • Continuation of phototherapy
may reduce the necessity for subsequent exchange
transfusions.
 Nursing Care Plan

Topic : hyperbilirubinemia

Demographic data :
Name : Baby girl Fatema Hassan Ali
ID number : 1665487232
Ward/room/bed : NICU
Age : 1 day
Sex : Female
Nationality : Saudi
Address : albaha – baljurashi
Date of admission : 2/2/2020
Admitted from : Nursery
General history :

Chief complaint : Jaundice

Vital signs : PR110 / RR30 / T36.3
Weight/length : 2.45kg/49cm
Head circumference : 32/5 cm
Family history / Past history : no diseases in family / no past
history
 assessment Nursing diagnosis /Planning /Intervention /Outcome Evaluation

goal input output

: SUBJECTIVE Hyperbilirubinemia Baby status will Photo therapy- Baby weight : Date
related to low birth be stable become
  Ampicilline :- 7/2/2020
weight as manifested normal
Baby skin color dose 120mg
: OBJECTIVE by jaundice  
most be pink route IV Baby skin color
PR:110bpm ,frequency BID become pink Baby discharged
Baby most have
and normal
RR:30bpm have normal  
weight Baby status
T:36.3 Gentamycine :-
become stable
  dose 9mg route
  IV , frequency  
Skin appearing OD
light to bright
yellow

Low weight

Mohammad Saeed Jamaan

438004046