Neonatal Jaundice

Wong Ann Cheng

MD (UKM) MRCPCH (UK)
 OUTLINE
• Introduction
• Bilirubin metabolism
• Physiological/ Pathological jaundice
• Risk factors for severe jaundice
• Screening and detection of NNJ
• Management of jaundice
• Special issues
 Introduction
• Jaundice is yellow discoloration of sclera,
skin and mucous membrane

• Detected clinically if bilirubin level above

85 µmol/l (5mg/dl)

• Neonatal jaundice progression cephalo-

caudally
 Incidence
• Full term infants: at least 50%

• Preterm infants: over 80%

• Significant jaundice occurs : 6% term

Bilirubin Metabolism:
1. RBC: Heme bilirubin (UCB)
2. Blood: carried by bound to albumin
3. Liver: uptake
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 in newborns
3.8mg/Kg/d in adults
2. Bilirubin-albumin complex formation
a. preterm infant;

b. acidosis
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
 Physiological jaundice
• Appears after 24 hours
• Maximum intensity by 4th-5th day in term & 7th
day in preterm
• Unconjugated hyperbilirubinaemia (below
phototherapy level)
• Clinically not detectable after 14 days
• Well baby

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Course of physiological jaundice

15
Bilirubin level

10
mg/dl

Term
Preterm

1 2 3 4 5 6 10 11 12 13 14

Age in Days
10
 Pathological jaundice
1. Appears within 24 hours of age
2. Increase of bilirubin > 8.5 µmol/l per hour
(0.5 mg/dl per hour) or 85 µmol/l per day(5
mg / dl per day)
3. Serum bilirubin > 340 µmol/l (20 mg / dl)
4. Jaundice persisting after 14 days
5. Direct bilirubin> 34 µmol/l (2 mg / dl) or
more than 15% of total bilirubin

11
 Causes of jaundice
Appearing within 24 hours of age
• Hemolytic disease of NB : Rh, ABO, G6PD deficiency
• Infections: TORCH, bacterial

Appearing between 24-72 hours of life

• Physiological
• Breast milk jaundice
• Breastfeeding jaundice
• Sepsis
• Polycythemia
• Cephalohaematoma, SAH, extensive bruising

Beyond 14DOL in term (21 days in preterm)

• See unconjugated and conjugated hyperbilirubinaemia

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Acute bilirubin encephalopathy
Decreased alertness
Hypotonia
Poor feeding
Hypertonia,
Retrocollis, opisthotonus
Seizures
 Kernicterus
High mortality 10%
Survivors usually suffer sequelae 70%
athetoid cerebral palsy
intellectual disability
high frequency hearing loss
Risk factors for severe jaundice
• Preterm infants
• Small for gestational age
• Sepsis
• Acidosis
• Asphyxia
• Hypoalbuminaemia
• Jaundice < 24 hours of age
Risk factors for severe jaundice
Maternal blood group O/ Rhesus –ve
Infant of diabetic mother
G6PD deficiency
Inadequate breastfeeding
Dehydration
Siblings with severe NNJ or exchange
transfusion
Screening and detection of NNJ
Antenatal care
Education on NNJ to all expectant mother
All mothers have blood taken for ABO and
rhesus blood group
Identify risk factors for significant jaundice
e.g. family history of severe NNJ, exchange
transfusion and haemolytic diseases
Screening and detection of NNJ
Intrapartum care
Take cord blood for G6PD screening
Obtain G6PD results before discharged and
document in home based child health card
If G6PD deficiency, baby admitted for observation
for at least 5 days
If mother Rh –ve, direct coombs test, ABO and Rh
blood type, bilirubin and haemoglobin level of
infant’s (cord) blood required
Screening and detection of NNJ
Postnatal care
Education on NNJ reinforced
Support mother to breastfeeding
adequately. Supplements may be needed
temporarily to ensure adequate hydration.
Actively look for signs of jaundice during
routine care
If jaundice detected, serum bilirubin should
be done and managed appropriately.
Home visit during postnatal period

Home visit should be for all newborns on day

1,2,3,4,6,10 and 20. Special attention for NNJ
at D 2,3 and 4 of life
If jaundice detected, check serum bilirubin and
conduct daily visit to monitor severity
For jaundice infants, sunlight exposure NOT
recommended; risk of dehydration and
sunburn
 Clinical assessment of jaundice

Blanching
of skin with
finger
pressure
under good
lighting

Only as a guide, may be difficult in dark skinned infants

 Clinical assessment of NNJ
(Kramer's rule)
Zone Jaundice (detected by blanching skin Estimated serum bilirubin
with finger pressure) (mg/dl)
1 Head and neck 4-8

2 Upper trunk above umbilicus 5-12

3 Lower trunk and thigh (below umbilicus) 8-16

4 Arms and lower legs 11-18

5 Palms and soles >18

Criteria for serum bilirubin testing
Any jaundice before 24 hours of life
(these infants should be admitted)
Any jaundice below umbilicus after 24
hours of life
Any unwell infants with jaundice
Criteria for admission for NNJ
Onset of jaundice within 24 hours
Jaundice up to level of soles
Infants who required phototherapy
Rapid rise of serum bilirubin >8.5µmol/l/hour
(0.5mg/dl/hour)
All G6PD deficiency infants (at least 5 days)
Other haemolytic disorders e.g ABO
incompatibility and rhesus isoimmunization
Clinical sepsis
Consideration for admission
Jaundice in infants who has previous
siblings with severe NNJ/ exchange
transfusion
Infants with large cephalohaematoma or
severe bruising
Jaundice in infants with logistic problems
e.g. remoteness or social reasons for
difficulty in follow up
Guidelines for phototherapy
Guideline for intensive phototherapy
 Management of infants
admitted for NNJ
Approach to infant with NNJ
History
Physical examination
Investigations
Treatment
 History
• Age of onset
• Gestation
• Previous siblings with NNJ, kernicterus,
neonatal death, G6PD deficiency
• Mother's blood group
• Presence of abnormal symptoms such
as apnoea, difficulty feeding,
temperature instability
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 Physical examination
• General condition- weight, hydration
status, signs of sepsis
• Signs of kernicterus- lethargy,
hypotonia, opisthotonus, high pitch cry,
seizures
• Pallor, plethora, cephalohaematoma,
subaponeurotic haemorrhage
• Signs of intrauterine infection-
petechiae, hepatosplenomegaly
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 Investigations
• Total serum bilirubin
• G6PD status
• Others as indicated:
– MBG, BBG, direct coomb's test
– FBC, retic count, PBF
– Blood culture, urine culture+ FEME (if
infection suspected)

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 Treatment
Phototherapy
Conventional phototherapy
Intensive phototherapy
Exchange transfusion
Intravenous immunoglobulin
 Phototherapy
Conventional phototherapy with blue green
spectrum (wavelength 430-490nm) should be
maintained with minimum irradiance 30
µW/cm2 per nm
Intensive phototherapy using LED
Position light source 35-50cm from top of infant
Expose infant appropriately
Cover infant’s eye
 Phototherapy (cont)
Monitor infant’s temperature 4 hourly to avoid
chilling or overheating
Ensure adequate hydration through
breastfeeding (8-10 x/24 hours).
Supplements may be needed temporarily
Monitor urine output
Allow parent-infant interaction
Check serum bilirubin as indicated
Side effects of phototherapy
Hyperthermia/ Hypothermia
Diarrhoea
Skin rash
Bronze baby syndrome (conjugated
bilirubin >4mg/dl)
Indications for intensive phototherapy

Total bilirubin >300 µmol/l (17.5 mg/dl)

Early onset jaundice (first 24 hours)
Rapidly rising jaundice >8.5 µmol/l/hr
(0.5mg/dl/hr)
Based on guidelines level
 Guidelines for intensive phototherapy
and exchange transfusion

Risk factors – isoimmune haemolytic disease, G6PD deficiency,

asphyxia, significant lethargy, temperature instability, sepsis,
acidosis, or albumin <3 g/dl
Indications for exchange transfusion

Failure of phototherapy to reduce bilirubin of

17-34 µmol/l (1-2mg/dl) after 4-6 hours and
keep bilirubin below exchange transfusion
level (use total bilirubin level; do not subtract
direct bilirubin)
Signs of acute bilirubin encephalopathy
(hypertonia, arching, retrocollis, opisthotonus,
high pitch cry)
 Exchange transfusion
Informed consent
Grouping of blood to be used
Preparation of infant
Pre-exchange blood
Procedure
Post-exchange blood
 Exchange transfusion (procedure)

Volume to be exchange is twice blood volume (2x

80ml/kg)
Use fresh whole blood (less than 5/7 old)
Connect baby to cardiac monitor and take baseline
observation then every 15 min (HR, RR, SpO2)
ET performed under aseptic technique
Cannulate umbilical vessel for isometric or
continuous technique perform over 2 hours
Recording of amount of blood withdrawn and given
 Investigations for ET
Pre-exchange (1st volume of blood removed)
Serum bilirubin
FBC
Blood culture (if indicated)
HIV, hepatitis B (baseline)

Post-exchange (discard blood remaining in UVC before sampling)

Serum bilirubin and 4 hours after
FBC
Dextrostix
Serum electrolytes
Serum calcium
 Complications of ET
Catheter related
Infection
Haemorrhage
NEC
Air embolism
Portal and splenic vein thrombosis (late)

Haemodynamic problems
Overload cardiac failure
Hypovolaemic shock

Electrolyte imbalance
High potassium
Low calcium
High or low blood sugar
Acidosis
Intravenous immunoglobulin
High dose immunoglobulin (IVIG) 0.5-
1g/kg single dose has been shown to
reduce need for ET in Rh and ABO
haemolytic disease.
Can be given as early as possible if ET
no yet indicated but TSB rising despite
intensive phototherapy
Breastfeeding jaundice and
breast milk jaundice
Breastfeeding jaundice
Inadequate breast milk flow
Infants may be dry with more than 10% weight loss in from
birth weight
Supplementary feed may be needed temporarily to ensure
adequate hydration

Breast milk jaundice

Diagnosis of exclusion
Infants exclusively breastfed, well, gaining weight
appropriately and stool yellow
Continue breastfeeding
 G6PD deficiency
Most common human enzyme deficiency, X-
linked recessive condition
Affects 2.5% newborn locally (Malays 2.2-
3.5%, Chinese 3.1-4.5%, Dayaks 5%, Orang
asli 8-23%)
Universal G6PD screening on cord blood
Screening semi-quantitative fluorescent spot
test. (sensitivity 97.9%, specificity 86.6%)
 Management of G6PD deficiency
All infants with G6PD deficiency,
observed in hospital for at least 5 days.
G6PD status documented in home
based child health card.
Parents educated and given written
guidelines on drugs and foods/ herbs to
be avoided.
 Prolonged jaundice
Jaundice persist beyond D14 in term
and D21 in preterm
Causes may be conjugated or
unconjugated hyperbilirubinaemia
Conjugated hyperbilirubinaemia defined
as direct or conjugated fraction of
bilirubin more than 34 µmol/l (2mg/dl)
or more than 15% of total bilirubin
 Causes of unconjugated and
conjugated hyperbilirubinaemia
Investigations for unconjugated and
conjugated hyperbilirubinaemia
 Referral for prolonged jaundice

All infants with conjugated hyperbilirubinaemia

must be referred to the paediatrics urgently to
exclude biliary atresia
Those with unconjugated hyperbilirubinaemia can
be investigated first and refer if jaundice did not
resolved or no definitive cause found
THANK YOU

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