NEONATAL JAUNDICE

OUTLINE
• Introduction.

• Definition.

• Classification.

• Clinical Features.

• Diagnostic test.

• Management.
 INTRODUCTION
o Jaundice is an important problem in the first week of
life.

o High bilirubin levels may be toxic to the developing

central nervous system and it cause neurological
impairments in term newborns.

o Almost 60% term neonate and 80% preterm neonate

have bilirubin levels greater than 5mg/dl in the first
week of life.
 DEFINITION
 It is also called Icterus neonatrum , neonatal
hyperbilirubinemia.

 Neonatal jaundice defined as a total serum bilirubin

level above 5mg/dl.

 It refers to an excessive accumulation of unconjugate

bilirubin in blood resulting in yellowish discoloration
of skin & mucous membrane.
BILIRUBIN PRODUCTION
AND EXCRETION
IN PRESENCE OF
BILIVERDIN
REDUCTASE

UDP: URIDINE
DIPHOSPHATE
When CB is acted
upon by beta
glucoronidase it is
converted to UCB
which is
reabsorbed back
to the liver for
reconjugation
called
enterohepatic
circulation.
 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
PHYSIOLOGICAL PATHOLOGICAL

CLASSIFICATION

BREAST MILK BREAST FEEDING

PHYSIOLOGICAL
JAUNDICE
 INTRODUCTION
 Peak level of bilirubin (>12mg/dl) is reached on 4 th to
5th day and disappears by 7-14 days.

 In premature babies, maximum bilirubin level reaches

15mg/dl on 5th to 7th day & disappears by 14-28 days.
 Physiological Causes
• Increased red cell volume & increased red cell
destruction.
• Decreased conjugation of bilirubin R/t decreased
UDPG-T activity.
• Increased enterohepatic circulation R/t
decreased gut motility.
• Decreased hepatic excretion of bilirubin.
• Decreased liver cell uptake of bilirubin R/t
decreased ligandin.
 CHARACTERSTICS
 IN TERM BABIES: It appears between 30 to 72 hours
of age .

 Intensity is found on the 4th day.

 Disappears by 7th to 10th day.

 Conti..

 IN PRETERM BABIES: It appears earlier but not

before 24 hours of age.

 Intensity is found on 6th to 7th day.

 Disappears by 14th.

 Serum bilirubin does not exceeds 15mg/dl.

PATHOLOGICAL JAUNDICE
 INTRODUCTION
 Jaundice occurring within 24hrs.of birth is
called pathological jaundice.

 About 5% of neonates develop pathological

jaundice.
CAUSES
 CHARACTERSTICS
 Appears within 24 hrs. of birth.

 In term babies: It persist more than 1 week.

 In preterm babies: It persist more than 2 weeks.

 Bilirubin level is increasing by more than 5mg/dl per day or

0.5mg/dl per hour.
 Conti…
 Total bilirubin level is more than 15mg/dl.

 Palms & soles are yellow.

 Stool clay or white colored & urine is staining

clothes.
 PATHOLOGICAL CAUSES
• Excessive Red cell hemolysis.
• Defective conjugation of bilirubin.
• Breast milk jaundice.
• Metabolic and endocrine disorders.
• Increased enterohepatic circulation.
• Substances and disorders that affect binding.
BREAST FEEDING JAUNDICE

• Inadequacy of breast feeding.

• Decreased hepatic clearance of bilirubin.
• Begin at 2-4 days of age.
• Occur in approx.10-25% of breast fed infants.
• Peaks by 5-15 days of life.
• Disappears by 3rd week of life.
 BREAST MILK JAUNDICE

 It is caused by factors in breast milk like fatty acids,

pregnanediol that inhibit conjugation or decrease excretion of
bilirubin.
 Begins at the age of 5-7 days.
 Occur in 2-3% of breast feed infants.
 Peak level is seen during 2nd week of life and then gradually
diminishes.
 CAUSES:
Divided into two major headings:
• Increased bilirubin production
1. Hemolytic diseases:
a) ABO incompatibility
b) Rh incompatibility
2. Sepsis
3. DIC
• Decreased bilirubin clearance
a) Prematurity
b) Increased enterohepatic circulation
1. Bowel obstruction
C) Inborn error of metabolisms
a) Gilberts syndrome: Gilbert's (zheel-BAYRS) syndrome is a common, harmless liver condition in
which the liver doesn't properly process bilirubin.
b) Najjar syndrome: Crigler–Najjar syndrome is a rare inherited disorder affecting the metabolism
of bilirubin, a chemical formed from the breakdown of the heme in red blood cells.
 PATHOPHYSIOLOGY

THIS BILIRUBIN IS
UNCONJUGATED AND INSOUBLE

SO, THEY GET BOUND TO

ALBUMIN FOR TRAVEL

CONJUGATION WITH
THIS REACTION IS CATALYSED BY GLUCURONIC ACID FORMING
UDP-GLUCURONYL TRANSFERASE CONJUGATED BILIRUBIN
 CLINICAL FEATURES

• Yellow
discoloration of
skin. Sclera or
nails.
• Lethargy.
• sleepiness
 Refusal to food.
 Poor feeding
 High pitch cry
 vomiting
 Dark urine and stool.
 DIAGNOSTIC TEST
HISTORY

• History of Present Illness

–Onset and progression of jaundiced skin
–Feeding: breast milk or formula?
–Current weight compared to birth weight. Gaining weight appropriately?
–Number of wet diapers per day? (Indicator of hydration status)
–Consistency and colour of stool?(pale stool implies poor bili excretion)
–Infections or fever?
–Medications? (newborn or mother)
–General activity: irritable? lethargic?
–Gender & ethnicity? (Males, Asians, and Blacks have some increased risk
• Perinatal History
– Maternal blood group
– Maternal illnesses or infections
– Maternal medicine or drug intake
– Birth trauma with bruising
– Results of newborn screening tests
Conti…..
 PHYSICAL EXAMINATION
o Inspection of skin in natural or bright light.
o Should also be examined for presence of IUGR &
cephalohematoma.
ASSESSMENT
 KRAMER’S CRITERIA FOR
ASSESSMENT OF JAUNDICE
AREA OF THE BODY RANGE OF INDIRECT
BILIRUBIN
Head and neck 4-8mg/dl

Upper trunk 5-12mg/dl

Lower trunk & thighs 8-16mg/dl

Arms & lower legs 11-18mg/dl

Palms & soles >15mg/dl

Cont…
BLOOD TESTS:
• Serum bilirubin : Total serum level > 5mg/dl
• Hemoglobin
• Hematocrit value.
• Serum albumin.
• COOMBS test.
• ABO & Rh-blood groups.
• Liver function test .
o Non- invasive Assessment
• It is done with Ingram icterometer & transcutaneous
bilirubinometer.
 MANAGEMENT
MANAGEMENT

EXCHANGE
PHARMACOLOGI
PHOTOTHERAPY BLOOD
CAL
TRANSFUSION

PHENOBARBITON METALLOPORPH IV
AGAR AGAR
E YRINS IMMUNOGLOBINS
PHOTOTHERAPY
 INTRODUCTION
o The main aim is reduction of serum bilirubin level
within safe limit & prevention of CNS toxicity.

o Non-invasive, inexpensive & easy method of

degradation of unconjugated bilirubin by photo-
oxidation.

o The light waves convert toxic bilirubin into water

soluble non-toxic form which is excreted from blood in
the bile,stool,urine.
 Conti…..
 RECOMMENDATION

 APP recommends phototherapy should be started if

serum bilirubin level is 15 mg/dl in full term baby.
 In preterm babies, it started at serum bilirubin level of
10mg/dl or more.
 Conti….
 Technique

 Blue or white lights are used and most effective, 6-8 light sources are used.

 Wavelength of light should be 420-600nm.

 The distance between naked infant or light sources is 45cm from the skin
of the baby.
 Conti…
 When to stop phototherapy

 When serum bilirubin level are less than 10mg/dl for 2

times.

 Intensive phototherapy usually reduces 1to2mg/dl of

serum bilirubin within 4 to 6 hrs. of exposure.
 TECHNIQUE
• Perform hand wash
• Place baby naked in cradle or incubator
• Fix eye shades
• Keep baby at least 45 cm from lights
• Start phototherapy
• Frequent extra breast feeding every 2 hourly
• Turn baby after each feed
• Temperature record 2 to 4 hourly
• Weight record- daily
• Monitor urine frequency
• Monitor bilirubin level
 COMPLICATION
IMMEDIATE PROBLEMS

•Increased insensible water loss: Frequent Breast feeding. •Loose

green stools: weigh often and compensate with breast milk.
•Skin rashes: Harmless, no need to discontinue phototherapy.
•Bronze baby syndrome: occurs if baby has conjugated
hyperbilirubinemia. If so, discontinue phototherapy.
•Hypo or hyperthermia: monitor temperature frequently.
 Contii..

LONG TERM PROBLEMS

 Disturbance of endocrine or sexual

maturation.
 Retinal damage.
 Skin cancer.
 ROLE OF NURSE
o Baby’s eyes should be covered.

o Diaper to be kept on to cover the genital(specially in

male baby to prevent gonadal damage).

o Position should be changed every 2nd hrly or after

each feed.
 Contii…
o Temperature to be recorded 2nd hrly.

o 2nd hrly breastfeeding to be given or extra

fluids to be provided.
CONTI….
 Conti….
o Baby’s weight to be recorded.

o Constant observation should be made for

urine,stool,skin rashes etc.

o Serum bilirubin level to be estimate at least

every 12 hours.
 PHARMACOLOGICAL
MANAGEMENT
 PHENOBARBITONE
 It promote hepatic glucuronyl transferase synthesis.
 It promote synthesis of albumin.
 Dosage: Therapeutic- 5-8 mg/kg/day
 METALLOPORPHYRINS
 Tin-protoporphyrin & tin-mesoporphyrin inhibit heme
oxygenase activity.
Cont…
• Agar Agar:

oMechanism of Action : Binds bilirubin to gut &

diminishes enterrohepatic circulation.

oDosage: 125 mg/3 hrly in mild to moderate

hyper-bilirubinemia.
 EXCHANGE BLOOD
TRANSFUSION
• It is used when serum bilirubin levels is more than
20mg/dl in term baby or more than 15mg/dl in
preterm baby.
Conti…

• It also help to stop hemolysis in affected baby.

• It is given when phototherapy fails to prevent a

rise in bilirubin to toxic levels.
• Exchange is carried out over 45-60 min period
by alternating aspiration of 10 ml of newborn’s
blood & infusions of 10 ml of the donor blood.
 Nursing responsibilities
Keep the newborn NPO for 2-4 hours before exchange to prevent aspiration.

Keep resuscitation equipment at bedside : oxygen , ambu bag, endotracheal

tubes & laryngoscope

Assist physician with exchange transfusion procedure

Maintain body temperature to avoid hypothermia.

Monitor vital signs & observe for rash.

After transfusion, continue to monitor vital signs & check umbilical cord for
bleeding or signs of infection.
CONTI…
 COMPLICATION

IMMEDIATE DELAYED
• Cardiac failure. • Portal vein
• Air embolism. thrombosis.
• Hypoglycemia. • HIV.
• Ulcerative colitis etc.
 COMPLICATION

TRANSIENT
KERNICTERUS ENCEPHALOPATHY
 TRANSIENT
ENCEPHALOPATHY
 TRANSIENT
ENCEPHALOPATHY
• It is reversible neurological complication
suspected in increasing lethargy along with
bilirubin level.
KERNICTERUS
 KERNICTERUS
Kern :-Nuclear region of the brain &
Icterus :- Jaundice
It occurs as a result of necrosis of neurons in basal ganglia,subthalmic nuclei.

• Problems in neonates are:

Poor sucking.
Lethargy.
Fever.
High pitched cry.

Death.
 Nursing care plan
• Risk
 SUMMARY
• Introduction

• Definition.

• Classification.

• Clinical Features.

• Diagnostic test.

• Management.
 CONCLUSION
• Newborn jaundice is yellowing of a baby’s skin and
eyes.
• Newborn jaundice is very common and can occur when
babies have a high level of bilirubin.
• So, carefully monitor the baby the first five days of life
for symptoms of jaundice such as yellow of skin and
eyes.
 BIBLIOGRAPHY
• .
• Gupta Piyush.EssGhai.Essential Pediatric Nursing.8th ed.New Delhi.CBS
publishers.p.172-174ential Pediatric Nursing.2nd ed.New Delhi.CBS
publishers.p.74-77.
• Sharma Rimple.Essential Pediatric Nursing.1st ed.New Delhi;Jaypee
brothers.p.198-200.
• Datta Parul.Pediatric Nursing.2nd ed.New delhi.Jaypee brothers.p.98-100.
• www.wikipedia.com.