NEONATAL JAUNDICE
BY KASTURI SEKAR
SUPERVISED BY DR.JUSTINA TING YIH YANN
WHAT IS NEONATAL JAUNDICE?
Jaundice is a common and usually harmless condition in newborn babies that causes yellowing
of the skin and the whites of the eyes, indicative of excessive bilirubin production or disordered
bilirubin metabolism or excretion. When the serum concentration of bilirubin exceeds 5 mg/dL,
jaundice usually becomes apparent and is best appreciated on the palms and soles.
Other symptoms of newborn jaundice can include:
•dark, yellow urine (a newborn baby's urine should be colourless)
•pale-coloured stool (it should be yellow or orange)
The etiologies of neonatal jaundice range from physiologic jaundice to potentially life-
threatening conditions. These can be differentiated by a thorough history, physical examination,
and laboratory evaluation.
TIME FRAME FOR JAUNDICE
DAYPATHOLOGICAL DAYPHYSIOLOGICAL DAYPROLONGED JAUNDICE
1 JAUNDICE 7 JAUNDICE 14/21
CLASSIFICATIONS
• Physiological
1. Appears after 24hrs
2. Maximum intensity by 3rd -5th day in term,
7th day in preterm
3. TSB <15mg/dL (<255umol/L)
4. Not detectable clinically after 14days
5. No underlying cause
6. Disappears spontaneously
• Pathological
1. Appears within 24hrs of age
2. Serum bilirubin level increase >6mg/dl/day
3. TSB >20mg/dL(340umol/dL)
4. Conjugated/Direct bilirubin >2mg/dL(34umoLdL)
RISK FACTORS OF SEVERE NNJ
• Prematurity
• Low birth weight
• Jaundice in the first 24hours of life
• Mother with blood group O or Rhesus Negative
• G6PD deficiency
• Rapid rise of serum bilirubin
• Sepsis
• Lactation failure in exclusive breastfeeding
• High predischarge bilirubin level
• Cephalhematoma or bruises
• Babies of diabetic mother
• Family history of severe NNJ in siblings
PATHOPHYSIOLOGY
Bilirubin is created from the breakdown of hemoglobin and other heme-
containing proteins.
Bilirubin produced by this degradation process is unconjugated and poorly water
soluble.
Unconjugated bilirubin is conjugated in the liver with glucuronic acid (which is
water soluble) and excreted into the biliary tract and in the stool
CLINICAL PRESENTATION
• Some of these neonates may appear dehydrated or have significant reduction in weight from
birth weight suggesting insufficient oral intake
• Temperature instability, lethargy, apnea, or poor feeding suggest a serious bacterial infection
• Pallor may indicate anemia
• Jaundice and vomiting suggest upper gastrointestinal obstruction
• Acholic stools suggest biliary tract obstruction
• Hepatomegaly may be associated with liver dysfunction
• Splenomegaly may indicate a hypersplenic state
• Neonates with acute bilirubin encephalopathy (kernicterus) may present with
lethargy, hypotonia, and poor suckling in the initial stages, and irritability and
hypertonia in more advanced stages
• Infants who present after the first 2 weeks of life with jaundice have pathologic
jaundice and must be fully evaluated to determine the cause. These infants may be
otherwise well appearing without any associated symptoms or they may exhibit any
of the above signs and symptoms
ASSESSMENT
• History
• Physical Examination
• Lab Investigations
*Phototherapy must always be started
while awaiting further assessment &
investigation
INVESTIGATIONS
*Total serum bilirubin
*G6PD status
• Others as indicated:
-infant’s blood group
-Maternal blood group
-Direct coombs’ test (indicated in day 1 jaundice and
severe jaundice)
-FBC, reticulocyte count, peripheral blood smear
-Blood culture, urine microscopy, and culture
TREATMENT
1. Phototherapy
• Light with wavelenght of 450nm convert
unconjugated bilirubin into harmless water soluble
pigment excreted predominantly in the urine
2. Exchange Transfusion
• Twice the infant’s blood volume 2x80ml/kg is
Exchange
3. IVIG (Intravenous immunoglobulin)
• high dose IVIG (0.5-1 gm/kg over 2hours) reduce the need for ET in Rh
and ABO hemolytic disease
• Give as early as possible in hemolytic disease with positive Coomb’s test or
when the serum bilirubin increasing despite intensive phototherapy.
MEASURES TO PREVENT SEVERE NNJ
• Promote & support breastfeeding.
• Advise a frequency of 8 to 10 feedings per day
• Formula milk for term infants should be 1 to 2 ounce every 2 to
3 hrs in the 1st week.
• If phototherapy in infants with hemolytic jaundice is initiated early and discontinue before infant 3-
4 days old, must monitor for rebound jaundice and adequacy of breast feeding within the next 24-
48 hours.
• Routine supplements with water or dextrose water will not help prevent hyperbilirubinemia
FOLLOW UP
• All infant discharge < 48hrs after birth should be monitor in ambulatory setting or at
home
• Infants with risk factors for severe neonatal jaundice, early follow up is a must to detect
• rebound jaundice
• Infant with hemolytic diseases not requiring ET should be closely followed up for anemia
until risk of ongoing hemolysis is minimal.
REFERENCES
1. Malaysia Clinical Practice Guidelines: Management of Neonatal Jaundice, 2nd
edition, 2014.
2. Paediatric Protocol. 4TH ed: KKM, 2015
3. Tom Lissauer, Illustrated TextBook of Paediatrics, 4th ed.2012
4. Nelson essential of pediatrics.
5. http://emedicine.medscape.com/article/9
74786
6. https://doctorlib.info/medical/clinical-practice-emergency-medicine/222.html
