NEONATAL
JAUNDICE
By: Dr. Pratik Dattatraya Shrimandilkar
Guided by –Dr Sadhana P. Babel
Dr Kiran P. Shinde
Dr Yogesh S. Surse
Objectives
Definition of jaundice
Metabolism of bilirubin
Types of jaundice
Causes of neonatal jaundices
Management of neonatal jaundice
Definition : Jaundice is the yellow
color of the skin and sclerae caused
by deposits of bilirubin When is visible
Neonatal ? Adult sclera > 2mg / dl Newborn
skin > 5 mg / dl
hyperbilirubinemia
Term : Occurs in 60%
Preterm : 80% of preterm neonates
Incidence of Jaundice is the most common condition that
requires medical attention in newborns.
neonatal
jaundice
Types of
bilirubin
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 Mechanisms of
Neonatal Jaundice
Etiology Of
Jaundice
CAUSES
Appears after 24 hours
Total bilirubin rises by less than 5 mg/dl per
day
Physiological Maximum intensity by 4th-5th day in term &
7th day in preterm
Jaundice 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%
Breast milk jaundice
It is caused by prolonged increased
enterohepatic circulation of bilirubin. (β-GD↑)
Bilirubin peaks at 10-15 days of age.
The level of unconjugated bil. is at 10-30
mg/dL
If nursing is interrupted for 24 hours, the
bilirubin level falls quickly
β glucuronidase present in the breast milk of some
mothers
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
Pathological jaundice
5. Stool clay / white colored and urine staining
yellow staining clothes 6. Direct bilirubin > 2 mg /
dl
1-Unconjugated (Indirect) hyperbilirubinemia
1. Hemolysis
• Rh , ABO and other blood group incompatibilities •
spherocytosis , elliptocytosis, Alpha thalassemia •
Pathological jaundice Sepsis ,DIC • Hematomas • Polycythemia
2. Non hemolytic
• Breast milk jaundice • Crigler-Najjar syndrome,
types I and II • Gilbert syndrome Pathological jaundice
Mothers with type O blood may have
circulating antibodies of Ig G class to other
red cell antigens that can cross the placenta
and cause hemolytic disease in a baby with a
Hemolytic disease different blood type, such as blood type A or
of the newborn B. (ABO incompatibility )
due to ABO incompatibility
The baby develop jaundice in the 1st day of
life
Physiological
Blood group incompatibility
Common G6PD deficiency
Breast milk jaundice
causes of Cephalhaematoma
jaundice Infections
J - jaundice within first 24 hrs. of life or premature
A - a sibling who was jaundiced as neonate
U - unrecognized hemolysis (ABO)
Risk factors N nursing – non-optimal sucking/nursing
for jaundice
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
Total & direct bilirubin*
Blood group and Rh for mother and baby*
Hematocrit, retic count and peripheral smear*
Laboratory G6PD assay
tests
Coomb’s test
Sepsis screen
Liver and thyroid function
TORCH titers
Liver scan when conjugated hyperbilirubinemia
Ultrasonography of the liver and bile ducts in
cholestatsis
(Must in
all)*
Laboratory Features Of Hemolytic Disease
Laboratory
Diagnosis
Other Tests
Hearing tests (Brainstem auditory-
evoked potentials) should be obtained in
aftermath of severe neonatal jaundice to
exclude sensorineural hearing loss
MRI in kernicterus
bilateral basal
ganglia
hyperintensity
1. Phototherapy
2. intravenous immune globulin (IVIG)
3. Exchange transfusion
Management 4. Drugs
Baby under triple unit intense
phototherapy
Baby under conventional Baby under triple unit intense
phototherapy phototherapy
Native bilirubin (water Insoluble)
450-460nm of light
Principle of
phototherapy `Photo isomers of bilirubin (water Soluble)
Urine
Perform hand wash
Place baby naked in cradle or incubator
Fix eye shade
Keep baby at least 45 cm from lights
Start phototherapy
Phototherap Frequent extra breast feeding every 2 hourly
y Technique Turn baby after each feed
Temperature record 2 to 4 hourly
Weight record- daily
Monitor urine frequency
Monitor bilirubin level
A common mistake while managing hyperbilirubinemia is
the false believes in the efficacy of the ordinary florescent
lamps (not Day-light), and D5% orally
Increased insensible water loss
Loose stools
Side effects Skin rash
Bronze baby syndrome
of Hyperthermia
phototherapy May result in hypocalcemia
IVIG in infants with Rh or ABO isoimmunization can
significantly reduce the need for exchange
transfusions.
Intravenous Now IVIG has replaced exchange transfusion as the
second-line treatment in infants with isoimmune
immune jaundice.
globulin 1 gm/kg/dose IV
Exchange transfusion
Exchange transfusion is indicated for
avoiding bilirubin neurotoxicity when other
therapeutic modalities have failed or are not
sufficient.
The procedure may be indicated in infants
with erythroblastosis who present with severe
anemia, hydrops, or both, even in the
absence of high serum bilirubin
Phenobarbital Hyperbilirubinemia: 3-8 mg/kg/d PO/IV
initially; may increase up to 12 mg/kg/d Not to
(Luminal) exceed IV administration rate of 1 mg/kg/min
or 30 mg/min for infants
Breast milk jaundice
Prolonged Hypothyroidism
indirect jaundice Pyloric stenosis
Causes
Ongoing hemolysis
Crigler Najjar syndrome
Conjugated hyperbilirubinemia
Suspect
- High colored urine
- White or clay colored stool
Caution
- Always refer to hospital for investigations so that biliary atresia or
metabolic disorders can be diagnosed and managed early
Remember that:
Jaundice is the most frequent cause of admission after early
discharge from nursery.
It is not physiological if: appear in first 24 hrs. increases by > 0.5
mg/dL/hr. evidence of hemolysis, abnormal examination, direct bilirubin
is > 20% of total, or persists > 3 weeks.
Jaundice present in the first 24 hrs. of life must be investigated and
treated as an emergency.
Thank You
