Neonatal jaundice by dr nahed al nagger
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Neonatal Jaundice By Dr. Nahed Al-Nagger. Neonatal Jaundice. Learning Objectives: Define hyperbilirubinemia. Differentiate between physiological and pathological jaundice. State causes of hyperbilirubinemia. Discuss the pathophysiology of hyperbilirubinemia.

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Neonatal Jaundice By Dr. Nahed Al-Nagger

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Neonatal JaundiceBy Dr. Nahed Al-Nagger


Neonatal Jaundice

  • Learning Objectives:

  • Define hyperbilirubinemia.

  • Differentiate between physiological and pathological jaundice.

  • State causes of hyperbilirubinemia.

  • Discuss the pathophysiology of hyperbilirubinemia.

  • Describe the most dangerous complication of hyperbilirubinemia.

  • List the three elements of therapeutic management.

  • Design plan of care for baby has hyperbilirubinemia.


Neonatal Jaundice(Hyperbilirubinemia)

  • Definition: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails.

  • Unconjugated bilirubin = Indirect bilirubin.

  • Conjugated bilirubin = Direct bilirubin.


Neonatal Jaundice

  • Visible form of bilirubinemia

    • Newborn skin >5 mg / dl

  • Occurs in 60% of term and 80% of preterm neonates

  • However, significant jaundice occurs in 6 % of term babies


Bilirubin metabolism

Hb → globin + haem

1g Hb = 34mg bilirubin

Non – heme source

1 mg / kg

Bilirubin

Ligandin

(Y - acceptor)

Intestine

Bilirubin glucuronidase

Bil glucuronide

Bil glucuronide

β glucuronidase

bacteria

Bilirubin

Stercobilin


Bilirubin Production & Metabolism


Clinical assessment of jaundice

Area of body Bilirubin levels mg/dl(*17=umol)

Face 4-8

Upper trunk 5-12

Lower trunk & thighs 8-16

Arms and lower legs 11-18

Palms & soles > 15


Physiological jaundice

Characteristics

  • Appears after 24 hours

  • 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

  • Disappears without any treatment

    Note: Baby should, however, be watched for worsening jaundice.


Why does physiological jaundice develop?

  • Increased bilirubin load.

  • Defective uptake from plasma.

  • Defective conjugation.

  • Decreased excretion.

  • Increased entero-hepatic circulation.


15

10

5

Bilirubin level

mg/dl

Term

Preterm

1 2 3 4 5 6 10 11 12 13 14

Age in Days

Course of physiological jaundice


Pathological jaundice

  • Appears within 24 hours of age

  • Increase of bilirubin > 5 mg / dl / day

  • Serum bilirubin > 15 mg / dl

  • Jaundice persisting after 14 days

  • Stool clay / white colored and urine staining clothes yellow

  • Direct bilirubin> 2 mg / dl


Causes of jaundice

Appearing within 24 hours of age

  • Hemolytic disease of NB : Rh, ABO

  • Infections: TORCH, malaria, bacterial

  • G6PD deficiency


Causes of jaundice

Appearing between 24-72 hours of life

  • Physiological

  • Sepsis

  • Polycythemia

  • Intraventricular hemorrhage

  • Increased entero-hepatic circulation


Causes of jaundice

After 72 hours of age

  • Sepsis

  • Cephalhaematoma

  • Neonatal hepatitis

  • Extra-hepatic biliary atresia

  • Breast milk jaundice

  • Metabolic disorders (G6PD).


Risk factors for jaundice

JAUNDICE

  • J - jaundice within first 24 hrs of life

  • A - a sibling who was jaundiced as neonate

  • U - unrecognized hemolysis

  • N – non-optimal sucking/nursing

  • D - deficiency of G6PD

  • I - infection

  • C – cephalhematoma /bruising

  • E - East Asian/North Indian


Diagnostic evaluation:

  • Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.

  • Investigate the cause of jaundice.


Therapeutic Management

  • Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity

  • Prevention of hyperbilirubinemia: early feeds, adequate hydration

  • Reduction of bilirubin levels: phototherapy, exchange transfusion,

  • Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.


Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy


Prognosis

  • Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.


Nursing considerations of Hyperbilirubinemia

  • Assessment:

  • observing for evidence of

    jaundice at regular intervals.

  • Jaundice is common in

    the first week of life and

    may be missed in dark skinned

    babies

Blanching the tip

of the nose


Approach to jaundiced baby

  • Ascertain birth weight, gestation and postnatal age

  • Ask when jaundice was first noticed

  • Assess clinical condition (well or ill)

  • Decide whether jaundice is physiological or pathological

  • Look for evidence of kernicterus* in deeply jaundiced NB

    *Lethargy and poor feeding, poor or absent Moro's, or convulsions


Nursing diagnosis

  • See the high risk infant plan of care. Plus:

  • Body T., risk for imbalanced T. related to use of phototherapy.

  • Fluid volume, risk for deficient related to phototherapy.

  • Interrupted family process related to situational crisis, re hospitalization for the therapy.


The goals of planning

  • Infant will receive appropriate therapy if needed to reduce serum bilirubin levels.

  • Infant will experience no complications from therapy.

  • Family will receive emotional support.

  • Family will be prepared for home phototherapy (if prescribed).


QUESTIONS?


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