Neonatal Jaundice

1. NeonatalJaundice Promoting multiprofessional education and development in Scottish maternity care

2. Neonatal Jaundice • Definition = Total serum bilirubin • (SBR) > 85 µmol/L.

3. Why is it important? • Common • Worrying for parents and / or staff • Condition and treatment • Sign of underlying disease • Can cause neurological problems.

4. Where does bilirubin come from?

5. Causes • Benign • Physiological • Breast milk and breastfeeding • Pathologic.

7. Physiological Jaundice Features: • Elevated unconjugated bilirubin • SBR generally peaks @ 85-100 µmol/L on day 3-4 and then declines to adult levels by day 10 • Asian infants peak at higher values (110 µmol/L ) • Exaggerated physiological (up to 290 µmol/L).

8. Asian infant Breastfed infant Non-breastfed infant Physiological Jaundice

9. Increased rbc’s Shortenedrbc lifespan Immature hepatic uptake and conjugation Increased enterohepatic circulation. Physiological Jaundice

10. Breast Milk Jaundice • Elevated unconjugated bilirubin • Prolongation of physiological jaundice • May be second peak @ day 10 • Average max SBR = 170-205 µmol/L • SBR may reach 376-410 µmol/L • ?Milk factor.

11. Pathologic Jaundice • Features • Jaundice in first 24 hrs • Rapidly rising SBR • > 85 µmol/L per day • SBR > 290 µmol/L. • Categories • Increased bilirubin load • Decreased conjugation • Impaired bilirubin excretion.

12. 1.Increased Bilirubin Load • Elevated unconjugated bilirubin • Haemolytic Disease • Non-haemolytic Disease.

15. 2. Decreased Bilirubin Conjugation • Elevated unconjugated bilirubin • Genetic Disorders • Hypothyroidism.

16. 3. Impaired Bilirubin Excretion - usually later • Elevated conjugated bilirubin • > 35 µmol/L or > 20% of SBR • Biliary Obstruction • Important to diagnose by 4 weeks • Infection • Metabolic Disorders • Chromosomal Abnormalities • Drugs.

17. Diagnosis and Evaluation • Physical Examination • Jaundice visible when bilirubin reaches 85 µmol/l • Milder jaundice generally confined to face and upper chest • Downward extension generally signifies increasing bilirubin values.

18. Diagnosis and Evaluation • Laboratory • Blood test • Indirect measurements • Transcutaneous.

19. Jaundice in first 24 hrs Visible jaundice prior to discharge Previous jaundiced infant Gestation 35-38wk. Exclusive breastfeeding Asian race Bruising, cephalohaematoma Male sex. Risk Factors for increased Hyperbilirubinemia AAP, Subcommittee on Neonatal Hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics 2001;108.

20. Treatment • Underlying Cause • Where one is identified • Fluids and Nutrition • Phototherapy.

21. Phototherapy • Mechanism • Forms • Breastfed infants are slower to recover • Rebound hyperbilirubinemia is rare • Average increase is 17 µmol/L.

22. Treatment

23. Treatment • Underlying Cause • Where one is identified • Fluids and Nutrition • Phototherapy • Monitoring and follow up • ? Repeat hearing checks • ? Hb checks for late anaemia.

24. Exchange Transfusion • Mechanism: removes bilirubin and antibodies from circulation • Most beneficial to infants with haemolysis • Generally never used until after intensive phototherapy attempted.

25. Kernicterus What is it? • Bilirubin induced toxicity to Basal Ganglia and brainstem nuclei. Increase in cases beginning in early 1990s • At least partially related to early hospital discharge.

26. Any questions?

27. Summary • Jaundice is common and “normal” • Recognition of at risk infant • Assessment - clinical and biochemical • Treatment.