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Neonatal Jaundice Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University.

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Presentation on theme: "Neonatal Jaundice Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University."— Presentation transcript:

1 Neonatal Jaundice Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University

2 Introduction Jaundice is quite common (5mg/dl). Full term infants: at least 50% Preterm infants: over 80% Elevated blood bilirubin levels: 97%

3 Introduction continued When? in the first week of life Where? skin, mucosa and white of eye How many? blood bilirubin concentrations is ≥5-7mg/dl.

4 Introduction continued

5 Producing Excreting Why Jaundice occurred?

6

7 Bilirubin Metabolism: 1. RBC: Heme bilirubin (UCB) 2. Blood: carried by bound to albumin 3. Liver: uptaken : Y protein, Z protein conjugated: UDPGT excreted : to the biliary system 4. Intestine: stercobilins  -glucuronidase enterohepatic circulation

8 The metabolic characteristics of bilirubin in newborns: 1. Bilirubin production 8.8mg/Kg/d in newborns 3.8mg/Kg/d in adults 2. Bilirubin-albumin complex formation a. preterm infant; b. acidosis

9 3. Bilirubin metabolism of hepatocyte a. Hepatic uptake of bilirubin b. Bilirubin conjugation: UDPGT (uridine diphosphate glucoronyl transferase) c. Defective bilirubin excretion ability to bile system 4. Enterohepatic circulation The metabolic characteristics of bilirubin continued

10 Bilirubin toxicity 1. Conjugated bilirubin water-soluble 2. Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy ( kernicterus )

11 Clinical Manifestations Jaundice appears When: at any time during the neonatal period Where: from face chest abdomen feet

12 Evaluation of jaundice : 1. By eyes: face, 5mg/dl ( 85μmol/L ); abdomen, 10-15mg/dl; feet, 15-20mg/dl ; 2. By transcutaneous measurement : used for screening 3. By serum levels : standard Manifestations continue

13 Classification: Physiological Jaundice Pathological Jaundice Manifestations continue

14 Physiological jaundice : 1. General state is well 2. Appears 2-3days (>24h of age) peaks < 12.9mg/dl (full term infants) <15mg/dl (preterm infants) fades <2 week (term infants) <4 weeks (preterm infants) 3. Accumulates <5mg/dl/d 4. Direct bilirubin <2mg/dl Manifestations continue

15 Pathological Jaundice 1. Appears earlier (first 24 hours of life) 2. Peaks >12.9mg/dl (full term infants) >15mg/dl (preterm infants) Fades >2 weeks (term infants) >4 weeks (preterm infants) 3. Accumulates >5mg/dl/d 4. Direct bilirubin >2mg/dl 5.Jaundice recurrent Manifestations continue

16 Common causes of pathological jaundice 1. Unconjugated bilirubinemia: a. hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice

17 2. Conjugated bilirubinemia: a. Neonatal hepatitis b. Biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. Congenital metabolic diseases α-1 antitrypsin deficiency Causes of pathological jaundice continue

18 Hemolytic disease of newborn Hemolytic disease: ABO: 85.3% Rh : 14.6% MN : 0.1%

19 Hemolytic disease of newborn continued ABO incompatibility the mother: type O the infant: type A or B Rh incompatibility the mother : Rh ( - ) the infant: Rh ( + ) D,E,C,d,e,c

20 Pathogenesis

21 Pathophysiology Red blood cell breakdown Hyperbilirubinemia Jaundice Kernicterus Seizures etc. Anemia 1.Liver 2.Spleen 3.Heart, other organs 4.Hydrops

22 Clinical Manifestations: ABO Rh 1.Jaundice : mild severe 1-2 day 24 h 2.Anemia: mild severe (3-6 weeks) heart failure 3.Hepato- rare common splenomegaly

23 Complication Kernicterus: Phase 1: decreased alertness Hypotonia Poor feeding Phase 2:Hypertonia, Retrocollis, opisthotonus Phase 3:Hypotonia

24 1. Blood type incompatibility 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1). Hemoglobin level : low 2). Reticulocytes:10–15% 3). Nucleated RBC Laboratory tests:

25 Antibody test 1). Direct Coombs test (+) confirm 2). Antibody release test (+) confirm 3). Free antibody test (+) judge Laboratory tests continued

26 1). Phototherapy 2). Exchange transfusion 3). Internal Medicine Treatments

27 During pregnancy 1. Intrauterine blood transfusion 2. Early delivery Treatments continued

28 After birth 1. Phototherapy Principle : photon of light Three photochemical reactions: 1). Structure isomer 2). Geometric isomer 3). Photo-oxidation Photoproducts excretion: w/o conjugation Treatments continued

29 Indications of phototherapy : Unconjugated bilirubinemia Bilirubin level >12mg/dl Light source: Spectral outputs 420 to 500nm Treatments continued

30 Side effects of phototherapy : a. diarrhea b. fever c. skin rash d. bronze baby syndrome (conjugated bilirubin>4mg/dl) Treatments continued

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33 2. Exchange Transfusions: a. Severe hemolytic disease b. Refractory to phototherapy Treatments continued

34 Aims of transfusions: a. Remove antibodies b. Remove bilirubin c. Correct anemia Treatments continued

35 Indication of transfusions: one of the follows a. 20mg/dl (340 μmol/L) b. >4mg/dl,Hgb<120g/L, edema c. 0.7mg/dl/h d. Kernicterus Treatments continued

36 Source of the blood mother newborns For Rh: Rh ABO incompatibility For ABO: “AB” plasma “O” cells incompatibility packed RBC Treatments exchange transfusions

37 Potential complications: a. Infection b. Necrotizing enterocolitis NEC c. Thromboembolic complications Treatments exchange transfusions

38 3. Pharmacological agents: a. Phenobarbital Effects: Uptake, Conjugation Excretion b. Albumin c. IVIG Treatments continued

39 Preventions For ABO incompatibility: No For Rh incompatibility 300 μg of human anti-D globulin within 72 h of delivery.

40 1.Unconjugated bilirubinemia: a. Hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice

41 1.Unconjugated bilirubinemia: b. G-6-PD deficiency; male, jaundice, enzyme activity c. Breast milk jaundice causes: unclear,  -glucuronidase follows physiologic jaundice: 4-7 d breast feeding persist for several weeks.

42 Conjugated bilirubinemia: 2.Conjugated bilirubinemia: a. neonatal hepatitis b. biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. congenital metabolic diseases α-1 antitrypsin deficiency

43 Case analysis : 24 old male infant, gravida1,para 1. Apgar scores: 8 at 1 min Mother: blood type “O” PE: icterus appeared on face and trunk skin liver edge 1cm palpable spleen tip

44 Case analysis continued Lab tests: Hgb:13g/dl, reticulocyte count : 7% Blood smear: nucleated RBC Blood type: A, Rh-positive Serum bilirubin: 12.9mg/ml Direct Coomb’s test: weakly positive Question: what’s the risk factor ?

45 Thank you! Questions ? Department of Pediatrics


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