1. Neonatal Jaundice By Dr. Nahed Al-Nagger

2. 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.

3. 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.

5. Neonatal Jaundice Newborn skin >5 mg / dl
Visible form of bilirubinemia
Newborn skin >5 mg / dl
Occurs in 60% of term and 80% of preterm neonates
However, significant jaundice occurs in % of term babies

6. Bilirubin metabolism Non – heme source Hb → globin + haem 1 mg / kg
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 metabolism

7. Bilirubin Production & Metabolism

8. Clinical assessment of jaundice
Area of body Bilirubin levels mg/dl (*17=umol)
Face
Upper trunk
Lower trunk & thighs
Arms and lower legs
Palms & soles > 15

9. 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.

10. Why does physiological jaundice develop?
Increased bilirubin load.
Defective uptake from plasma.
Defective conjugation.
Decreased excretion.
Increased entero-hepatic circulation.

11. Course of physiological jaundice
Age in Days
Term
Preterm 15 10 5
Bilirubin level
mg/dl

12. 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

13. Causes of jaundice Appearing within 24 hours of age
Hemolytic disease of NB : Rh, ABO
Infections: TORCH, malaria, bacterial
G6PD deficiency

14. Causes of jaundice Appearing between 24-72 hours of life Physiological
Sepsis
Polycythemia
Intraventricular hemorrhage
Increased entero-hepatic circulation

15. Causes of jaundice After 72 hours of age Sepsis Cephalhaematoma
Neonatal hepatitis
Extra-hepatic biliary atresia
Breast milk jaundice
Metabolic disorders (G6PD).

16. Risk factors for 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

17. Diagnostic evaluation:
Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.
Investigate the cause of jaundice.

18. 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.

19. Babies under phototherapy
Baby under conventional phototherapy
Baby under triple unit intense phototherapy

20. Phototherapy if hemolysis
Maisel’s chart
Sr Bilirubin (mg/dl)
Birth weight
Age in hrs
< 24
24 – 48
49 – 72
>72
<5
All
5-9
Phototherapy if hemolysis
10-14
< 2500g
PHOTOTHERAPY
> 2500g
Investigate if bilirubin
> 12mg%
15-19
EXCHANGE
Consider Exchange
Phototherapy
> 20

21. Prognosis
Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.

22. 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

23. 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

24. 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.

25. 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).

26. QUESTIONS?