NEONATAL JAUNDICE DR NADEEM ALAM ZUBAIRI MBBS, MCPS, FCPS Consultant Neonatologist / Paediatrician

Scenario 1 A baby boy is born 3.5 kg to a mother as a result of SVD. He did not need any resuscitation at birth and went home within 24 hrs. Mother noticed him to be jaundiced on D3 of life and brought him to you.

A house officer takes history and asks following questions. –When did the mother first notice jaundice? After first 24 hrs –Is this mother’s first pregnancy / H/O abortions? She is a primigravida –Is the baby breast fed? Exclusively and feeding well –What is the color of the stool? Yellow Scenario 1 Continued

House officer makes a provisional diagnosis of: Physiological Jaundice –Serum total bilirubin –Mother and baby’s blood group –FBC, retics and peripheral film Scenario 1 Continued

Serum bilirubin 180 umol/l on day 3 of life( 10 mg/dl) FBC Hb 18.3 g/dl, retics 2% TLC 18 x 10 3 Baby’s blood group A+ Mother A+ Coomb’s test Negative ( Scenario 1 Continued

Physiological Jaundice Why ? Scenario 1 Continued

EXCLUSION CRITERIA  Unconjugated bilirubin > 12.9 mg/dl  Bilirubin level increasing > 5 mg/dl/day  Jaundice in first 24 hours of life  Conjugated bilirubin level > 2 mg/dl  Clinical jaundice persisting > 2 week

Neonatal Jaundice Hyperbilirubinemia in infants ≥35 weeks gestation is defined as a TSB >95th percentile for hours-of-age on the Bhutani nomogram PHYSIOLOGIC & PATHOLOGIC JAUNDICE

Bilirubin Metabolism

Mechanism of Neonatal Jaundice Increased production of bilirubin Decreased uptake Decreased conjugation Increased enterohepatic circulation

Decreased RBC life span Decreased Y protein and Ligandin in liver Decreased activity of UDP glucronyl transferase Increased enterohepatic circulation Why do newborns develop physiological jaundice?

Physiological Jaundice Appear after 24 hours Maximum intensity by 4th-5th day in term & 7th day in preterm Clinically not detectable after 14 days Disappears without any treatment

A baby boy is born to a multigravida mother at term gestation following an uneventful pregnancy. He develops jaundice at 16 hours of age. Scenario 2

A house officer takes history and asks following questions. –When did the mother first notice jaundice? Within 1 st 24 hrs –Is this mother’s first pregnancy / H/O abortions? She is a multigravida –Is the baby breast fed? Started breastfeeding –What is the color of the stool? Yellow Scenario 2 Continued

House officer makes a provisional diagnosis of: Pathological Jaundice –Serum total bilirubin –Mother and baby’s blood group –FBC, retics and peripheral film Scenario 2 Continued

Serum bilirubin 280umol/l i.e.15.5mg/dl (at 16 hrs of age) FBC Hb 12.3 g/dl TLC 18 x 10 3, retics 10% Baby’s blood group O + ve Mother O - ve Coomb’s test positive Scenario 2 Continued

Pathological Jaundice Secondary to Rh Incompatability Scenario 2

Pathological Jaundice Appears within 24 hours of age Serum bilirubin > threshold line

A baby boy is born to a primigravida mother. He develops jaundice at 18 hrs of age. He is brought to you for evaluation and management. Scenario 3

A house officer takes history and asks following questions. –When did the mother first notice jaundice? Within 1 st 24 hrs –Is this mother’s first pregnancy / H/O abortions? She is a primigravida –Is the baby breast fed? Feeding poorly –What is the color of the stool? Yellow Scenario 3 Continued

House officer makes a provisional diagnosis of: Pathological Jaundice –Serum total bilirubin –Mother and baby’s blood group –FBC, retics and peripheral film Scenario 3 Continued

Serum bilirubin 230 umol/l (at 20 hrs of age) FBC Hb 12.3 g/dl TLC 18 x 10 3, retics 10% Baby’s blood group O + ve Mother O + ve Coomb’s test negative Peripheral film spherocytes Scenario 3 Continued

Pathological Jaundice Secondary to Hemolysis due to Hereditary spherocytosis Scenario 3

A baby boy is born to a primigravida mother. He had a prolonged labor and was delivered secondary to ventouse application. After delivery he did not require any resuscitation but had a massive cephalhematoma on the head. He develops jaundice at 3 days of life. He is brought to you for evaluation and management. Scenario 4

A house officer takes history and asks following questions. –When did the mother first notice jaundice? After 1 st 24 hrs –Is this mother’s first pregnancy / H/O abortions? She is a primigravida –Is the baby breast fed? Feeding adequately –What is the color of the stool? Yellow Scenario 4 Continued

House officer makes a provisional diagnosis of: Physiological Jaundice –Serum total bilirubin –Mother and baby’s blood group –FBC, retics and peripheral film Scenario 4 Continued

Serum bilirubin 350 umol/l (at 72 hrs of age) FBC Hb 12.3 g/dl TLC 18 x 10 3, retics 3% Baby’s blood group O + ve Mother O + ve Coomb’s test negative Peripheral film Normal Scenario 4 Continued

Pathological Jaundice Secondary to Cephalhematoma Scenario 4

OTHER CAUSES OF UNCONJUGATED HYPERBILIRUBINEMIA  BREAST MILK JAUNDICE  DEFECTS OF CONJUGATION #Crigler Najjar Syndrome I & II #Gilbert Syndrome  METABOLIC DISORDERS #Glactosemia #Hypothyroidism  POLYCYTHEMIA

Kramer’s rule Clinically jaundiced when the bilirubin level reaches μmol/L

Deposition of unconjugated bilirubin in brain leads to BIND (bilirubin induced neurologic dysfunction) Prevention of Acute bilirubin encephalopathy and Kernicterus Why bother?

Treatment Goals –Prevention of kernicterus –Maintenance of hydration and nutrition Interventions –Intensive Phototherapy –Exchange transfusion

Phototherapy Mechanism of action –Skin exposure to lights causing geometric photoisomerization allowing excretion Technique –Light source Lamps, spotlights, fiber optic blankets, Blue light Wave length: nm –Positioned 50 cm above infant –Largest surface area possible exposed

Complications of Phototherapy Dehydration –Increased insensible water loss –loose stools Irritability or lethargy Skin rashes Overheating Retinal injury

Exchange Transfusion

Bilirubin Encephalopathy Deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei causing neurotoxic effects Acute manifestations are lethargy & poor feeding Severe cases, irritability, increased muscle tone opisthotonos, seizures and coma Survivors may develop choreoathetoid cerebral palsy (due to damage to the basal ganglia), learning difficulties and sensorineural deafness

Summary Neonatal jaundice is a fairly common condition Keep a vigilant eye Try to differentiate physiological from pathological jaundice Early and effective phototherapy Prevent BIND