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Neonatal Jaundice Dezhi Mu MD/PhD

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Presentation on theme: "Neonatal Jaundice Dezhi Mu MD/PhD"— 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 Why Jaundice occurred? Producing Excreting


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 The metabolic characteristics of bilirubin continued
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

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 Manifestations continue
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

13 Manifestations continue
Classification: Physiological Jaundice Pathological Jaundice

14 Manifestations continue
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

15 Manifestations continue
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

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 Causes of pathological jaundice continue
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

18 Hemolytic disease of newborn
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 Anemia
Jaundice Liver Spleen Heart, other organs Hydrops Kernicterus Seizures etc.

22 Clinical Manifestations:
ABO Rh 1.Jaundice : mild severe 1-2 day 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 Laboratory tests: 1. Blood type incompatibility
2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1). Hemoglobin level : low 2). Reticulocytes:10–15% 3). Nucleated RBC

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

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

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

28 Treatments continued 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

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

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



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

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

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

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

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

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

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:
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 Department of Pediatrics
Thank you! Questions?

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