DIPLOMA PEMBANTU PERUBATAN K34TAHUN 2 SEMESTER 1

CASE STUDY FOR PRE CLINICAL POSTING

NEONATAL JAUNDICE

NAMA : MUHAMMAD MUZAMIR BIN MOHD MYDIN

NO MATRIK : BPP 2014-2019 NO I/C : 911112-11-5185

INTRODUCTION

Neonatal jaundice in a disorder that affects nearly 50% of all newborns to at least a small degree. The yellow coloration of the skin and sclera of the eyes is due to the accumulation of bilirubin in adipose tissue and its adherence to collagen fibers. In neonatal jaundice, the excess bilirubin is not due to an abnormal level of red blood cell destruction. It is due to the inability of the young liver cells to conjugate bilirubin, or make it soluble in bile, so that it can be excreted and removed from the body by the digestive tract. This inability is corrected, usually within one week, as the liver cells synthesize the conjugation enzymes. If uncorrected, sufficiently high bilirubin concentrations can cause brain damage. Frequent feedings of a newborn with jaundice increase gastrointestinal tract motility and decrease the likelihood of reabsorbing significant amounts of bilirubin in the small intestine. Radiation from sunlight alters the chemical form of bilirubin, making is easier for the liver to excrete.

Treatment is usually only necessary if your baby has high levels of a substance called bilirubin in their blood, so tests will need to be carried out to check this.Most babies with jaundice do not need treatment because the level of bilirubin in their blood is found to be low. In these cases, the condition will usually get better within 10-14 days and won't cause any harm to your baby.

CASE STUDY

A two-day-old boy was admitted to the paediatric ward in after a maternal-newborn postnatal visit where he was found to be jaundiced with a total serum bilirubin of 373 umol/L. His weight on the day of admission was 2.52 kg, while his birth weight had been 2.9 kg.

The pregnancy and family history were normal , and the boy was born SVD at term with an uncomplicated initial stay in the hospital. Breastfeeding had been established before discharge home where the boy was found to have lost over 10% of his birth weight. His parents reported that he was becoming less and less interested in eating, and by the day of admission, they needed to wake him for most feeds.

On admission, he was jaundiced and moderately dehydrated but otherwise had a normal physical examination. Other than the hyperbilirubinemia, the remainder of the initial blood work was unremarkable. The direct antiglobulin test was negative.

Early diagnosis suggest the baby had neonatal jaundice with renal impairment and dehydration. There was also concern of early onset sepsis considering the high level of serum bilirubin during admission.

MANAGEMENT

Phototherapy is treatment with light. It is used in some cases of newborn jaundice to lower the bilirubin levels in your baby’s blood through a process called photo-oxidation. Oxidation is the process of adding oxygen to change a substance (in this case, the bilirubin).The photo-oxidation converts the bilirubin into a substance that dissolves easily in water. This makes it easier for your baby’s liver to break down and remove the bilirubin from their blood.

The baby was started on phototherapy and intravenous rehydration, and within 6 h, he had a repeat total bilirubin of 273.5 umol/L, with a direct bilirubin of 34 umol/L.

The mother was encouraged to continue breastfeeding or bottle feed the baby regularly, waking them up for feeds if necessary. Evidence suggests that the simple expedient of supplementing feeds of breast milk with 5 mL of a breast milk substitute reduces the level and duration of jaundice in breast milk–fed infants.

The baby was put on postnatal care during the time at the ward with close monitoring on the serum bilirubin levels and others complication that might happen.

After nine days of close monitoring and continous treatments the baby was allowed to discharge with serum bilirubin level at 246umol/L. A significant decrease suggesting with continous breastfeeding and home care from the

mother would be necessary to maintain the normal level of the serum biirubn level. However the mother are advised to continue postnatal clinic appointment for further monitoring and treatment.

DISCUSSION

Whether jaundice is dangerous depends on what is causing it, how high the bilirubin level is, and how quickly the bilirubin level rises. Some disorders that cause jaundice are dangerous regardless of what the bilirubin level is. However, an extremely high bilirubin level, regardless of cause, is dangerous.

The most serious consequence of a high bilirubin level is kernicterus , a disorder in which bilirubin is deposited in the brain and causes brain damage. Kernicterus occurs only when the level of bilirubin is high. The risk of this disorder is higher for newborns who are premature, seriously ill, or who are given certain drugs. If untreated, kernicterus may lead to unresponsiveness (stupor) or lethargy, loss of muscle tone, a high-pitched cry, poor feeding, and seizures. Later, children can have cerebral palsy, hearing loss, a permanent upward gaze, or other signs of brain damage. Kernicterus is now rare because of increased screening for hyperbilirubinemia and early treatment.

Common causes

The most common causes of jaundice in the newborn are :

Physiologic jaundice (most common)

Breastfeeding jaundice

Breast milk jaundice

Excessive breakdown of red blood cells (hemolysis)

Risk factors

Major risk factors for jaundice include prematurity (35 to 36 weeks' gestation), blood type incompatibility with the mother, jaundice that begins soon after birth (high levels occur in the first 24 hours), birth-related bruising, and family history of jaundice. Also at major risk of jaundice are newborns who are exclusively breastfed and who have lost a significant amount of weight and have a high-risk bilirubin level before discharge from the hospital.

Newborns who have a low-risk level of bilirubin before discharge from the hospital, who are postmature (over 41 weeks' gestation), and who are exclusively bottle-fed are at low risk of jaundice.

CONCLUSION

Newborns with warning signs should be evaluated by a doctor right away. If the newborn is discharged from the hospital on the first day after birth, a bilirubin level should be done before discharge. A follow-up visit to measure the bilirubin level should be scheduled within 2 days of discharge. Newborns with risk factors for a high jaundice level or who had a high level before discharge may need to be seen at least twice after discharge from the hospital.

Once at home, if the newborn had not been jaundiced before but parents now notice that their newborn’s skin or eyes look yellow, they should contact their doctor immediately. The doctor can decide how urgently to evaluate the newborn based on whether the newborn has any symptoms or risk factors (such as prematurity).