DR.FADI ALFAQAWI

MEDICAL OFFICER

UNRWA

10th FEB 2013

NEONATAL JAUNDICE1-PHYSIOLOGICAL

Email: dr.alfaqawi@yahoo.co.uk

Objectives:

1-How to -Suspect? -Measure? -Diagnose? 2-How to approach? And When to refer to hospital ?3-How to manage ?3-What to tell parents ?4-To Vaccinate or not ?

Introduction:

~60% of term and 80% of preterm babies develop jaundice in the first wk of life.

10% of BF babies are still jaundiced at 1 month.

For most babies, jaundice is not an indication of an underlying disease (termed 'physiological jaundice') is generally harmless.

Prolonged jaundice –persisting beyond the first 14 days in term babies and beyond 21 days in PT babies.

Introduction:

How to suspect:

Babies are more likely to develop significant hyperbilirubinaemia if they have: gestational age under 38 weeks. a previous sibling with NJ requiring

phototherapy. mother's intention to breastfeed

exclusively Visible jaundice in the first 24 hours.

How to measure: Kramer’s Index

When looking for jaundice (visual inspection):1-check the naked baby in bright & preferably natural light2-examine the sclerae, gums and blanched skin is useful across all skin tones.

1- Face 5 mg /dl

2-Upper trunk 10

3-Lower trunk & thighs 12 4-Arms &lower legs 15

5-Palms and soles >15

How to measure: TC Bilirubinometer

Use a TC bilirubinometer in babies with GA of 35 weeks or more and PN age of >24 hours

If a TC bilirubinometer is not available, measure the serum TB.

If a TC bilirubinometer measurement > 250μmol/l (15 mg/dl) … check the result by measuring the serum TB

How to diagnose: Causes

1. Appearing within 24 hours of age-Hemolytic disease of newborn: Rh, ABO and minor group incompatibility-Infections: intrauterine viral, bacterial; malaria-G-6PD deficiency

2. Appearing between 24-72 hours of life-Physiological-Sepsis neonatorum-Polycythemia-Concealed hemorrhages: cephalhematoma, subarachnoid bleed, IVH.-Increased enterohepatic circulation

3. Appearing after 72 hours-Sepsis neonatorum-Neonatal hepatitis-Extra hepatic biliary atresia-Breast milk jaundice -Metabolic disorders

Why to diagnose:

Physiological Jaundice:

Immaturity in bilirubin metabolism at multiple steps...

Characteristics:· First appears between 24-72 hours of age· Maximum intensity seen on 4-5th day in term and 7th day in preterm neonates· Does not exceed 15 mg/ dl· Clinically undetectable after 14 days.· No treatment is required but baby should be observed closely for signs of worsening jaundice.

Pathological Jaundice:

1-Clinical jaundice detected before 24 hours of age.2-Rise in serum bilirubin by > 5 mg/dl/day.3-Serum bilirubin >15 mg/dl.4-Clinical jaundice persisting beyond 14 days of life.5-Clay/white colored stool and/or dark urine staining the clothes yellow.6-Direct bilirubin >2 mg/ dl at any time.

*One should investigate to find the cause.*Treatment is required in the form of phototherapy or EPT.

How To Approach:

Check birth wt, GA ,PN age. FH/o Jaundice or anemia or neonatal

death.. Maternal and perinatal history… Ask when jaundice was first noticed ? Assess clinical condition… Physiological or Pathological… Look for clinical picture of kernicterus in

Newborns..

When to refer to hospital:

Ain Sham Children Hospital

Refer for further investigation if: Clinically unwell… poor feeding and lethargy … Jaundice within 24 hours of life. Jaundice below umbilicus, corresponding to serum bilirubin of

12-15 mg/dl (200-250 μmol/l ). Jaundice up to level of the sole of the feet - likely to need

exchange transfusion. Rapid rise of serum bilirubin of more than 8.5 μmol/l /hour

(>0.5 mg/dl/hour). Prolonged jaundice of >14 days - other causes/conditions

need to be excluded e.g. neonatal hepatitis, biliary atresia. Family history of significant haemolytic disease or kernicterus Clinical symptoms/signs suggestive of other diseases e.g.

sepsis. Direct bilirubin >20 %

Reduce level of bilirubin and prevent its toxicity by:

1-Early feeds and adequate hydration.

2-Reduction of Bilirubin by (Threshold table):

1-Phototherapy 2-IVIG 3-EBT.

How to manage in general :

What to tell parents:

Offer parents or carers information about NJ that is tailored to their needs and expressed concerns. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include:

1-Factors that influence the development of significant hyperbilirubinaemia

2-How to check the baby for jaundice

3-What to do if they suspect jaundice

4-The importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice

5-The importance of checking the baby's nappies for dark urine or pale chalky stools

6-The fact that NJ is common, &reassurance that it is usually transient and harmless

7-Reassurance that breastfeeding can usually continue.

8-Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced.

To vaccinate or not:

Physiological Jaundice IS NOT a contraindication.