Neonatal jaundice

05/03/2023 Aklilu Endalamaw 1

Neonatal Jaundice UOGRH, 2017

By: Aklilu Endalamaw (Department of Pediatrics and Child Health Nursing)


Presentation outline• Objective

• Case study

• Epidemiology

• Pathogenesis

• Clinical features

• Diagnosis modality

• Evidence based nursing management

• Key points

• References


Objective

The main objective of this session is managing neonatal jaundice.


Case-studyA 36 weeks GA, 3k.g neonate born from a primi para 24

years women labor was complicated and he was

asphyxiated. At 36 hour of birth, a child was developed

yellowish discoloration of skin and sclera. No other

physical finding was identified. Up on laboratory

examination serum bilirubin level was 16 mg/dl.

=>If you were there, what could be your diagnosis

and How could you manage it?


Baby was under phototherapy care

(TSB) > 5mg/dL, >7mg/dl N. Jaundice (NICU manual, 2014)

Neonatal Hyperbilirubinemia


Why we are focusing on neonatal jaundice?

1. Almost all newborn infants develop a total serum or

plasma bilirubin (TB) level greater than 1 mg/dL (17

micromol/L) (uptodate 21.2)

2. It is a very common condition worldwide occurring

in up to 60% of term and 80% of preterm newborns

in the first week of life (Slusher et al., 2004; Haque

and Rahman, 2000).


Cont…

3 Sixty-five percent of newborns develop clinical jaundice

with a bilirubin level above 5 mg/dL during the first

week of life (Current pediatrics diagnosis & treatment

18th edition).

4. TSB >25 to 30 mg/dL (428 to 513 micromol/L) leads to

"acute bilirubin encephalopathy" (ABE) and "kernicterus“

(23%). (Daynia E, Gilbert R ,2006-2011)


• A total of 13 studies with 1,951 subjects and 32,208 controls from India, Nigeria, Pakistan, Nepal and Egypt were identified and analyzed. The pooled data showed that primi-parity (OR, 1.59; 95% CI:1.26-2.00), delivery outside public hospitals (OR, 6.42; 95% CI:1.76-23.36), ABO incompatibility (OR, 4.01; 95% CI:2.44-6.61), Rhesus hemolytic disease (OR, 20.63; 95% CI:3.95-107.65), G6PD deficiency (OR, 8.01; 95% CI:2.09-30.69), UGT1A1 polymorphisms (OR, 4.92; 95% CI:1.30-18.62), low gestational age (OR, 1.71; 95% CI:1.40-2.11), underweight/weight loss (OR, 6.26; 95% CI:1.23-31.86),

sepsis (OR, 9.15; 95% CI:2.78-30.10) and high transcutaneous/total serum bilirubin levels (OR, 1.46; 95% CI:1.10-

1.92)=> placed infants at increased risk of severe hyperbilirubinemia or bilirubin induced neurologic dysfunctions (Bolajoko O. et al., 2015).

5. Risk Factors for Severe Neonatal Hyperbilirubinemia in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis, PLOS 2015


IntroductionBilirubin:

• Yellow pigment,

• Anti-oxidative agent :to avoid oxygen toxicity in the

days after birth.

• Increased by immature liver or liver damage or

hereditary disorder

Sources of bilirubin in the body: Heme -containing

proteins (cytochromes and catalase) and hemoglobin.


Mechanism of Biluribin

Located in spleen ,liver ,all nucleated cellsCO

Hepatic uptake=>(Conjugation)Bilirubin + glucuronic acid=bilirubin di and monoglucuronides=> Biliary excretion-intestine

conserved

Exhaled

Current pediatrics diagnosis & treatment 18th edition).

05/03/2023 11

Cont…• In the presence of normal gut flora, the conjugated bilirubin is

metabolized further to stercobilins and excreted in the stool.

• At birth ,may flora absent, very little conjugated bilirubin is

reduced to urobilin.

• Infants have beta-glucuronidase in the intestinal mucosa,

which deconjugates the conjugated bilirubin. =>

• Unconjugated bilirubin can be reabsorbed and recycled into

the circulation, a process known as the "enterohepatic

circulation of bilirubin“=> Jaundice.

Aklilu Endalamaw

05/03/2023 Aklilu Endalamaw 12UpToDate21.2, NICU manual, 2014

Features Physiological jaundice

Pathological jaundice

Clinical onset of jaundice (after birth)

>24 hrs <24 hrs

Jaundice still clinically visible (day after birth)

Term < 8 daysPreterm < 14 days

Term >8 daysPreterm > 14 days

Peak Total Serum Bilirubin ( TSB)

Term < 12 mg/dlPreterm < 15 mg/dl

Term > 12 mg/dlPreterm > 15 mg/dl

Rise in TSB < 5mg/dl/24 hrs > 5mg/dl/24 hrs

Conjugated serum bilirubin level

<2mg/dl >2mg/dl or 15 % of TB


The causes of pathological jaundice

A. Overproduction of bilirubin

Isoimmune-mediated hemolysis (eg, ABO or Rh(D)

incompatibility)

Inherited red blood cell membrane defects (eg,

hereditary spherocytosis and elliptocytosis)

Erythrocyte enzymatic defects

Sepsis, Polycythemia, Macrosomic neonate


Cont…B. Decreased clearance

Crigler-Najjar syndrome types I and II

Gilbert's syndrome

Organic Anion Transporting Polypeptide-2

polymorphism

Other causes: maternal diabetes, congenital

hypothyroidism and galactosemia


Cont…

C. Increased enterohepatic circulation

Breastfeeding associated jaundice ( lack-of-breast-

milk jaundice“)

Breast milk jaundice

Impaired intestinal motility (obstruction)


Diagnosis method

• Clinical feature• CBC• Hgb• Blood group & RH factor• VDRL• G6PD screening• Thyroid function tests• LFT• Bilirubin measurement


Evidence based nursing intervention

Bhutani curve: phototherapy indication in hospitalized infants of 35 or more weeks’ gestation.

1.


Intervention…

Phototherapy care- By emitting blue light over the

patient’s skin, by photo-oxidation and

photoisomerization bilirubin into two other

compounds, called lumirubin and photobilirubin –

Isomers of bilirubin , which can removed from the

body without the involvement of the liver.


Phototherapy…

• Cover the baby’s eye & genitalia (male), put diaper

• Distance between the light source and the baby should be less than

40 cm.

• The position should be changed every 2 hours from supine to prone.

• Measure weight daily and increase fluid intake by 25 % extra over

the usual requirement.

• Give a bolus of fluid with Normal saline 20ml/kg if bilirubin

remains high.

(NICU Manual, 2014)


Phototherapy…

• Side effects of phototherapy

- Insensible water loss

- Watery and frequent stool

- Retinal damage

- Erythema and increased blood flow

- Bronze baby syndrome

- Low calcium level (in preterm)

- Interferes with maternal infant bondingFanaroff and Martine, 9th edition


Intervention…2.

Bhutani curve: Exchange transfusion in infants of 35 or more weeks’ gestation


Intervention…

Involved in double exchange transfusion

• If the TSB is at a level at which exchange transfusion

is recommended or if the TSB level is 25 mg/dL (428

μmol/L) (Stern L,1965).

• Immediate exchange transfusion is indicated for

jaundiced manifests the signs acute bilirubin

encephalopathy.


Exchange transfusion…

• The amount of blood volume to be exchanged is equivalent to 2x

the blood volume of the baby (85ml/kg ). e.g 4kg babyx85mlx2

• Umbilical catheterization=>Heparinize the catheter=>Removed

at a time is 5ml to 20 ml.

Caution:

Strict monitoring of vital sign during the procedure.

Determine post transfusion hematocrit 4-6 hours after the

procedure.



Determine bilirubin 4 hourly after the procedure.

Monitor RBS every 30-60 minutes during the

procedure and 2-4 hourly for the first 24 hours after

procedure.

Administer 1ml/kg of Calcium gluconate slowly via

a peripheral vein under strict cardiac monitoring after

100ml of blood is exchanged.



If the cord is infected or there is a breach in the

aseptic technique, it is wise to start on prophylactic

dose of Cloxacillin 50mg/Kg bid for 2- 3 days and

gentamicin 5mg/kg BID for 2-3 days.

Keep baby NPO for 4 hours before and after

procedure because it can predispose the baby to

necrotizing enterocolitis.


exchange transfusion…

Selection of blood to be transfused to the newborn

If there is Rh hemolytic disease – give blood group compatible

to the baby and RH to the mother.

If there is ABO hemolytic disease – give blood group of the

mother and Rh compatible to the newborn

• NB: - O negative blood is the most preferable type for

exchange transfusion. (NICU Manual, 2014)


exchange transfusion…

Complication of exchange transfusion Cardiac and respiratory disturbancesShock InfectionClot formation (thromboembolism)Alterations in blood chemistry (high potassium, low

calcium, low glucose, decreased in pH) air embolism, portal hypertension and necrotizing

enterocolitis.

Fanaroff and Martine, 9th edition


Intervention…

Weight in grams Bilirubin level for phototherapy

Bilirubin level for exchange transfusion

<1000g Phototherapy with in 24 hours

10 to 12 mg/dl

1000-1500g 7 - 9 mg/dl 12-15mg/dl

1500-2000g 10-12mg/dl 15-18mg/dl

2000-2500g 13-15mg/dl 18-20mg/dl

Current practice for treating jaundice in premature infant


Intervention…

3. Assessment for the risk of severe hyperbilirubinemia,

4. Prevent complication of hyperbilirubinimea

Acute bilirubin encephalopathy

Kernictrus

Chronic bilirubin encephalopathy

(Su Yuen Ng, 2012)


Cont…

Acute bilirubin encephalopathy is an early

bilirubin toxicity, which is transient and

reversible. It may progress to permanent

neurologic impairment-Kernicterus (bilirubin

staining of brainstem nuclei and cerebellum).


Cont…Acute bilirubin encephalopathy has three phases o Phase -1 ( 1st – 2 Days of Age): Poor motor reflex,

high pitched cry, Decreased tone, lethargy, poor feeding

o Phase- 2 (middle of 1st week age): Hypertonia, seizure and depressed sensorium, fever, opisthotonos posturing, paralysis of upward gazing.

o Phase -3 (after 1week of age): Hypertonia decreases, Hearing and visual abnormality, poor feeding, Athetosis and seizure may also occur.


Cont…

Chronic bilirubin encephalopathy (Kernicterus) seen after

1 year of age and manifests with

• Choreo athetoid cerebral palsy

• Upward gaze palsy

• Sensorineural hearing loss

• The intellect may be spared with severe physical handicap


Cont…Recognize Risk factors aggravates bilirubin encephalopathy

Prematurity

Metabolic acidosis

Hypoglycemia,

Sepsis,

Temperature instability,

Significant lethargy

Low serum albumin


Intervention…

5. Increase breastfeeding in breast-feeding failure

jaundice And decrease it in Breast milk jaundice,

discontinuation of breast milk for 1-3days usually

causes a prompt decline. (AAP, 2002, Bertini et al.,

2001).

6. Perform a systematic assessment on all infants before

discharge for the risk of severe hyperbilirubinemia


Cont…• Checking the baby's nappies for dark urine or pale

chalky stools.

• The assessment of jaundice must be performed in a

well-lit room or, preferably, in daylight at a window.

• Jaundice is usually seen first in the face and

progresses caudally to the trunk and extremities.

(Kramer LI, 1969).


Intervention…

7. Provide parents with information about newborn

jaundice.

8. Provide appropriate follow-up based on the time of

discharge and the risk assessment.

9. Collect specimen: Infants who have an elevation of

direct-reacting or conjugated bilirubin should have a

urinalysis and urine culture (Garcia FJ, Nager AL, 2002).


Intervention…11. Aware about medications increasing bilirubin

toxicity: Sulfisoxazole (displacement or G6PD

hemolysis), Ceftriaxone (displacement from

albumin), anti convulsants (interfere bilirubin

metabolism).12. Phenobarbital 5 mg/kg to stimulate liver enzyme in

Crigler-Najjar syndrome.13. High dose of IV immunoglobulin.


Prognosis Gestational age < 38 weeks, Jaundice within 24 hours of birth,

severe clinically apparent jaundice (NICE Clinical Guidelines,

2010) , immaturity, concurrent neonatal disease, cholestasis,

use of total parenteral nutrition or drugs that alter bilirubin-

binding abilities augment the clinical risk of neurotoxicity

(Vinod K, Ronald J, 2013). Phototherapy initiated at 24±12 hr effectively prevented

hyperbilirubinemia in infants <2,000 g even in the presence of

hemolysis (Vinod K, Ronald J, 2013).

https://www.ncbi.nlm.nih.gov/books/n/nicecg98/abbreviations.s1/def-item/abbreviations.gl2-d112/


Key points

• The exact mechanism by which bilirubin is toxic to cells is

unknown.

• Each 1 g of hemoglobin breakdown results in the production of

34 mg of bilirubin (1 mg/dL = 17.2 mmol/L of bilirubin).

• ABO blood group incompatibility can accompany any

pregnancy in a type O mother which leads to

hyperbilirubinimea.


References• Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia

. N Engl J Med 2001; 344:581. • American Academy of Pediatrics, American College of Obstetricians and

Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002:220– 224

• Bolajoko O. Olusanya , Tina M. Slusher. Risk Factors for Severe Neonatal Hyperbilirubinemia in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis. PLOS, 2015.

• Bertini G, Dani C, Trochin M, Rubaltelli F. Is breastfeeding really favoring early neonatal jaundice? Pediatrics.2001;107 (3). Available at:www.pediatrics.org/cgi/content/full/107/3/e41

• De Carvalho M, Holl M, Harvey D. Effects of water supplementation on physiological jaundice in breast-fed babies. Arch Dis Child.1981;56 :568– 569

http://www.pediatrics.org/cgi/content/full/107/3/e41





Cont…• Nicoll A, Ginsburg R, Tripp JH. Supplementary feeding and

jaundice in newborns. Acta Paediatr Scand.1982;71 :759– 761

• Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child.1969;118 :454– 458

• Newman TB, Liljestrand P, Escobar GJ. Jaundice noted in the first 24 hours after birth in a managed care organization. Arch Pediatr Adolesc Med.2002;156 :1244– 1250

• Garcia FJ, Nager AL. Jaundice as an early diagnostic sign of urinary tract infection in infancy. Pediatrics.2002;109 :846– 851


Cont…

• Ebbesen F, Brodersen R. Risk of bilirubin acid precipitation in preterm infants with respiratory distress syndrome: considerations of blood/brain bilirubin transfer equilibrium. Early Hum Dev.1982;6 :341– 355

• Bratlid D. How bilirubin gets into the brain. Clin Perinatol.1990;17 :449– 465

• Daynia E, Gilbert R. Exchange Transfusion for Neonatal Hyperbilirubinemia in Johannesburg, South Africa. International Scholarly Research Notices. 2006-2011.


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Health & Medicine

Neonatal jaundice