Neonatal Jaundice

By Dr. Nahed Al-Nagger

Neonatal Jaundice

Learning Objectives: Define hyperbilirubinemia. Differentiate between physiological and pathological jaundice. State causes of hyperbilirubinemia. Discuss the pathophysiology of hyperbilirubinemia. Describe the most dangerous complication of hyperbilirubinemia. List the three elements of therapeutic management. Design plan of care for baby has NJ - 2 hyperbilirubinemia.

Neonatal Jaundice (Hyperbilirubinemia)

Definition: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails.

Unconjugated bilirubin = Indirect bilirubin. Conjugated bilirubin = Direct bilirubin.

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Neonatal Jaundice
Visible form of bilirubinemia

Newborn skin >5 mg / dl

Occurs in 60% of term and 80% of preterm neonates However, significant jaundice occurs in 6 % of term babies

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Hb globin + haem 1g Hb = 34mg bilirubin

Non heme source 1 mg / kg

Bilirubin
Ligandin (Y - acceptor)
Bilirubin glucuronidase

Intestine

Bil glucuronide

Bil glucuronide

glucuronidase bacteria
Bilirubin

Stercobilin

Bilirubin metabolism
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Bilirubin Production & Metabolism

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Clinical assessment of jaundice

Area of body
Face Upper trunk Lower trunk & thighs Arms and lower legs Palms & soles

Bilirubin levels mg/dl (*17=umol)

4-8 5-12 8-16 11-18 > 15
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Physiological jaundice
Characteristics Appears after 24 hours Maximum intensity by 4th-5th day in term & 7th day in preterm Serum level less than 15 mg / dl Clinically not detectable after 14 days Disappears without any treatment
Note: Baby should, however, be watched for worsening jaundice.
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Why does physiological jaundice develop?

Increased bilirubin load. Defective uptake from plasma. Defective conjugation. Decreased excretion. Increased entero-hepatic circulation.
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Course of physiological jaundice

Bilirubin level mg/dl 15 10 5 1 14 2 3 4 5 Term 6 10

Preterm 11 12 13

Age in Days
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Pathological jaundice
Appears within 24 hours of age Increase of bilirubin > 5 mg / dl / day Serum bilirubin > 15 mg / dl Jaundice persisting after 14 days Stool clay / white colored and urine staining clothes yellow Direct bilirubin> 2 mg / dl
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Causes of jaundice
Appearing within 24 hours of age Hemolytic disease of NB : Rh, ABO Infections: TORCH, malaria, bacterial G6PD deficiency

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Causes of jaundice
Appearing between 24-72 hours of life Physiological Sepsis Polycythemia Intraventricular hemorrhage Increased entero-hepatic circulation
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Causes of jaundice
After 72 hours of age Sepsis Cephalhaematoma Neonatal hepatitis Extra-hepatic biliary atresia Breast milk jaundice Metabolic disorders (G6PD).
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Risk factors for jaundice

JAUNDICE J - jaundice within first 24 hrs of life A - a sibling who was jaundiced as neonate U - unrecognized hemolysis N non-optimal sucking/nursing D - deficiency of G6PD I - infection C cephalhematoma /bruising E - East Asian/North Indian
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Diagnostic evaluation:
Normal values of unconjugated B. are 0.2 to 1.4 mg/dL. Investigate the cause of jaundice.

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Therapeutic Management
Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity Prevention of hyperbilirubinemia: early feeds, adequate hydration Reduction of bilirubin levels: phototherapy, exchange transfusion, Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.
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Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy

Prognosis
Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.

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Nursing considerations of Hyperbilirubinemia Assessment:

observing for evidence of

jaundice at regular intervals. Jaundice is common in the first week of life and may be missed in dark skinned babies

Blanching the tip of the nose

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Approach to jaundiced baby

Ascertain birth weight, gestation and postnatal age Ask when jaundice was first noticed Assess clinical condition (well or ill) Decide whether jaundice is physiological or pathological Look for evidence of kernicterus* in deeply jaundiced NB
*Lethargy

and poor feeding, poor or absent Moro's, or convulsions

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Nursing diagnosis
See the high risk infant plan of care. Plus: Body T., risk for imbalanced T. related to use of phototherapy. Fluid volume, risk for deficient related to phototherapy. Interrupted family process related to situational crisis, re hospitalization for the therapy.
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The goals of planning

Infant will receive appropriate therapy if needed to reduce serum bilirubin levels. o Infant will experience no complications from therapy. o Family will receive emotional support. o Family will be prepared for home phototherapy (if prescribed).
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QUESTIONS?

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