Neonatal Jaundice

Neonatal Jaundice
Neonatal Jaundice
yellow discoloration of skin due to hyperbilirubinemia
All babies have a transient rise in serum bilirubin but only about 75%
are visibly jaundiced
clinically detectable when the serum bilirubin levels are >85 mol/L
Commonest reason for admission in the neonatal unit
Important as it is
A sign of another disorder, e.g. infection, hemolysis, biliary atresia
may cause irreversible brain damage (Kernicterus)
Classification of Neonatal Jaundice
Physiological Jaundice
>24H to 2 weeks of life (Term) or 3 weeks of life (Preterm)
Pathological Jaundice
<24H
>2 weeks of life (Term) or 3 weeks of life (Preterm)
Physiological Jaundice
Physiological jaundice in babies:
is due to excessive bilirubin production (higher haemoglobin content and shorter

red blood cell life span in newborn babies) and poor bilirubin clearance (liver
immaturity)
usually appears two to four days after birth, resolving after one to two weeks
(three weeks if preterm)
is not associated with underlying disease and is usually benign
o Bilirubin by product of breakdown of haemoglobin (unconjugated & conjugated)

o Metabolised in liver and excreted through urine and stool
o Red cell life span of newborn infants is 70 days which is much shorter than that of
adults(120 days)
Jaundice <24H of life
Hemolytic disorders
Rhesus hemolytic disease
ABO incompatibility
G6PD deficiency
Spherocytosis
Congenital infection
TORCH - Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19),

Rubella, Cytomegalovirus (CMV), and Herpes
Jaundice >24H to 2 (3) weeks of life
Physiological
Breast feeding & Breast milk Jaundice
Sepsis
Cephalohematoma & Bruising
Polycythaemia
Hemolytic disorders
Crigler-Najjar syndrome
Jaundice >2(3) weeks (prolonged)
Unconjugated Hyperbilirubinemia
Infection (UTI)
Congenital hypothyroidism
Breast milk jaundice
Conjugated Hyperbilirubinemia
TORCH
Biliary atresia
Metabolic disorders
Jaundice >2(3) weeks (prolonged)
Risk Factors
Risk factors of severe NNJ are:
prematurity
low birth weight
jaundice in the first 24 hours of life
mother with Blood Group O or Rhesus Negative
G6PD deficiency
rapid rise of total serum bilirubin
sepsis
lactation failure
exclusive breastfeeding
high predischarge bilirubin level
cephalhaematoma or bruises
babies of diabetic mothers
family history of severe NNJ in siblings
Approach to infant with jaundice

History
Age of onset.
Previous infants with NNJ, kernicterus, neonatal death, G6PD
deficiency.
Mothers blood group (from antenatal history).
Gestation: the incidence of hyperbilirubinaemia increases with
prematurity.
Presence of abnormal symptoms such as apnoea, difficulty in
feeding, feed intolerance and temperature instability.
Approach to infant with jaundice

Physical examination
General condition, gestation and weight, signs of sepsis, hydration

status.
Signs of kernicterus: lethargy, hypotonia, seizure, opisthotonus, high

pitch cry.
Pallor, plethora, cephalohaematoma, subaponeurotic haemorrhage.
Signs of intrauterine infection e.g. petechiae, hepatosplenomegaly.
Cephalo-caudal progression of severity of jaundice.
Pale/clay coloured stool, tea coloured urine
Opisthotonus
Pale/clay stool
Pale/clay stool
Tea coloured urine
Plethora
Cephalohematoma
Methods and assessment of Jaundice

severity
Total Serum Bilirubin (TSB) Gold Standard
Transcutaneous bilirubinometer
Icterometer
Visual Assessment (Kramers rule)
Transcutaneous bilirubinometer
Icterometer
Visual Assessment (Kramers rule)
Treatment & Management
Phototherapy
Exchange transfusion
Pharmacotherapy
PHOTOTHERAPY
PHOTOTHERAPY
mainstay of treatment in NNJ

fluorescent tubes, Light Emitting Diode (LED), fibreoptic and halogen bulbs
Effective phototherapy consists of:
blue light range (400 - 500 nm)
irradiance of minimum of 15 W/cm/nm for conventional phototherapy
irradiance of minimum of 30 W/cm/nm for intensive phototherapy
distance of the light source not exceeding 30 - 50 cm from the baby
PHOTOTHERAPY
Phototherapy should be commenced when total serum bilirubin reaches

the phototherapy threshold for neonatal jaundice.
Irradiance of phototherapy units (non-Light Emitting Diode) should be

regularly checked.
Overhead phototherapy is preferred to underneath phototherapy.
Babies should be placed in the supine position with adequate exposure.
Phototherapy should be started at a lower threshold in preterm and low

birth weight babies.
PHOTOTHERAPY
Care of babies during phototherapy
Babies should be regularly monitored for vital signs including temperature

and hydration status.
Babies should be adequately exposed.
Babies eyes should be covered to prevent retinal damage.
Breastfeeding should be continued.
Exchange Transfusion (ET)
A potentially life-saving procedure that is done to counteract the effects

of serious jaundice
The procedure involves slowly removing the patient's blood and

replacing it with fresh donor blood or plasma
Indications
Bilirubin rises to the dangerous level
Continues to rise above the recommended level in spite of intensive

phototherapy
Exchange Transfusion (ET)
TSB Levels for Phototherapy and ET
TSB Levels
for Phototherapy and ET
TSB Levels for Phototherapy and ET
Prevention of NNJ
Advice that should be given to parents/carers during antenatal and

postnatal visits include
Look for jaundice daily during the first week of life.
Check the naked baby for jaundice in bright and preferably natural light, by
blanching the skin with gentle finger pressure over the chest.
Presence of jaundice needs to be confirmed by healthcare providers; blood

tests may be required.
Jaundice in the first 48 hours of life needs urgent review by healthcare

providers.
Continue breastfeeding even if the baby is jaundiced. Contact a healthcare

provider for assistance with breastfeeding if needed.
Prevention of NNJ
Untreated jaundice may lead to deafness and brain damage.
Phototherapy is a safe and effective form of treatment for neonatal

jaundice.
Traditional and alternative methods of treating jaundice are

unproven and likely to be ineffective.
Exposing the baby to sunlight as a form of treatment may be harmful

due to dehydration and sunburn.
Prevention of NNJ
Healthcare providers should take note on the following in NNJ
management:
Antenatal education should include NNJ.
Routine postnatal visits should include the detection of NNJ.

Effectiveness of breastfeeding should be assessed during postnatal
visits. Individualised lactation support and help should be given to
breastfeeding mothers.
Prevention of NNJ
Home visits by community healthcare providers during the
postnatal period:
Home visits should be done for all newborns on day 1, 2, 3, 4, 6, 8,
10 and 20. Special attention for jaundice must be given on day 2, 3
and 4 of life.
If jaundice is detected, TSB should be measured and managed
accordingly.
Prevention of NNJ
Weight loss 7% of birth weight increases the risk of significant

hyperbilirubinaemia
The adequacy of breastfeeding, weight and hydration status of all

babies should be assessed during the first week of life.
Babies with weight loss >7% of birth weight should be referred for
further evaluation and closely monitored for jaundice
Prevention of NNJ

Neonatal Jaundice

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Neonatal Jaundice

yellow discoloration of skin due to hyperbilirubinemia

Commonest reason for admission in the neonatal unit

A sign of another disorder, e.g. infection, hemolysis, biliary atresia

may cause irreversible brain damage (Kernicterus)

Classification of Neonatal Jaundice

>24H to 2 weeks of life (Term) or 3 weeks of life (Preterm)

>2 weeks of life (Term) or 3 weeks of life (Preterm)

Physiological jaundice in babies:

is due to excessive bilirubin production (higher haemoglobin content and shorter

is not associated with underlying disease and is usually benign

o Bilirubin by product of breakdown of haemoglobin (unconjugated & conjugated)

Jaundice <24H of life

Rhesus hemolytic disease

TORCH - Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19),

Jaundice >24H to 2 (3) weeks of life

Breast feeding & Breast milk Jaundice

Cephalohematoma & Bruising

Jaundice >2(3) weeks (prolonged)

Breast milk jaundice

Jaundice >2(3) weeks (prolonged)

Risk factors of severe NNJ are:

low birth weight

jaundice in the first 24 hours of life

mother with Blood Group O or Rhesus Negative

rapid rise of total serum bilirubin

high predischarge bilirubin level

babies of diabetic mothers

family history of severe NNJ in siblings

Approach to infant with jaundice

Approach to infant with jaundice

General condition, gestation and weight, signs of sepsis, hydration

Signs of kernicterus: lethargy, hypotonia, seizure, opisthotonus, high

Pallor, plethora, cephalohaematoma, subaponeurotic haemorrhage.

Signs of intrauterine infection e.g. petechiae, hepatosplenomegaly.

Cephalo-caudal progression of severity of jaundice.

Pale/clay coloured stool, tea coloured urine

Tea coloured urine

Methods and assessment of Jaundice

Visual Assessment (Kramers rule)

Treatment & Management

mainstay of treatment in NNJ

Effective phototherapy consists of:

blue light range (400 - 500 nm)

irradiance of minimum of 15 W/cm/nm for conventional phototherapy

irradiance of minimum of 30 W/cm/nm for intensive phototherapy

distance of the light source not exceeding 30 - 50 cm from the baby

Phototherapy should be commenced when total serum bilirubin reaches

Irradiance of phototherapy units (non-Light Emitting Diode) should be

Overhead phototherapy is preferred to underneath phototherapy.

Babies should be placed in the supine position with adequate exposure.

Phototherapy should be started at a lower threshold in preterm and low

Care of babies during phototherapy

Babies should be regularly monitored for vital signs including temperature

Babies should be adequately exposed.

Babies eyes should be covered to prevent retinal damage.

Breastfeeding should be continued.

Exchange Transfusion (ET)

A potentially life-saving procedure that is done to counteract the effects