Neonatal Jaundice &

Prolonged Jaundice Dr Lee Phaik Ngan

Paediatrician Sibu Hospital 8 April 2017

Neonatal Jaundice

• Yellowish discoloration of the sclera and skin in a newborn

• Visible jaundice when SB>85umol/L (5mg/dl)

• Start from the

– face→ neck→chest→abdomen→limbs

• Common condition

– cause morbidity and mortality

Bilirubin Metabolism

Newborn more prone to jaundice?

• High hemoglobin mass at birth

• Shorter fetal hemoglobin life span

• Low enzyme Glucuronyltransferase activity (reach adult level by 14 days regardless of gestation)

• Low concentration of ligandin Y protein (carries unconjugated bilirubin to the smooth endoplasmic reticulum) – increase to adult level by 5-10 days of age

Conditions causes severe neonatal jaundice

• Haemolysis

– ABO or Rh-isoimmunisation, G6PD deficiency

• Cephalhaemotama, subaponeurotic haemorrhage

• Polycythemia

• Sepsis

– Septicaemia, meningitis, Urinary tract infection

• Gastrointestinal tract obstruction

Danger of acute severe neonatal jaundice

• Risk of bilirubin neurotoxicity (Kernicterus) – Unconjugated bilirubin cross blood brain barrier

toxic to deep grey matter (esp globus pallidus) athetoid cerebral palsy &SNHL

• Higher risk of Kernicterus – sepsis, prematurity, small for gestational age,

acidosis, asphyxia, hypoalbuminemia and jaundice < 24 hrs of life

• The risk decreases as the baby

grows older

Assessment

History

• Age of onset

• Previous infant with NNJ, kernicterus, neonatal death, G6PD deficiency

• Mother’s blood group

• Gestational

• Presence of symptoms suggestive of sepsis

Physical examination

• General condition, weight, hydration status, sign of sepsis

• Sign of kernicterus: lethargy, hypotonia, seizure, opisthotonus, high pitch cry

• Pallor, plethora, SAH, cephalhaematoma

• Sign of intra-uterine infection: petechiea, hepatospelnomegaly

• Severity of jaundice

Assessment 2

Baby looks more jaundice than the SB level?

• Watch out for sepsis

• Repeat SB if needed

• Sometimes occurs in anaemic or fair baby

Baby looks less jaundice than the SB?

• Polycythaemic baby

• Dark baby

• If the baby is under photo, look at the area which is not exposed to the light

Management

Investigations

• Total serum bilirubin

• G6PD status

• If hemolysis is suspected, in severe/ within 24 hours – Blood group, Direct Coomb’s test

– FBC, reticulocyte count, PBF

• If infection is suspected – Blood culture, urine culture

Refer to hospital if …

• Jaundice level requires phototherapy

• Any unwell infant with jaundice

• G6PD deficient – observe for 5 days

Management2

• Depends on the SB level and the underlying condition

• Antibiotic coverage for unwell baby

• Phototherapy (single/double)

• Hydration if baby is dehydrated

• Exchange transfusion (ET)

• Human albumin

• AntiD immunoglobulin or pooled immunoglobulin

Guideline for phototherapy and ET

Phototherapy

• Phototherapy lights with minimum irradiance of 15µW/cm2/nm

• Intensive photo >30µW/cm2/nm • Photo light source 35-50cm above the top surface

of the baby • Proper exposure • Cover the eyes • Turn baby 2 hourly • Monitor temperature and hydration • Off photo light when taking blood

Breastfeeding Jaundice

• Failure to successfully initiate breastfeeding

• occurs within the first week of life

• Lactation failure inadequate intake – Significant weight and fluid loss hypovolemia

hyperbilirubinemia & hypernatremia

– Slower bilirubin elimination & increased enterohepatic circulation

• Maternal breastfeeding issues (engorgement, cracked nipples, and fatigue)

• Neonatal factors (ineffective suck)

• Not be properly addressed prior to hospital discharge

Safe to discharge?

• SB is below photo level – The trend of the SB is important

• Can discharge the baby – if the baby is more than 7 days old even though

the SB level is still at the photo level but is not rising

• Remember, the role of the phototherapy is to prevent the SB level reaches the ET level

• All babies discharge from the ward need to be followed up at the polyclinic (1-3 days later)

Prolonged jaundice

• Prolonged jaundice

– Visible jaundice that persisted beyond 14 days of life in a term baby

• 21 days in a preterm baby

• Conjugated or Unconjugated Hyperbilirubinemia?

– Conjugated hyperbilirubinemia if conjugated bilirubin ≥ 25 µgmol/L or >15% of total bilirubin

Prolonged Jaundice 2

Unconjugated hyperbilirubinemia

• Breast milk jaundice

• Hemolytic anaemia

• Increased enterohepatic circulation

• Decreased conjugation eg UTI/hypothyroidism/Gilbert syndrome

Conjugated hyperbilirubinemia

• Cholestasis or impaired bile flow

• Always pathological

• Time sensitive

Extrahepatic Biliary atresia Choledochol cyst

Intrahepatic Infections Drugs/toxins Endocrine Genetic Idiopathic hepatitis

Unconjugated hyperbilirubinemia

• FBC/PBF

• Coomb’s test

• Urine Culture

• FT4/TSH if not done

• If all investigations normal, babies can be follow up in the polyclinic or district hospital with repeat LFT 4-8 weekly

Conjugated hyperbilirubinemia • γGT • Serum bile acids level • TORCHES • Hep B/VDRL • FT4/TSH • Urine culture • IEM if relevant (including

Galactosemia, urine for organic acid, serum for amino acid)

• U/S HBS

• Refer paediatrician for all conjugated hyperbilirubinemia

Conjugated hyperbilirubinemia –Extrahepatic cholestasis

• Biliary atresia

– Need early diagnosis

– Prognosis is better if surgery (Kasai operation) done within 60 days of age

– Diagnosis

• Ultrasound

• HIDA

• OTC/liver biopsy

Infant stool color card screening system

• Taiwan, adopted this chart, conducted a study 2002-2003

• Sensitivity 89.7% • Specificity 99.9% • The timely Kasai

operation (<60 days) improved significantly: – 47.2% (1976-2000), – 58.6% (2002-2003), – 60% (2004) – 74.3% (2005)

Ni Yen Hsuan, Department of Pediatrics College of Medicine and Children’s Hospital, National Taiwan University , Taipei, Taiwan

Breast milk jaundice

• Babies are well and thriving

– Seen in up to 1/3 of breastfed babies

– More severe in the presence of G6PD deficiency

– Can persist up to 4 months of age

How to follow up prolonged jaundice?

• Treat any treatable conditions

– Biliary atresia

– Hypothyroidism

– UTI

– Syphilis

– IEM

How to follow up prolonged jaundice?

• Follow up the baby 4-8 weekly with LFT

• Watch out for worsening LFT/liver cirrhosis/liver failure

• Once investigations for prolonged jaundice done and the SB is not increasing trend, no need to check regular SB