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Quality Education for a Healthier Scotland
Multidisciplinary
Neonatal Jaundice
Promoting multiprofessional education and development in Scottish maternity care
Quality Education for a Healthier Scotland
MultidisciplinaryNeonatal Jaundice
Definition = Total serum bilirubin
(SBR) > 85 µmol/L.
Quality Education for a Healthier Scotland
Multidisciplinary
Why is it important?
• Common• Worrying for parents and / or staff
• Condition and treatment• Sign of underlying disease• Can cause neurological problems.
Quality Education for a Healthier Scotland
Multidisciplinary
Where does bilirubin come from?
Quality Education for a Healthier Scotland
MultidisciplinaryCauses• Benign
• Physiological• Breast milk
and breastfeeding
• Pathologic.
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
MultidisciplinaryPhysiological JaundiceFeatures:
• Elevated unconjugated bilirubin• SBR generally peaks @ 85-100 µmol/L on
day 3-4 and then declines to adult levels by day 10• Asian infants peak at higher values (110
µmol/L )
• Exaggerated physiological (up to 290 µmol/L).
Quality Education for a Healthier Scotland
MultidisciplinaryPhysiological Jaundice
Asian Asian infantinfant
Breastfed infantBreastfed infant
Non-breastfed infantNon-breastfed infant
Quality Education for a Healthier Scotland
MultidisciplinaryPhysiological JaundiceIncreased rbc’s
Shortened rbc lifespan
Immature hepatic uptake and conjugation
Increased enterohepaticcirculation.
Quality Education for a Healthier Scotland
MultidisciplinaryBreast Milk Jaundice• Elevated unconjugated bilirubin• Prolongation of physiological
jaundice• May be second peak @ day 10
• Average max SBR = 170-205 µmol/L• SBR may reach 376-410 µmol/L
• ?Milk factor.
Quality Education for a Healthier Scotland
MultidisciplinaryPathologic Jaundice
• Features• Jaundice in first 24 hrs• Rapidly rising SBR
• > 85 µmol/L per day
• SBR > 290 µmol/L.
• Categories• Increased bilirubin
load• Decreased conjugation• Impaired bilirubin
excretion.
Quality Education for a Healthier Scotland
Multidisciplinary1.Increased Bilirubin
LoadElevated unconjugated bilirubin
•Haemolytic Disease
•Non-haemolytic Disease.
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Multidisciplinary2. Decreased Bilirubin ConjugationElevated unconjugated bilirubin
•Genetic Disorders
•Hypothyroidism.
Quality Education for a Healthier Scotland
Multidisciplinary3. Impaired Bilirubin Excretion - usually later
Elevated conjugated bilirubin
o> 35 µmol/L or > 20% of SBR
•Biliary Obstruction•Important to diagnose by 4 weeks
•Infection •Metabolic Disorders•Chromosomal Abnormalities •Drugs.
Quality Education for a Healthier Scotland
MultidisciplinaryDiagnosis and Evaluation
• Physical Examination
• Jaundice visible when bilirubin reaches 85 µmol/l• Milder jaundice generally confined to face and
upper chest• Downward extension generally signifies
increasing bilirubin values.
Quality Education for a Healthier Scotland
MultidisciplinaryDiagnosis and Evaluation
• Laboratory• Blood test• Indirect measurements
• Transcutaneous.
Quality Education for a Healthier Scotland
MultidisciplinaryRisk Factors for increased Hyperbilirubinemia
•Jaundice in first 24 hrs•Visible jaundice prior to discharge•Previous jaundiced infant•Gestation 35-38wk.
•Exclusive breastfeeding•Asian race•Bruising, cephalohaematoma•Male sex.
AAP, Subcommittee on Neonatal Hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics 2001;108.
Quality Education for a Healthier Scotland
MultidisciplinaryTreatment
• Underlying Cause• Where one is identified
• Fluids and Nutrition• Phototherapy.
Quality Education for a Healthier Scotland
MultidisciplinaryPhototherapy• Mechanism
• Forms
• Breastfed infants are slower to recover
• Rebound hyperbilirubinemia is rare
• Average increase is 17 µmol/L.
Quality Education for a Healthier Scotland
MultidisciplinaryTreatment
Quality Education for a Healthier Scotland
MultidisciplinaryTreatment• Underlying Cause
• Where one is identified
• Fluids and Nutrition• Phototherapy• Monitoring and
follow up• ? Repeat hearing checks• ? Hb checks for late
anaemia.
Quality Education for a Healthier Scotland
MultidisciplinaryExchange Transfusion• Mechanism: removes bilirubin and antibodies from circulation• Most beneficial to infants with haemolysis• Generally never used until after intensive phototherapy attempted.
Quality Education for a Healthier Scotland
Multidisciplinary
KernicterusWhat is it?
• Bilirubin induced toxicity to Basal Ganglia and brainstem nuclei.
Increase in cases beginning in early 1990s• At least partially related to early hospital discharge.
Quality Education for a Healthier Scotland
Multidisciplinary
Any questions?
Quality Education for a Healthier Scotland
MultidisciplinarySummary• Jaundice is common and “normal”
• Recognition of at risk infant
• Assessment - clinical and biochemical
• Treatment.