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NEONATAL JAUNDICE

By, Sharan Singh Sekhon

INTRODUCTION
Jaundice is evident clinically when serum bilirubin is > 85 mol/l (5mg/dl).

CAUSES OF NEONATAL JAUNDICE


Haemolysis (ABO or Rh-isoimmunisation, G6PD deficiency, microspherocytosis, drugs). Physiological jaundice. Cephalhaematoma, subaponeurotic haemorrhage. Polycythaemia. Sepsis septicaemia, meningitis,urinary tract infection, intra-uterine infection. Breastfeeding and breastmilk jaundice. Gastrointestinal tract obstruction (increase in enterohepatic circulation).

APPROACH TO AN INFANT WITH JAUNDICE


History -Age of onset. -Previous infants with NNJ, kernicterus, neonatal death, G6PD deficiency. -Mothers blood group. -Gestation age (the incidence of hyperbilirubinaemia increases with prematurity). -Presence of abnormal symptoms (apnoea, difficulty in feeding, feeding intolerance and temperature instability). Physical examination -General condition, gestation and weight, signs of sepsis, hydration status. -Signs of kernicterus (lethargy, hypotonia, seizure, opisthotonus, high pitch cry). -Pallor, plethora, cephalhaematoma, subaponeurotic haemorrhage. -Signs of intrauterine infection -Cephalo-caudal progression of severity of jaundice

MANAGEMENT
Indications for referral to hospital: -Jaundice < 24 hours of life. -Jaundice below umbilicus (corresponds to serum bilirubin 200250 mol/L). -Jaundice extending to soles of feet (Urgent referral, may need exchange transfusion ) -Family history of significant haemolytic disease or kernicterus. -Any unwell infant with jaundice. Prolonged Jaundice of >14 days - Refer infants with conjugated hyperbilirubinaemia urgently to a hospital. - Infants with unconjugated hyperbilirubinaemia can be investigated and referred only if the jaundice does not resolve or a definitive cause found.

INVESTIGATIONS
Total serum bilirubin G6PD status Others as indicated: -Infants blood group, maternal blood group, Direct Coombs test (indicated in Day 1 jaundice and severe jaundice). -Full blood count, reticulocyte count, peripheral blood film -Blood culture, urine microscopy and culture (if infection is suspected)

TREATMENT
Phototherapy -Phototherapy lights should have a minimum irradiance of 15 W/cm/nm. Intensive phototherapy implies irradiance in the bluegreen spectrum of at least 30 W/cm/nm. -Position light source 35-50 cm from the infant (when conventional fluorescent photolights are used). -Expose infant adequately (cover infants eyes). -Monitor serum bilirubin levels as indicated. -Monitor infants temperature 4 hourly to avoid chilling or overheating.

-Ensure adequate hydration and good urine output. Monitor for weight loss. -Adjust fluid intake (preferably oral feeds) accordingly. -Allow parental-infant interaction. -Discontinue phototherapy when serum bilirubin is below phototherapy level. -Turn off photolights and remove eyepads during feeding and blood taking. -Once the baby is on phototherapy, visual observation as a means of monitoring is unreliable. Serum bilirubin levels must guide the management. -In infants without haemolytic disease, the average increase of bilirubin level in rebound jaundice after phototherapy is < 1 mg/dl (17 mol/L). Hospital discharge need not be delayed to observe for rebound jaundice, and in most cases, no further measurement of bilirubin is necessary.

ADDITIONAL NOTES
-Failure of phototherapy has been defined as an inability to observe a decline in bilirubin of 1-2 mg/dl (17-34 mol/L) after 4-6 hours and/or to keep the bilirubin below the exchange transfusion level. -Do an immediate exchange transfusion if infant shows signs of acute bilirubin encephalopathy(hypertonia,opisthotonus, fever, high pitch cry) or if TSB is 5 mg/dL (85 umol/L) above exchange levels stated above. -During birth hospitalisation, ET is recommended if the TSB rises to these levels despite intensive phototherapy. -Infants who are of lower gestation will require phototherapy and ET at lower levels.

Intravenous Immunoglobulins (IVIG) -High dose IVIG (0.5 1 gm/kg over 2 hours) reduces the need for exchange transfusions in Rh and ABO hemolytic disease. -Give as early as possible in hemolytic disease with positive Coombs test or where the serum total bilirubin is increasing despite intensive phototherapy. -Dose can be repeated in 12 hours if necessary. If exchange transfusion is already indicated, IVIG should be given after ET

Measures to prevent severe neonatal jaundice -Inadequate breast milk flow in the first week may aggravate jaundice, (promote successful breastfeeding; at least 8-10 times/24 hours). -Supplementary feeds may be given to ensure adequate hydration, especially if there is more than 10% weight loss from birth weight. -G6PD status should be known before discharge. Observe infants with G6PD deficiency, for 5 days if not jaundiced and longer with moderate jaundice. -Infants of mothers with blood group O and with a sibling who had severe neonatal jaundice should be observed for at least the first 24 hours of life. -If phototherapy in infants with hemolytic diseases is initiated early and discontinued before the infant is 3 4 days old, monitor for rebound jaundice and adequacy of breast feeding within the next 24-48 hours

FOLLOW-UP
-All infants discharged < 48 hours after birth should be seen by a healthcare professional within 2-3 days of discharge. -For infants with risk factors for severe neonatal jaundice, early follow up to be arranged to detect rebound jaundice after discharge. -Infants with serum bilirubin > 20 mg/dl (340 mol/L) and those who require exchange transfusion should be followed for neurodevelopmental outcome. -Do a Hearing assessment at 0-3 months of corrected age. -Infants with hemolytic diseases not requiring ET should be closely followed up for anaemia until the risk of ongoing hemolysis is minimal.

TERIMA KASIH

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