NEONATAL JAUNDICE

DR NADEEM ALAM ZUBAIRI

MBBS, MCPS, FCPS

Consultant Neonatologist / Paediatrician

 Scenario 1

• A baby boy is born 3.5 kg to a mother as a result

of SVD. He did not need any resuscitation at
birth and went home within 24 hrs. Mother
noticed him to be jaundiced on D3 of life and
brought him to you.
 Scenario 1 Continued

• A house officer takes history and asks following questions.

– When did the mother first notice jaundice?

• After first 24 hrs

– Is this mother’s first pregnancy / H/O abortions?

• She is a primigravida

– Is the baby breast fed?

• Exclusively and feeding well

– What is the color of the stool?

• Yellow
 Scenario 1 Continued

• House officer makes a provisional diagnosis of:

Physiological Jaundice

– Serum total bilirubin

– Mother and baby’s blood group

– FBC, retics and peripheral film

 Scenario 1 Continued

• Serum bilirubin 180 umol/l on day 3 of life( 10 mg/dl)

• FBC Hb 18.3 g/dl, retics 2%

• TLC 18 x 103
• Baby’s blood group A+
• Mother A+
• Coomb’s test Negative

• (
Scenario 1 Continued
 Scenario 1 Continued

Physiological Jaundice

Why ?
 EXCLUSION CRITERIA

 Unconjugated bilirubin > 12.9 mg/dl

 Bilirubin level increasing > 5 mg/dl/day
 Jaundice in first 24 hours of life
 Conjugated bilirubin level > 2 mg/dl
 Clinical jaundice persisting > 2 week
 Neonatal Jaundice

• Hyperbilirubinemia in infants ≥35 weeks gestation is

defined as a TSB >95th percentile for hours-of-age on
the Bhutani nomogram

PHYSIOLOGIC & PATHOLOGIC

JAUNDICE
Bilirubin Metabolism
Mechanism of Neonatal Jaundice

• Increased production of bilirubin

• Decreased uptake

• Decreased conjugation

• Increased enterohepatic circulation

 Why do newborns develop
physiological jaundice?

• Decreased RBC life span

• Decreased Y protein and Ligandin in liver

• Decreased activity of UDP glucronyl

transferase

• Increased enterohepatic circulation

 Physiological Jaundice

• Appear after 24 hours

• Maximum intensity by 4th-5th day in term & 7th day in

preterm

• Clinically not detectable after 14 days

• Disappears without any treatment

 Scenario 2

• A baby boy is born to a multigravida mother

at term gestation following an uneventful
pregnancy.

He develops jaundice at 16 hours of age.

 Scenario 2 Continued

• A house officer takes history and asks following questions.

– When did the mother first notice jaundice?

• Within 1st 24 hrs

– Is this mother’s first pregnancy / H/O abortions?

• She is a multigravida

– Is the baby breast fed?

• Started breastfeeding

– What is the color of the stool?

• Yellow
 Scenario 2 Continued

• House officer makes a provisional diagnosis of:

Pathological Jaundice

– Serum total bilirubin

– Mother and baby’s blood group

– FBC, retics and peripheral film

 Scenario 2 Continued

• Serum bilirubin 280umol/l i.e.15.5mg/dl (at 16 hrs of age)

• FBC Hb 12.3 g/dl

• TLC 18 x 103, retics 10%
• Baby’s blood group O + ve
• Mother O - ve
• Coomb’s test positive

•
Scenario 2 Continued
 Scenario 2
Pathological Jaundice Secondary to
Rh Incompatability
 Pathological Jaundice

• Appears within 24 hours of age

• Serum bilirubin > threshold line

 Scenario 3

A baby boy is born to a primigravida mother. He

develops jaundice at 18 hrs of age.

He is brought to you for evaluation and

management.
 Scenario 3 Continued

• A house officer takes history and asks following questions.

– When did the mother first notice jaundice?

• Within 1st 24 hrs

– Is this mother’s first pregnancy / H/O abortions?

• She is a primigravida

– Is the baby breast fed?

• Feeding poorly

– What is the color of the stool?

• Yellow
 Scenario 3 Continued

• House officer makes a provisional diagnosis of:

Pathological Jaundice

– Serum total bilirubin

– Mother and baby’s blood group

– FBC, retics and peripheral film

 Scenario 3 Continued

• Serum bilirubin 230 umol/l (at 20 hrs of age)

• FBC Hb 12.3 g/dl

• TLC 18 x 103, retics 10%
• Baby’s blood group O + ve
• Mother O + ve
• Coomb’s test negative
• Peripheral film spherocytes

•
Scenario 3 Continued
 Scenario 3

Pathological Jaundice
Secondary to
Hemolysis due to
Hereditary spherocytosis
 Scenario 4

A baby boy is born to a primigravida mother. He

had a prolonged labor and was delivered
secondary to ventouse application. After delivery
he did not require any resuscitation but had a
massive cephalhematoma on the head.
He develops jaundice at 3 days of life.
He is brought to you for evaluation and
management.
 Scenario 4 Continued

• A house officer takes history and asks following questions.

– When did the mother first notice jaundice?

• After 1st 24 hrs

– Is this mother’s first pregnancy / H/O abortions?

• She is a primigravida

– Is the baby breast fed?

• Feeding adequately

– What is the color of the stool?

• Yellow
 Scenario 4 Continued

• House officer makes a provisional diagnosis of:

Physiological Jaundice

– Serum total bilirubin

– Mother and baby’s blood group

– FBC, retics and peripheral film

 Scenario 4 Continued

• Serum bilirubin 350 umol/l (at 72 hrs of age)

• FBC Hb 12.3 g/dl

• TLC 18 x 103, retics 3%
• Baby’s blood group O + ve
• Mother O + ve
• Coomb’s test negative
• Peripheral film Normal

•
Scenario 4 Continued
 Scenario 4

Pathological Jaundice
Secondary to
Cephalhematoma
 OTHER CAUSES OF UNCONJUGATED
HYPERBILIRUBINEMIA

 BREAST MILK JAUNDICE

 DEFECTS OF CONJUGATION
#Crigler Najjar Syndrome I & II
#Gilbert Syndrome
 METABOLIC DISORDERS
#Glactosemia
#Hypothyroidism
 POLYCYTHEMIA
 Kramer’s rule
Clinically jaundiced when the bilirubin level reaches 80-120 μmol/L
 Why bother?

 Deposition of unconjugated bilirubin in brain

leads to BIND (bilirubin induced neurologic
dysfunction)

 Prevention of Acute bilirubin encephalopathy

and Kernicterus
 Treatment
• Goals
– Prevention of kernicterus
– Maintenance of hydration and nutrition

• Interventions
– Intensive Phototherapy
– Exchange transfusion
 Phototherapy
• Mechanism of action

– Skin exposure to lights causing geometric

photoisomerization allowing excretion

• Technique
– Light source
• Lamps, spotlights, fiber optic blankets,
• Blue light
• Wave length: 420-500nm

– Positioned 50 cm above infant

– Largest surface area possible exposed

Complications of Phototherapy
• Dehydration
– Increased insensible water loss
– loose stools

• Irritability or lethargy

• Skin rashes

• Overheating

• Retinal injury
Exchange Transfusion
 Bilirubin Encephalopathy
• Deposition of unconjugated bilirubin in the basal
ganglia and brainstem nuclei causing neurotoxic
effects

• Acute manifestations are lethargy & poor feeding

• Severe cases, irritability, increased muscle tone

opisthotonos, seizures and coma

• Survivors may develop choreoathetoid cerebral

palsy (due to damage to the basal ganglia), learning
difficulties and sensorineural deafness
 Summary
• Neonatal jaundice is a fairly common
condition
• Keep a vigilant eye
• Try to differentiate physiological from
pathological jaundice
• Early and effective phototherapy
• Prevent BIND