1. Neonatal Jaundice
Dr. Abhijeet Deshmukh
DNB Pediatrics
PIMS & RC, Tiruvalla

2. Neonatal Jaundice
• Learning Objectives:
• Define hyperbilirubinemia.
• Differentiate between physiological and
pathological jaundice.
• Causes of hyperbilirubinemia.
• Discuss the pathophysiology of hyperbilirubinemia.
• Describe the most dangerous complication of
hyperbilirubinemia.
• therapeutic management.
• Design plan of care for baby has hyperbilirubinemia.

3. Neonatal Jaundice
(Hyperbilirubinemia)
• Definition: Hyperbilirubinemia refers to an
excessive level of accumulated bilirubin in the blood
and is characterized by jaundice, a yellowish
discoloration of the skin, sclerae, mucous
membranes and nails.
• Unconjugated bilirubin = Indirect bilirubin.
• Conjugated bilirubin = Direct bilirubin.

4. NJ - 4

5. Neonatal Jaundice
• Visible form of bilirubinemia
–Newborn skin >5 mg / dl
• Occurs in 60% of term and 80% of preterm
neonates
• However, significant jaundice occurs in 6 %
of term babies
• 6-10% require phototherapy/ other
therapeutic options.

6. Bilirubin metabolism
Hb → globin + haem
1g Hb = 34mg bilirubin
Non – heme source
1 mg / kg
Bilirubin
glucuronidase
Bilirubin
Bilirubin
Ligandin
(Y - acceptor)
Bil glucuronide
Intestine
Bil
glucuronide
Stercobilin
bacteria
β glucuronidase

7. NJ - 7
Bilirubin Production & Metabolism

8. Clinical assessment of jaundice
(Kramer’s staging)
Area of body Bilirubin levels
mg/dl (*17=umol)
Face Zone-1: 4-6
Upper trunk Zone-2: 6-8
Lower trunk & thighs 8-16
Arms and lower legs Zone-3: 8-12
Palms & soles Zone-4 :12-14
Zone-5 :>15

9. Physiological jaundice
Characteristics
• Appears after 24-72 hours
• Maximum intensity by 3th-5th day in term &
7th day in preterm
• Serum level less than 15 mg / dl
• Clinically not detectable after 14 days
• Disappears without any treatment
Note: Baby should, however, be watched for worsening
jaundice.

10. Why does physiological jaundice
develop?
• Increased bilirubin load.
• Defective uptake from plasma.
• Defective conjugation.
• Decreased excretion.
• Increased entero-hepatic circulation.

11. Pathological jaundice
• Appears within 24 hours of age
• Increase of bilirubin > 5 mg / dl / day
• Serum bilirubin > 15 mg / dl
• Jaundice persisting after 14 days
• Stool clay / white colored and urine staining
clothes yellow
• Direct bilirubin> 2 mg / dl

12. Causes of jaundice
Appearing within 24 hours of age
• Hemolytic disease of NB : Rh, ABO
• Infections: TORCH, malaria, bacterial
• G6PD deficiency

13. Causes of jaundice
Appearing between 24-72 hours of life
• Physiological
• Sepsis
• Polycythemia
• Intraventricular hemorrhage
• Increased entero-hepatic circulation

14. Causes of jaundice
After 72 hours of age
• Sepsis
• Cephalhaematoma
• Neonatal hepatitis
• Extra-hepatic biliary atresia
• Breast milk jaundice
• Metabolic disorders (G6PD).

15. Breast feeding jaundice
• In exclusively breast feed infants
• Appears at 24-48 hrs of age
• Peaks by 5-15 days
• Disappears by 3rd week
• Its related to inadequate B.F
• T/t:Proper & adequate B.F

16. Breast milk jaundice
• In 2-4 % EBF babies
• SBr>10mg/dl beyond 3rd-4th week
• Should be differentiated from Hemolytic
jaundice, hypothyroidism, G6PD def
• T/t: Some babies may require PT
Continue breast feeding
Usually declines over a period of time

17. Risk factors for jaundice
JAUNDICE
• J - jaundice within first 24 hrs of life
• A - a sibling who was jaundiced as neonate
• U - unrecognized hemolysis
• N – non-optimal sucking/nursing
• D - deficiency of G6PD
• I - infection
• C – cephalhematoma /bruising
• E - East Asian/North Indian

18. Diagnostic evaluation:
• Normal values of unconjugated B. are 0.2 to
1.4 mg/dL.
• Investigate the cause of jaundice.

19. Therapeutic Management
• Purposes: reduce level of serum bilirubin and
prevent bilirubin toxicity
• Prevention of hyperbilirubinemia: early feeds,
adequate hydration
• Reduction of bilirubin levels: phototherapy,
exchange transfusion,
• Drugs Use of Phenobarbital promote liver
enzymes and protein synthesis.

20. Babies under phototherapy
Baby under conventional
phototherapy
Baby under triple unit intense
phototherapy

21. Prognosis
• Early recognition and treatment of
hyperbilirubinemia prevents severe brain
damage.

22. Nursing considerations of Hyperbilirubinemia
• Assessment:
 observing for evidence of
jaundice at regular intervals.
 Jaundice is common in
the first week of life and
may be missed in dark skinned
babies
Blanching the tip
of the nose

23. Approach to jaundiced baby
• Ascertain birth weight, gestation and postnatal age
• Ask when jaundice was first noticed
• Assess clinical condition (well or ill)
• Decide whether jaundice is physiological or
pathological
• Look for evidence of kernicterus* in deeply
jaundiced NB
*Lethargy and poor feeding, poor or absent Moro's, or
convulsions

24. The goals of planning
• Infant will receive appropriate therapy if
needed to reduce serum bilirubin levels.
o Infant will experience no complications from
therapy.
o Family will receive emotional support.

25. Thank You!