3. Introduction:
~60% of term and 80% of preterm babies
develop jaundice in the first wk of life.
10% of BF babies are still jaundiced at
1 month.
For most babies, jaundice is not an indication
of an underlying disease (termed 'physiological
jaundice') is generally harmless.
Prolonged jaundice –persisting beyond the
first 14 days in term babies and beyond 21
days in PT babies.
5. How to suspect:
Babies are more likely to develop significant
hyperbilirubinaemia if they have:
gestational age under 38 weeks.
a previous sibling with NJ requiring
phototherapy.
mother's intention to breastfeed exclusively
Visible jaundice in the first 24 hours.
6. How to measure: Kramer’s
Index
When looking for
jaundice (visual
inspection):
1-check the naked
baby in bright &
preferably natural light
2-examine the sclerae,
gums and blanched
skin is useful across all
skin tones.
1- Face 5 mg /dl
2-Upper trunk 10
3-Lower trunk & thighs 12
4-Arms &lower legs 15
5-Palms and soles
>15
7. How to measure: TC
Bilirubinometer
Use a TC bilirubinometer in
babies with GA of 35 weeks or
more and PN age of >24 hours
If a TC bilirubinometer is not
available, measure the serum
TB.
If a TC bilirubinometer
measurement > 250μmol/l (15
mg/dl) … check the result by
measuring the serum TB
8. How to diagnose: Causes
1. Appearing within 24 hours of age
-Hemolytic disease of newborn: Rh, ABO and minor group
incompatibility
-Infections: intrauterine viral, bacterial; malaria
-G-6PD deficiency
2. Appearing between 24-72 hours of life
-Physiological
-Sepsis neonatorum
-Polycythemia
-Concealed hemorrhages: cephalhematoma, subarachnoid bleed,
IVH.
-Increased enterohepatic circulation
3. Appearing after 72 hours
-Sepsis neonatorum
-Neonatal hepatitis
-Extra hepatic biliary atresia
10. Physiological Jaundice:
Immaturity in bilirubin metabolism at multiple
steps...
Characteristics:
· First appears between 24-72 hours of age
· Maximum intensity seen on 4-5th day in term and
7th day in preterm neonates
· Does not exceed 15 mg/ dl
· Clinically undetectable after 14 days.
· No treatment is required but baby should be
observed closely for signs of worsening jaundice.
11. Pathological Jaundice:
1-Clinical jaundice detected before 24 hours of age.
2-Rise in serum bilirubin by > 5 mg/dl/day.
3-Serum bilirubin >15 mg/dl.
4-Clinical jaundice persisting beyond 14 days of life.
5-Clay/white colored stool and/or dark urine staining
the clothes yellow.
6-Direct bilirubin >2 mg/ dl at any time.
*One should investigate to find the cause.
*Treatment is required in the form of phototherapy or
EPT.
12. How To Approach:
Check birth wt, GA ,PN age.
FH/o Jaundice or anemia or neonatal death..
Maternal and perinatal history…
Ask when jaundice was first noticed ?
Assess clinical condition…
Physiological or Pathological…
Look for clinical picture of kernicterus in
Newborns..
14. Refer for further investigation if:
Clinically unwell… poor feeding and lethargy …
Jaundice within 24 hours of life.
Jaundice below umbilicus, corresponding to serum bilirubin of
12-15 mg/dl (200-250 μmol/l ).
Jaundice up to level of the sole of the feet - likely to need
exchange transfusion.
Rapid rise of serum bilirubin of more than 8.5 μmol/l /hour
(>0.5 mg/dl/hour).
Prolonged jaundice of >14 days - other causes/conditions
need to be excluded e.g. neonatal hepatitis, biliary atresia.
Family history of significant haemolytic disease or kernicterus
Clinical symptoms/signs suggestive of other diseases e.g.
sepsis.
Direct bilirubin >20 %
15. Reduce level of bilirubin and prevent its toxicity by:
1-Early feeds and adequate hydration.
2-Reduction of Bilirubin by (Threshold table):
1-Phototherapy 2-IVIG 3-EBT.
How to manage in
general :
16. What to tell parents:
Offer parents or carers information about NJ that is tailored to their needs
and expressed concerns. Care should be taken to avoid causing
unnecessary anxiety to parents or carers. Information should include:
1-Factors that influence the development of significant hyperbilirubinaemia
2-How to check the baby for jaundice
3-What to do if they suspect jaundice
4-The importance of recognising jaundice in the first 24 hours and of seeking
urgent medical advice
5-The importance of checking the baby's nappies for dark urine or pale chalky
stools
6-The fact that NJ is common, &reassurance that it is usually transient and
harmless
7-Reassurance that breastfeeding can usually continue.
8-Provide lactation/feeding support to breastfeeding mothers whose baby is
visibly jaundiced.
17. To vaccinate or not:
Physiological Jaundice IS NOT a
contraindication.
Notas do Editor
In clinical practice, differentiating between physiologic jaundice from breast milk jaundice is important so that the duration of hyperbilirubinemia can be predicted. Identifying the infants who become dehydrated secondary to inadequate breastfeeding is also important. These babies need to be identified early and given breastfeeding support and formula supplementation as necessary. Depending on serum bilirubin concentration, Medical CareTreatment recommendations in this section apply only to healthy term infants with no signs of pathologic jaundice and are based on the severity of hyperbilirubinemia. In preterm, anemic, or ill infants and those with early (< 24 h) or severe jaundice (>25 mg/dL or 430 µmol/L), different treatment protocols should be pursued (see Jaundice, Neonatal).For healthy term infants with breast milk or breastfeeding jaundice and with bilirubin levels of 12 mg/dL (170 µmol/L) to 17 mg/dL, the following options are acceptable:Increase breastfeeding to 8-12 times per day and recheck the serum bilirubin level in 12-24 hours. The mother should be reassured about the relatively benign nature of breast milk jaundice (BMJ). This recommendation assumes that effective breastfeeding is occurring, including milk production, effective latching, and effective sucking with resultant letdown of milk. Breastfeeding can also be supported with manual or electric pumps and the pumped milk given as a supplement to the baby.Continue breastfeeding and supplement with formula.Temporary interruption of breastfeeding is rarely needed and is not recommended unless serum bilirubin levels reach 20 mg/dL (340 µmol/L). For infants with serum bilirubin levels from 17-25 mg/dL (294-430 µmol/L), add phototherapy to any of the previously stated treatment options. The reader is referred to the American Academy of Pediatrics' practice parameter on the management of hyperbilirubinemia in healthy full-term newborn infants.[10]The most rapid way to reduce the bilirubin level is to interrupt breastfeeding for 24 hours, feed with formula, and use phototherapy; however, in most infants, interrupting breastfeeding is not necessary or advisable.Phototherapy can be administered with standard phototherapy units and fiberoptic blankets. See the image below.
GP notebook :Inactivated or killed vaccines are generally safe and the only absolute contraindication is a severe local or general reaction to a previous dose.Live vaccines are contraindicated in pregnancy and in those who are on systemic steroid therapy or immunosuppressed for any reason. Vaccination may however be performed if the risks of infection exceed the risks of vaccination.Live vaccines should either be given simultaneously (if possible at different sites) or after a 3 week gap. (Except when BCG is given to infants when oral polio need not be delayed).12 weeks should elapse after a dose of human immunoglobulin before a live vaccine is administeredavoid during acute febrile illnessesBCG should not be given to eczema patients though otherwise eczema, hayfever, asthma and topical steroids are not contraindications to immunization.Premature infants, and those suffering from heart and lung diseases should be immunised according to the usual schedules. Premature infants should be immunized at the times recommended for full term babies, without correction for gestational ageThe following are not contraindications to vaccination, but folklore has had it in the past that they were:previous history of infectionstable neurological conditionantibiotic therapyallergic history, such as allergy to egg proteinsbreast feedingsibling of immune suppressed patient, except for live polio vaccine where a killed vaccine should be usedweightneonatal jaundice