physiological jaundice

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Physiological Jaundice

Presented By:Nirsuba gurung

General objective

• At the end of this teaching learning session students will be able to know in detail about physiological jaundice

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Specific objective

At the end of the class students will be able to • define jaundice and physiological jaundice;• explain the physiology of physiological

jaundice;• enlist the causes of physiological jaundice;• enlist the risk factor associated with

physiological jaundice;

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Contd……….

• verbalise the sign and symptom of physiological jaundice;

• describe the assessment and diagnosis of physiological jaundice;

• describe the management and care of a baby with physiological jaundice.

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Jaundice:

• A yellow discolouration of the skin, sclera and mucous membrane due to an increase in the serum bilirubin level. This becomes clinically evident when serum bilirubin reaches about 5-7 mg/dl

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• The yellow discoloration of the skin is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities.

Physiological jaundice

• Jaundice occurring in most newborns, this mild jaundice is due to the immaturity of the baby's liver, which leads to a slow processing of bilirubin.

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Physiological jaundice:

• Most neonates develops visible jaundice due to elevation of unconjugated bilirubin concentration during 1st week . This common condition is called physiological jaundice.

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Physiological Jaundice

• 50-60% Term Babies• Occurs at day 3• Peaks at day 5• Lasts until approximately

day 8• Bilirubin levels should not

exceed 200μmol/l• 10% require phototherapy.

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Contd…….

The pattern of hyperbilirubinemia in physiological jaundice has been classified into two functionally distinct periods;

• Phase 1:– last for 5 days in term infants and – about 7 days in preterm infants when there is

rapid rise in serum levels to 12 to 15 mg/dl,respectively.

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Phase two -

• In phase two bilirubin levels decline to about 34 μmol/l (2 mg/dL) for two weeks, eventually mimicking adult values.

– Preterm infants - phase two can last more than one month.

– Exclusively breastfed infants - phase two can last more than one month.

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Physiology of jaundice• Blood heme+globulin

biliverdin +CO

bilirubin reductase

bilirubin 05/02/2023 05:19 AM 14Nirsuba gurung

Pathway of Bilirubin • After the liver, the bilirubin enters the gall bladder and is

excreted in bile into the intestine.

• In the gut under the action of bacteria bilirubin is reduced to urobilinogen, a small proportion is excreted in urine with the majority excreted in faeces as stercobilinogen.

• An enzyme β glucuronidase is also present in the gut and converts conjugated bilirubin back to unconjugated bilirubin. There is 10times the amount of β glucuronidasae in the neonate compared with the adult.

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Facts:

• 1gm Hb=35 mg of bilirubin

• Normal newborn=8.5+-2.3 mg/kg/day

• In adult:3.6 mg/kg/day

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Causes of Physiological Jaundice• Short life span of fetal red blood cells• Change from fetal cells to adult cells• Insufficient albumin to bind to the excess

unconjugated bilirubin, leads to free unconjugated fat soluble bilirubin.

• Sterile gut• Poor peristalsis allows the β glucuronidase to

hydrolyse the conjugated bilirubin back to un-conjugated bilirubin which then goes back to the liver for further metabolism.

• Immature liver that reduces the hepatic metabolism

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Causes condt…

• Higher levels of red blood cells, which is more common in small-for-gestational age (SGA) babies and some twins

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Other Risk Factors For Jaundice

• Breast feeding• Asian /Greek• Delay in clamping the cord, increasing the volume of

blood• Bruising – caput, cephalhaematoma• Prematurity• Low birth weight• Drug • Hypoglycemia & hypothermia

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Signs and Symptoms of Jaundice

• Discoloration of the skin, sclera

• Lethargy• Poor feeding• Yellow urine and stool• Irritability

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Complications of Jaundice

High levels of bilirubin — usually above 25 mg — can cause deafness, cerebral palsy, or other forms of brain damage in some babies.

Risk that the fat soluble bilirubin crosses to the brain to cause Bilirubin Encephalopathy known as Kernicterus.

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Assessment of Physiological Jaundice

• Clinical observation. Jaundice visible at 5-7 mg/dl.

• Jaundice is caudal in direction, i.e. from head down the body.

• Kramer’s rule

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Kramer's Rule

Zone 1 2 3 4 5

SBR (umol/L) 100 150 200 250 >250

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Kramer’s rule

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Investigation

• Clinical history of mother/family.• History of bruising / cephalohematoma / birth

trauma.• Blood grouping and rhesus factor.• Feeding pattern.• Infection.• Drugs.

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Management

• No action for the vast majority of babies with physiological jaundice

• Measure the Serum Bilirubin• The level of serum bilirubin actually indicates

what treatment is required:– To continue to observe but no additional

intervention– Repeat test– Phototherapy– Exchange blood transfusion (unlikely for

physiological jaundice)

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Medical Management

Phenobarbital

Increases liver metabolism and thus lowering bilirubin levels.

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Phototherapy

• First discovered, accidentally, at Rochford Hospital in Essex, England

• Ward sister of the premature baby unit firmly believed that the infants under her care benefited from fresh air and sunlight in the courtyard

• When serum bilirubin was checked indicated a much lower level of bilirubin tha earlier

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• Dr. Cremer's published the facts in the Lancet in 1958

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Mode of action

• Isomerization that changes trans-bilirubin into the water-soluble cis-bilirubin isomer.

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• Blue-green light in the range of 460-490 nm is most effective for phototherapy.

• The absorption of light by the normal bilirubin (4Z,15Z-bilirubin) generates configuration isomers, structural isomers, and photooxidation products.

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Factors affecting dose of phototherapy

• Irradiance of light used,

• The distance from the light source, and

• The amount of skin exposed.

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• Standard phototherapy is provided at an irradiance of 8-10 microwatts per square centimeter per nanometer (mW/cm2 per nm).

• Intensive phototherapy is provided at an irradiance of 30 mW/cm2 per nm or more (430–490 nm).

• For intensive phototherapy, an auxiliary light source should be placed under the infant.

• The auxiliary light source could include a fiber-optic pad, a light-emitting diode (LED) mattress, or a bank of special blue fluorescent tubes.

• Term and near-term infants should receive phototherapy in a bassinet and the light source should be brought as close as possible to the infant, typically within 10-15 cm.

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Guidelines for management of hyperbilirubinemia in healthy, full-term

infants (American Academy of Pediatrics)

• Age 25-48 hours**: >12 -Consider phototherapy >15 -Initiate phototherapy >20 -Initiate exchange transfusion if intense phototherapy* fails >25 -Initiate exchange transfusion

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• Age 49-72 hours>15 -Consider phototherapy >18 -Initiate phototherapy >25 -Initiate exchange transfusion if intense phototherapy* fails >30 -Initiate exchange transfusion

Age >72 hours>17 -Consider phototherapy >20 -Initiate phototherapy >25 -Initiate exchange transfusion if intense phototherapy* fails >30 -Initiate exchange transfusion

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An example of an action chart for bilirubin results

www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/downloads/phototherapy.pdf05/02/2023 05:19 AM 38Nirsuba gurung

INDICATIONS OF PHOTOTHERAPY AND EBT: PROTOCOL BPKIHS

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Care of baby• Early feeding/ Nutrition/ Hydration

• Increase frequency of breast feeding

• Neutral thermal environment

• Prevent hypoglycaemia and hypoxia

• Avoid constipation• Hygiene

•

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Summary

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Reference

• Ghai . OP.Essential Paediatric. 6th edition CBS publication and distributors page no:169-171

• Dutta D.C. Text book of obstretics. 7th edition.New book agency(p)ltd page no:476

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Contd……..

• College of Family Physicians of Canada (1999) Approach to the management of hyperbilirubinemia in term newborn infants paeditrics & Child Health 4(2); 161-164 http://www.cps.ca/english/statements/FN/fn98-02.html (retrived on 11 dec 2o11)

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Contd……

• Dutta Parul. Paediatric Nursing. 2nd edition Jaypee brothers mediccal publisher(p) ltd page no:313-314.

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Multiple choice questions

1.physiological jaundice starts to appear on:A. At the time of birth;B. 2-3 day of life;C. 7 days of life;D. 15 days of life

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2.End product of R.B.C destruction which causes yellowish discoloration of body is:

A. GlobulinB. AlbuminC. BiliverdinD. Bilirubin

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3. Conjugation of bilirubin takes place in:A. IntestineB. LungC. LiverD. kidney

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4. All of the following are the causes of physiological jaundice, except:

A. Sterile gutB. Short life span of R.B.C C. ConstipationD. Mature liver

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5. Jaundice first appears in A. FootB. HandsC. Sclera of eyesD. abdomen

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Assignment

• While you are posted in pediatric ward:1 a 5 days old baby is having serum total bilirubin level 10 mg/dl , and not sucking breast milk . Make a nursing care plan for the baby.

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