quality education for a healthier scotland multidisciplinary neonatal jaundice promoting...

Quality Education for a Healthier Scotland

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Neonatal Jaundice

Promoting multiprofessional education and development in Scottish maternity care

Quality Education for a Healthier Scotland

MultidisciplinaryNeonatal Jaundice

Definition = Total serum bilirubin

(SBR) > 85 µmol/L.

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Why is it important?

• Common• Worrying for parents and / or staff

• Condition and treatment• Sign of underlying disease• Can cause neurological problems.

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Where does bilirubin come from?

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MultidisciplinaryCauses• Benign

• Physiological• Breast milk

and breastfeeding

• Pathologic.

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MultidisciplinaryPhysiological JaundiceFeatures:

• Elevated unconjugated bilirubin• SBR generally peaks @ 85-100 µmol/L on

day 3-4 and then declines to adult levels by day 10• Asian infants peak at higher values (110

µmol/L )

• Exaggerated physiological (up to 290 µmol/L).

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MultidisciplinaryPhysiological Jaundice

Asian Asian infantinfant

Breastfed infantBreastfed infant

Non-breastfed infantNon-breastfed infant

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MultidisciplinaryPhysiological JaundiceIncreased rbc’s

Shortened rbc lifespan

Immature hepatic uptake and conjugation

Increased enterohepaticcirculation.

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MultidisciplinaryBreast Milk Jaundice• Elevated unconjugated bilirubin• Prolongation of physiological

jaundice• May be second peak @ day 10

• Average max SBR = 170-205 µmol/L• SBR may reach 376-410 µmol/L

• ?Milk factor.

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MultidisciplinaryPathologic Jaundice

• Features• Jaundice in first 24 hrs• Rapidly rising SBR

• > 85 µmol/L per day

• SBR > 290 µmol/L.

• Categories• Increased bilirubin

load• Decreased conjugation• Impaired bilirubin

excretion.

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Multidisciplinary1.Increased Bilirubin

LoadElevated unconjugated bilirubin

•Haemolytic Disease

•Non-haemolytic Disease.

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Multidisciplinary2. Decreased Bilirubin ConjugationElevated unconjugated bilirubin

•Genetic Disorders

•Hypothyroidism.

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Multidisciplinary3. Impaired Bilirubin Excretion - usually later

Elevated conjugated bilirubin

o> 35 µmol/L or > 20% of SBR

•Biliary Obstruction•Important to diagnose by 4 weeks

•Infection •Metabolic Disorders•Chromosomal Abnormalities •Drugs.

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MultidisciplinaryDiagnosis and Evaluation

• Physical Examination

• Jaundice visible when bilirubin reaches 85 µmol/l• Milder jaundice generally confined to face and

upper chest• Downward extension generally signifies

increasing bilirubin values.

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MultidisciplinaryDiagnosis and Evaluation

• Laboratory• Blood test• Indirect measurements

• Transcutaneous.

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MultidisciplinaryRisk Factors for increased Hyperbilirubinemia

•Jaundice in first 24 hrs•Visible jaundice prior to discharge•Previous jaundiced infant•Gestation 35-38wk.

•Exclusive breastfeeding•Asian race•Bruising, cephalohaematoma•Male sex.

AAP, Subcommittee on Neonatal Hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics 2001;108.

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MultidisciplinaryTreatment

• Underlying Cause• Where one is identified

• Fluids and Nutrition• Phototherapy.

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MultidisciplinaryPhototherapy• Mechanism

• Forms

• Breastfed infants are slower to recover

• Rebound hyperbilirubinemia is rare

• Average increase is 17 µmol/L.

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MultidisciplinaryTreatment

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MultidisciplinaryTreatment• Underlying Cause

• Where one is identified

• Fluids and Nutrition• Phototherapy• Monitoring and

follow up• ? Repeat hearing checks• ? Hb checks for late

anaemia.

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MultidisciplinaryExchange Transfusion• Mechanism: removes bilirubin and antibodies from circulation• Most beneficial to infants with haemolysis• Generally never used until after intensive phototherapy attempted.

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KernicterusWhat is it?

• Bilirubin induced toxicity to Basal Ganglia and brainstem nuclei.

Increase in cases beginning in early 1990s• At least partially related to early hospital discharge.

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Any questions?

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MultidisciplinarySummary• Jaundice is common and “normal”

• Recognition of at risk infant

• Assessment - clinical and biochemical

• Treatment.