Download - Neonatal jaundice(reference msia cpg)
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NEONATAL JAUNDICE
YEE WEI HOONG121303147
31B (L1)1
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DEFINITION
• Jaundice is a yellowish discolouration of skin, sclerae, mucous membranes & nails from accumulation of bilirubin.
• Hyperbilirubinemia refers to an excessive level of bilirubin in blood.
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Neonatal Jaundice• One of the most common medical
conditions in newborn babies• All babies have transient rise in
serum bilirubin, but only 75% are visibly jaundiced.
• Jaundice is clinically detectable when serum bilirubin levels are >5mg/dL (85 umol/L)
• Jaundice is more common in Asian babies
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Day 1 Day 7 Day 14/21
PATHOLOGICAL jaundice
PHYSIOLOGICAL jaundice
PROLONGED jaundice
Time Frame for Jaundice
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CLASSIFICATIONS• Physiological
1. Appears after 24hrs2. Maximum intensity by 3rd -5th day in term, 7th day in preterm3. TSB <15mg/dL (<255umol/L)4. Not detectable clinically after 14days5. No underlying cause6. Disappears spontaneously
• Pathological 1. Appears within 24hrs of age2. Serum bilirubin level increase >6mg/dl/day3. TSB >20mg/dL(340umol/dL)4. Conjugated/Direct bilirubin >2mg/dL(34umoLdL) 5
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Pathophysiology of Physiological Jaundice
1. Decreased erythrocyte life span (80 to 90 days) in a full term infant
2. Increased erythrocyte volume3. Increased bilirubin load on the hepatic cell4. Defective uptake from plasma into liver cell –
decreased ligandin5. Defective conjugation - relatively low activity of the
enzyme glucuronosyltransferase which normally converts unconjugated bilirubin to conjugated bilirubin
6. Low conversion of bilirubin to urobilinogen by the intestinal flora resulting in higher entero-hepatic circulation
7. Decreased excretion
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RBC vol & RBC survival
Bil monoglucoronide Bil Diglucoronide
UCB
Prod
uctio
nTr
ansp
ort
Uptake
Excretion
Conjugation
ineffective erythropoiesis & haem turnover
Non availability of albumin binding sites
Defective conjugation
Ligandin
Decreased excretion
gut motility Poor evacuation beta glucoronidase, intestinal
bacteria
BILIRUBIN load
Defective uptake from plasma
Entero-hepatic circulation
Bilirubin Load Causing Jaundice in Newborn
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CAUSES OF PATHOLOGICAL JAUNDICE
1. Haemolytic disease of newborn: Rh, ABO & minor group (anti-Kell, Duffy) incompatibility
2. Infections: Intrauterine infection (Bacterial, viral)
3. Membrane defects: Spherocytosis, elliptocytosis
4. RBC enzyme defects: G6PD deficiency, pyruvate kinase deficiency
5. Polycythemia
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NNJ & Mother’s Knowledge
• A Malaysian study found that less than 50% of the mothers had good knowledge & awareness about the risks & complications of NNJ.1
1. Boo NY, et al. Med J Malaysia. 2011 Aug;66(3):239-243
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MONITORING• Extract (1) from Malaysia CPG :
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MONITORING• Extract (2) from Malaysia CPG :
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MONITORING• Extract (3) from Malaysia CPG :
82. Division of Family Health Development, Ministry of Health. Integrated Plan for Detection and Management of Neonatal Jaundice. Putrajaya: MoH; 2009
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MONITORING• Extract (4) from Malaysia CPG :
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P.P.A.P Physiological, Pathological and Prolonged
Physiological Jaundice
Pathological Jaundice
Prolonged jaundice
Starts within 24 hours
Starts after 24 hours; usually disappear by 14th day
Jaundice lasting >14 days
MIX & MATCH!!!
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Maybe Previous Q was too easy…Try This Pulak.
In the development of physiological NNJ, there is:a.decreased bilirubin load F b.defective uptake of bilirubin from plasma Tc.defective conjugation Td.increased excretion Fe.decreased entero-hepatic circulation F
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Three Components of Assessment
• History• Physical Examination• Lab Investigations
*Phototherapy must always be started while awaiting further assessment & investigation
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Objectives of Proper Assessment (History, Physical Examination, Lab
Investigations)
End Point
Prevention of bilirubin neurotoxicity(acute/ chronic)
To identify
Risk Factors (for severe NNJ and neurotoxicity)
Severity of NNJ(level of SB or extent of hemolysis)
Complications (signs of ABE)
To decide on
Management (phototherapy, exchange transfusion)
Follow-up (ABR, MRI, development)
But not at the cost of overinvestigating or overtreating low risk babies
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1. Risk Factor Identification
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2. ASSESSMENT OF SEVERITY
• Visual assessment
• Transcutaneous measurement
• Analysis of blood serum
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VISUAL ASESSMENT-KRAMER’s RULE
Kramer’s rule describes the relationship between serum bilirubin levels & the progression of skin discolouration 20
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Transcutaneous bilirubinometer (TcB)
• The transcutaneous bilirubinometer is a hand-held device that measures the amount of bilirubin in the skin.
Bilicheck (Philips)Does not require any disposable material & less time consuming
JM 103 (Draeger)
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Serum Bilirubin (SB) Measurement
• Gold standard for detecting & determining the level of hyperbilirubinaemia.
• May be estimated on either a capillary or a venous blood sample.
• Blood sample should be analysed as soon as possible & should be shielded from light during transport (exposure to light rapidly & significantly decreases bilirubin).
• Remove phototherapy prior to sample collection.
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CPG says…
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3. Assessing Complications
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Dangers of Hyperbilirubinemia• If untreated, it will lead to acute & chronic bilirubin
encephalopathy, eventually kernicterus.• C/F:
Refusal of feeds, shrill cry, setting sun sign, convulsions, retrocollis & opisthotonus
Sluggish Moro’s response, lethargy, poor feeding Preterm – Non specific. Die due to apnoeic attacks Infancy – Athetoid cerebral palsy, choreo-athetosis, brownish
staining of teeth, dental dysplasia, deafness, paralysis of upward gaze, intellectual retardation & learning disabilities
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Images taken from: Vinod K, et al. Bilirubin Neurotoxicity in Preterm Infants: Risk and Prevention. J Clin Neonatol. 2013 Apr-Jun; 2(2): 61–69.
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Acute Bilirubin Encephalopathy (ABE)
• ABE: Changes of mental (behavioural) status & muscle tone during the neonatal period when the baby is having hyperbilirubinaemia.
• Identifying & Monitoring of ABE:• Term Babies: Use BIND Score • Preterm Babies: Difficult, as signs are
subtle. Auditory Brainstem Response (ABR) could be used.
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BIND Score
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Indications for Referral to Hospital
• Jaundice within 24hours of life• All babies that require phototherapy• Jaundice below umbilicus• Jaundice extending to soles and feet• Rapid increase of bilirubin level (>0.5mg/h)• Diagnosed with G6PD deficiency• Haemolytic disorder• Symptoms and signs of sepsis
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Investigations • *Total serum bilirubin• *G6PD status• Others as indicated:-infant’s blood group-Maternal blood group-Direct coombs’ test (indicated in day 1 jaundice and severe jaundice)-FBC, reticulocyte count, peripheral blood smear-Blood culture, urine microscopy, and culture (infection
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TREATMENT1. Phototherapy
• Light with wavelenght of 450nm convert unconjugated bilirubin into harmless water soluble pigment excreted predominantly in the urine
2. Exchange Transfusion• Twice the infant’s blood volume 2x80ml/kg is exchange
3. IVIG (Intravenous immunoglobulin)• high dose IVIG (0.5-1 gm/kg over 2hours) reduce the need for ET in Rh and
ABO hemolytic disease• Give as early as possible in hemolytic disease with positive Coomb’s test or
when the serum bilirubin increasing despite intensive phototherapy.
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Hmm…Final Q• Following vessels can be utilised
for exchange transfusion, except:A. Femoral VeinB. Umbilical ArteryC. Umbilical VeinD. Subclavian VeinE. Peripheral Artery
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Measures to Prevent Severe Neonatal Jaundice
• Promote & support breastfeeding.• Advise a frequency of 8 to 10 feedings per day • Formula milk for term infants should be 1 to 2 ounce every 2 to 3
hrs in the 1st week.• If phototherapy in infants with hemolytic jaundice is initiated early
and discontinue before infant 3-4 days old, must monitor for rebound jaundice and adequacy of breast feeding within the next 24-48 hours.
• Routine supplements with water or dextrose water will not help prevent hyperbilirubinemia
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Follow up
• All infant discharge < 48hrs after birth should be monitor in ambulatory setting or at home
• Infants with risk factors for severe neonatal jaundice, early follow up is a must to detect rebound jaundice
• Infant with hemolytic diseases not requiring ET should be closely followed up for anemia until risk of ongoing hemolysis is minimal.
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REFERENCES
1. Malaysia Clinical Practice Guidelines: Management of Neonatal Jaundice, 2nd edition, 2014.
2. Paediatric Protocol. 3rd ed: KKM,20153. Tom Lissauer, Illustrated TextBook of
Paediatrics, 4th ed.20124. Nelson essential of pediatrics.5. http://emedicine.medscape.com/
article/974786