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Jaundice: what’s all the fuss

about?

David Cordiner 

Oct 2008

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Where does it come from?

• Haemoglobin

• 4 Haem + 4 protein globin chains

• porphyrin ring + iron • Biliverdin

• Bilirubin

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So we have bilirubin, what happens

next?•  Albumen transports unconjugated bilirubin to

hepatocyte

• Conjugated with glucuronate

• Passes to GI tract

• Some is de-conjugated and absorbed in the E-Hrecirculation

• Rest is converted to urobilinogen

• Urobilinogen can be reabsorbed and mayappear in urine

• In GI tract, urobilinogen is changed tostercobilinogen that pigments stool

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So why do ‘normal’ neonates taunt

us so much with their jaundice?

• ‘physiological factors’-diagnosis of exclusion

 – Haemolysis of RBC with fetal Hb

 – Immaturity of conjugation in liver 

• Dehydration

• Bowel stasis

• Bruising• Breast milk jaundice

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Particularly in the teeny-weenies

•  Antibiotic treatment

• TPN/lack of GI feeds

• sepsis

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Why worry?

•  Avoid kernicterus

•  Avoid need for exchange transfusion

• Identify pathological causes which mayrequire treatment

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When to suspect a problem

• Jaundice <24 hours

• Jaundice > 10 days in term

• Jaundice > 2 weeks in preterm• Background history

 – Maternal blood group and antibodies

 – FH of neonatal jaundice/liver disorders

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Jaundice less than 24 hours:beware as may be aggressive process

Top Culprits:

• Sepsis/TORCH

• Haemolysis

 – Blood group incompatability – Haemoglobinopathies

 – Membranopathies

 – Enzymopathies

• Metabolic

 – galactossaemia

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Investigation:

• FBC

• U&E

• G&C• SBR

• Cultures

• Urine reducing substances

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In-betweeny jaundice

• Most common group that you may

encounter 

• May still be a pathological cause

• May still need treatment

• Flash device may guide on those requiring

formal blood testing. Not a valid test inpigmented skin or if has already had

phototherapy

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Prolonged Jaundice: Major 

Considerations

• Biliary atresia (split SBR)

• Congenital hypothyroidism ( TFT’s) 

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Small print causes to impress your 

friends!

• Cystic Fibrosis

• alpha-1-antitrypsin deficiency

• Rotor, Dubin Johnson• Gilbert’s, Criglar Najar  

• Alagille’s 

• Choledocal cyst• Metabolic disorders

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What is phototherapy?

• Not UV as we don’t want to cook baby 

• Visible spectrum light (can be red or green)

• Helps with unconjugated jaundice

• Photo-isomerises it into water soluble form that

can be excreted in urine

• Depends on:

 – surface area of body exposed – duration of exposure

 – distance of light away from baby (intensity)

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Once started on phototherapy

• Check SBR after 6hrs to ensure

responding

• Consider giving useful course eg 12hrs

•  After stopping therapy, need follow-up

SBR at 6 hrs to ensure remains stable

• Need to monitor thetrend 

of the SBR 

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Other measures that help

• Ensure good enteral feed volumes

•  Avoid dehydration

• Cholestasis may be helped byursodeoxycholic acid and phenobarbitone

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What about conjugated?

•  As this is water soluble, will be excreted in

kidney

• The importance is in identifying cause

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So there we are, nice and

simple

No need to take a jaundiced view!

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 Turn me over 

I’m done on this side