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Neonatal JaundiceLearning Objectives:Learning Objectives:
• Define hyperbilirubinemia.Define hyperbilirubinemia.• Differentiate between physiological and Differentiate between physiological and
pathological jaundice.pathological jaundice.• State causes of hyperbilirubinemia.State causes of hyperbilirubinemia.• Discuss the pathophysiology of Discuss the pathophysiology of
hyperbilirubinemia.hyperbilirubinemia.• Describe the most dangerous complication Describe the most dangerous complication
of hyperbilirubinemia.of hyperbilirubinemia.• List the three elements of therapeutic List the three elements of therapeutic
management.management.• Design plan of care for baby has Design plan of care for baby has
hyperbilirubinemia.hyperbilirubinemia.
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Neonatal Jaundice(Hyperbilirubinemia)
Definition: Definition: Hyperbilirubinemia Hyperbilirubinemia refers to an refers to an excessive level of accumulated bilirubin in excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, yellowish discoloration of the skin, sclerae, mucous membranes and nails. mucous membranes and nails.
UnUnconjugated bilirubin = conjugated bilirubin = InIndirect bilirubin.direct bilirubin.Conjugated bilirubin = Direct bilirubin.Conjugated bilirubin = Direct bilirubin.
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Neonatal Jaundice
Visible form of bilirubinemia Visible form of bilirubinemia
–Newborn skin >5 mg / dlNewborn skin >5 mg / dlOccurs in 60% of term and 80% of preterm Occurs in 60% of term and 80% of preterm neonatesneonates
However, significant jaundice occurs in However, significant jaundice occurs in 6 % of term babies 6 % of term babies
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Bilirubin metabolism
Hb → globin + haem1g Hb = 34mg bilirubin
Non – heme source1 mg / kg
Bilirubin glucuronidase
Bilirubin
Bilirubin
Ligandin(Y - acceptor)
Bil glucuronide
Intestine
Bil glucuronide
Stercobilin
bacteria
β glucuronidase
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Clinical assessment of jaundice
Area of body Area of body Bilirubin levels Bilirubin levels mg/dl mg/dl
(*17=umol)(*17=umol)
Face Face 4-8 4-8Upper trunkUpper trunk 5-12 5-12Lower trunk & thighsLower trunk & thighs 8-16 8-16Arms and lower legsArms and lower legs 11-18 11-18Palms & solesPalms & soles > 15 > 15
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Physiological jaundice
CharacteristicsCharacteristics
Appears after 24 hoursAppears after 24 hours
Maximum intensity by 4th-5th day in term Maximum intensity by 4th-5th day in term & 7th day in preterm& 7th day in preterm
Serum level less than 15 mg / dlSerum level less than 15 mg / dl
Clinically not detectable after 14 daysClinically not detectable after 14 days
Disappears without any treatmentDisappears without any treatment
Note: Baby should, however, be watched for Note: Baby should, however, be watched for worsening jaundice.worsening jaundice.
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Why does physiological jaundice develop?
Increased bilirubin load.Increased bilirubin load.
Defective uptake from plasma.Defective uptake from plasma.
Defective conjugation.Defective conjugation.
Decreased excretion.Decreased excretion.
Increased entero-hepatic Increased entero-hepatic circulation.circulation.
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Age in Days
TermPreterm
1 2 3 4 5 6 10 11 12 13 14
15
10
5Bil
iru
bin
leve
lm
g/d
l
Course of physiological jaundice
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Pathological jaundice
Appears within 24 hours of ageAppears within 24 hours of age
Increase of bilirubin > 5 mg / dl / dayIncrease of bilirubin > 5 mg / dl / day
Serum bilirubin > 15 mg / dlSerum bilirubin > 15 mg / dl
Jaundice persisting after 14 daysJaundice persisting after 14 days
Stool clay / white colored and urine Stool clay / white colored and urine staining clothes yellowstaining clothes yellow
Direct bilirubin> 2 mg / dlDirect bilirubin> 2 mg / dl
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Causes of jaundice
Appearing within 24 hours of age
Hemolytic disease of NB : Rh, ABOHemolytic disease of NB : Rh, ABO
Infections: TORCH, malaria, Infections: TORCH, malaria,
bacterialbacterial
G6PD deficiencyG6PD deficiency
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Causes of jaundice
Appearing between 24-72 hours of
life
PhysiologicalPhysiological
SepsisSepsis
PolycythemiaPolycythemia
Intraventricular hemorrhageIntraventricular hemorrhage
Increased entero-hepatic circulationIncreased entero-hepatic circulation
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Causes of jaundice
After 72 hours of ageAfter 72 hours of age
SepsisSepsis
CephalhaematomaCephalhaematoma
Neonatal hepatitisNeonatal hepatitis
Extra-hepatic biliary atresiaExtra-hepatic biliary atresia
Breast milk jaundiceBreast milk jaundice
Metabolic disorders (G6PD).Metabolic disorders (G6PD).
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Risk factors for jaundice
JAUNDICEJAUNDICEJJ - jaundice within first 24 hrs of life - jaundice within first 24 hrs of lifeA A - a sibling who was jaundiced as neonate - a sibling who was jaundiced as neonate U U - unrecognized hemolysis- unrecognized hemolysisN N – non-optimal sucking/nursing– non-optimal sucking/nursingDD - deficiency of G6PD - deficiency of G6PDI I - infection- infectionCC – cephalhematoma /bruising – cephalhematoma /bruisingE E - East Asian/North Indian- East Asian/North Indian
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Diagnostic evaluation:
Normal values of unconjugated B. are Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.0.2 to 1.4 mg/dL.
Investigate the cause of jaundice.Investigate the cause of jaundice.
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Therapeutic Management
PurposesPurposes: reduce level of serum bilirubin : reduce level of serum bilirubin and prevent bilirubin toxicityand prevent bilirubin toxicity
Prevention of hyperbilirubinemia: early Prevention of hyperbilirubinemia: early feeds, adequate hydrationfeeds, adequate hydration
Reduction of bilirubin levels: Reduction of bilirubin levels: phototherapy, phototherapy, exchange transfusion, exchange transfusion,
Drugs Drugs Use of Phenobarbital promote Use of Phenobarbital promote liver enzymes and protein synthesis.liver enzymes and protein synthesis.
Babies under phototherapy
Baby under conventional phototherapy
Baby under triple unit intense phototherapy
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Prognosis
Early recognition and treatment of Early recognition and treatment of hyperbilirubinemiahyperbilirubinemia prevents severe prevents severe brain damage.brain damage.
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Nursing considerations of Hyperbilirubinemia
Assessment:Assessment: observing for evidence ofobserving for evidence of
jaundice at regular intervals.jaundice at regular intervals. Jaundice is common in Jaundice is common in
the first week of life and the first week of life and
may be missed in dark skinned may be missed in dark skinned
babiesbabiesBlanching the tip
of the nose
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Approach to jaundiced baby
Ascertain birth weight, gestation and Ascertain birth weight, gestation and postnatal agepostnatal ageAsk when jaundice was first noticed Ask when jaundice was first noticed Assess clinical condition (well or ill)Assess clinical condition (well or ill)Decide whether jaundice is physiological or Decide whether jaundice is physiological or pathologicalpathologicalLook for evidence of Look for evidence of kernicterus*kernicterus* in deeply in deeply jaundiced NBjaundiced NB
**Lethargy and poor feeding, poor or absent Moro's, or Lethargy and poor feeding, poor or absent Moro's, or convulsionsconvulsions
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Nursing diagnosis
See the high risk infant plan of care. See the high risk infant plan of care. Plus:Plus:
Body T.,Body T., risk for imbalanced T. related risk for imbalanced T. related to use of phototherapy.to use of phototherapy.
Fluid volumeFluid volume, risk for deficient related , risk for deficient related to phototherapy.to phototherapy.
Interrupted family process related to Interrupted family process related to situational crisis, re hospitalization for situational crisis, re hospitalization for the therapy. the therapy.
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The goals of planning
Infant will receive appropriate therapy if Infant will receive appropriate therapy if needed to reduce serum bilirubin needed to reduce serum bilirubin levels.levels.
o Infant will experience no complications Infant will experience no complications from therapy.from therapy.
o Family will receive emotional support.Family will receive emotional support.o Family will be prepared for home Family will be prepared for home
phototherapy (if prescribed).phototherapy (if prescribed).
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