Neonatal jaundice

Notes

## Basic introduction

  • Jaundice or icterus is a visible manifestation of increased levels of bilirubin in the body
  • Hyperbilirubinemia is toxic to the developing Central Nervous System resulting in:

_Loss of hearing

_Athetosis (abnormal muscle contraction)

## Statistics

  • Globally, 60% of term and 80% of preterm babies will have jaundice with bilirubin > 5mg/dL in the 1st wk of life
  • Globally, 8 - 9% of term babies have bilirubin levels > 15mg/dL in the 1st days of life
  • In a study undertaken at Kilifi District Hospital (Kenya) between November 1999 and April 200, Neonatal jaundice was associated with a high mortality in the first week of life. Of the 87 infants admitted with jaundice as a primary problem, 23 received an exchange transfusion, seven (30%) of whom dieda.

## Causes of jaundice (hyperbilirubinemia)

  • Jaundice appearing at birth or within 24hrs after birth may be due to:

_Hemolytic Disease of Newborn (HDN or Erythroblastosis fetalis) –due to Rh antibodies

_G-6PD deficiency

_Infections:

||| Malaria

||| Bacterial infections

||| Viral infections

  • Jaundice appearing within 1- 3 days after birth may be due to:

_Sepsis neonatorum

_Polycythemia

_Physiological causes:

 ||| In some neonates, some degree of jaundice is physiologically normal as the liver is yet to be fully developed to metabolize bilirubin and there is physiological polycythemia

 ||| It tends to subside after about 14 days

 ||| The bilirubin blood level in most cases may not exceed 15mg/dL

_Subarachnoid

_Cephalhematoma

_Intraventricular hemorrhage

_Increased enterohepatic circulation 

  • Jaundice appearing within 3 - 7 days after birth may be due to:

_Sepsis neonatorum

_Syphilis

_Toxoplasmosis

_Drugs such as cephalosporins and sulphonamides

  • Jaundice appearing 7 days after birth may be due to:

_Prolonged direct jaundice such as:

||| Neonatal hepatitis that is caused mainly by unknown factors and to a lesser extent by viral infections such as cytomegalovirus, rubella, and hepatitis A, B or C

||| Breast milk jaundice

||| Metabolic disorders

||| Extrahepatic biliary atresia

||| Amino acid toxicity

_Prolonged indirect jaundice such as:

||| Hypothyroidism

||| Criggler-Najjar Syndrome

||| Breast milk jaundice

||| Infections such as malaria

||| Pyloric stenosis

## Factors that predisposes to bilirubin toxicity

  • Acidemia
  • Hypothermia
  • Hyperglycemia
  • Prematurity
  • Sepsis
Symptoms
  • Yellow baby
  • Clay or colored stool
  • Dark urine that stains the nappy yellow
  • Serum bilirubin > 15mg/dL in case of pathological jaundice but lower in physiological jaundice
  • Complications:

_Acute bilirubin encephalopathy (reversible brain damage)

_Chronic bilirubin encephalopathy or kernicterus (irreversible brain damage) that manifest as:

||| Absent startle reflex

||| Bulging fontanelle

||| Cerebral palsy

||| High-pitched cry

||| Opisthotonos (hypertonia of extensor muscles with arched back and hyperextended neck)

||| Hypotonia

||| Intellectual disability

||| Muscle rigidity

||| Poor sucking and feeding

||| Seizures

||| Sensory hearing loss

||| Speech difficulties

||| Coma

Diagnosis
  • Clinical review, especially for the sign of jaundice
  • Measurement of serum bilirubin
  • Blood grouping for the mother and the baby
  • Blood culture, if infection is suspected
  • Coomb’s test, which is antiglobulin serum that is used to detect RBC that is sensitized with:

_IgG alloantibodies such as Rh and ABO antibodies

_IgG autoantibodies

_Complete components

Differential
  • It depends on the underlying cause(s)
Prevention
  • It depends on the underlying cause (s)
Reference
  1. Bhutani, V. K., Johnson, L. H., & Keren, R. (2004). Diagnosis and management of hyperbilirubinemia in the term neonate: for a safer first week. Pediatric Clinics, 51(4), 843-861
  2. Gowen Jr C. Anemia and hyperbilirubinemia. Kliegman R Nelson Essentials of Pediatrics 5th ed Philadelphia, Pa: Elsevier Saunders. 2006; 313-22. ... 2005; 159(4):402-3. 4.
  3. English, M., Ngama, M., Musumba, C., Wamola, B., Bwika, J., Mohammed, S., ... & Newton, C. R. J. C. (2003). Causes and outcome of young infant admissions to a Kenyan district hospital. Archives of disease in childhood, 88(5), 438-443.
  4. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-
Management
  • Physiological jaundice requires no treatment but close observation
  • Adequate feeding and hydration
  • Pathological jaundice can be treated by:

_Phototherapy

_Exchange blood transfusion

||| One cycle should take 45-60 minutes

||| 10-20 mL of blood should be exchanged over this period

||| The target should be to exchange about twice the volume in infant (2x85mL/kg)

_Comprehensive investigations to establish the cause

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