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Neonatal Jaundice


NEONATAL JAUNDICE
Q&A COUNT: 37*

 HISTORY:
Early sign of Kernicterus - FEEDING PROBLEM

Antenatal drugs causing Neonatal Jaundice:
  1. Vitamin K in large doses (causes hemolysis)
  2. Gentamicin and Kanamicin (intefere with conjugation)
  3. Sulfonamides, Warfarin, Salicylates - compete with Albumin binding sites
  4. Oxytocin  with 5% dextrose - hyperosmolarity to cause hemolysis
  5. Antimalarials - Primaquine (G6PD deficiency)
  6. Dapsone

DISCUSSION:
How to differentiate Physiological and Pathological Jaundice?
1. Physiological Jaundice occurs between 2-14 days of life. Pathological Jaundice can occur before 2nd day or after 14th day.

2. Physiological Jaundice involve only Indirect hyperbilirubinemia, never Direct hyperbilirubinemia. Pathological Jaundice can involve both direct or indirect hyperbilirubinemia.

3. Total bilirubin will be always less than 15 mg/dl in Physiological Jaundice. Total bilirubin can be more than 15 mg/dl in Pathological Jaundice.

4. Physiological Jaundice never involves palms and soles. Pathological Jaundice can involve palms and soles

5. Physiological Jaundice do not require any treatment. Phototherapy or exchange transfusion is indicated in Pathological Jaundice.

Cause of prolonged physiological jaundice
Cephalhematoma

Some Important Causes of Neonatal jaundice:
  1. Congenital Hypothyroidism
  2. ABO/Rh incompatibility
  3. Cephalhematoma
  4. Bruising
  5. Breast Milk Jaundice
Causes based on the time of onset of Jaundice:
Within 1 day:
1. Hemolytic disease of newborn (incompatibility)
2. Intrauterine infections
3. G6PD deficiency

By 2nd and 3rd day:
1. Physiological Jaundice
2. Polycythemia
3. Concealed hemorrhages (cephalhematoma, SAH, IVH)

 After 3rd day:
1. Sepsis
2. Neonatal hepatitis
3. Extrahepatic biliary atresia
4. Breast milk Jaundice
5. Metabolic disorders

What is Breast Milk Jaundice?
Jaundice due to Breast milk drinking (due to inhibitory factors in breast milk - PREGANANEDIOL and FREE FATTY ACIDS)
Occurs beyond 3rd to 4th week of Jaundice
Note: Breastfeeding should not be stopped for diagnosis or treatment of this Jaundice

What is Breast feeding Jaundice?
Breast feeding Jaundice is due to inadequate breastfeeding
Occurs between 2nd and 3rd day

*Kindly understand the opposite nature of the above two Jaundice types

Reason for physiological jaundice:
  1. Polycythemia
  2. RBC lifespan is low
  3. Increased entero hepatic circulation
  4. Immature liver

Type of bilirubin elevated in physiological Jaundice - INDIRECT BILIRUBIN

Jaundice + No incompatibility - causes:
  1. G6PD deficiency
  2. Spherocytosis
  3. Sickle cell anemia
  4. Hypothyroidism

Direct hyperbilirubinemia (>20% of total bilirubin) - Causes?
  1. Neonatal hepatitis (TORCH)
  2. Metabolic (Galactosemia, Fructosuria, CF, alpha 1 antitrypsin deficiency, hemochromatosis)
  3. Sepsis
  4. Extrahepatic biliary atresia

Jaundice in day 1, Anemia, no incompatibility - suspect?
G6PD deficiency, Intrauterine infection

Kernicterus - problems after survival:
  1. Cerebral Palsy
  2. Status pulmoratus
  3. Deafness
  4. Imvoluntary movements
  5. Vertical gaze palsy
  6. Yellow stained teeth

Features or Signs of Kernicterus:
  1. Fever
  2. Moro reflex incomplete
  3. Seizures
  4. Hypertonia
  5. Abnormal posturing - arching, retrocollis, Opisthotonus

Moro reflex in early kernicterus?
INCOMPLETE reflex

Kramer Grading of Clinical estimation of Bilirubin level, according to dermal staining
Jaundice in Zone 1 (Head): 4-6 mg/dl
Jaundice in Zone 2 (Chest): 6-8 mg/dl
Jaundice in Zone 3 (Perineum, Pelvis): 8-12 mg/dl
Jaundice in Zone 4 (Proximal limbs): 12-14 mg/dl
Jaundice in Zone 5 (Palms, soles): >15 mg/dl

Note: Jaundice in palms and soles always indicate pathological jaundice

Why Thyroid function test is ideally done in 3rd day, not first two days?
There is a physiological TSH surge in first 1-2 days after birth in newborn, due to stress of delivery and new exposure to the cold temperature of the extrauterine environment.
This elevates TSH levels and causes high value of T4 and T3 in the first 1 or 2 days after birth. 
If there is congenital hypothyroidism, it will be masked during investigations.

Hypothyroid or Cretinoid facies - describe
Thick, heavy face with a dull look
Thick eyebrows
Thick protruding tongue

Quebec's criteria for Congenital Hypothyroidism
The above picture is taken from Google search

What is Floppy infant?
Floppy infant refers to an infant with severely reduced muscle tone, most often due to an insult in the foetal or neonatal period.
There is decreased resistance to passive range of movements with variable degree of muscle weakness
Quickening will be felt late*

Can be related to our cases:
1. Down syndrome
2. Congenital hypothyroidism in neonatal jaundice
3. Cerebral palsy

MANAGEMENT:
Cord blood sample - Purpose of taking sample in 4 bottles:
  1. Blood group
  2. Hb
  3. Bilirubin
  4. Direct Coombs test

Indications for Phototherapy:
  1. Pathological Jaundice
  2. Physiological Jaundice in a Preterm baby
  3. Prophylactic phototherapy in a normal very preterm baby
  4. In AAP Normogram chart - Total Bilirubin value is above the curve corresponding to the baby's age of gestation at birth
We do not own any copyright for this image taken through Google search



Prophylactic phototherapy:
Done for very preterm baby
As this baby will develop Jaundice

Bilirubin level for giving phototherapy in a term baby
Upto 20-25 mg/dl - we can wait
After that - start phototherapy
For Preterm - no wait until 20-25 mg/dl


Phototherapy - Light used:
  1. Ideal - Spectral blue light
  2. Alternatives - White fluorescence or LED

Distance between baby and phototherapy cell
Normal - 45 cm
For Severe jaundice - 15-20 cm

Name of Blanket used to cover baby under phototherapy
BILI blanket

Phototherapy methods:
  1. Photo oxidation
  2. Photo isomerization
  3. Structural isomerization (bilirubin is converted to LUMIRUBIN) (BEST method)

Problems of Phototherapy:
Acute:
  1. Dehydration (give 20-40 ml/kg more fluids)
  2. Hypothermia
  3. Rash
  4. Bronze baby syndrome (in case of direct bilirubinemia)
  5. Diarrhoea
Chronic:
  1. Eye problems (cover eyes)
  2. Genitalia of males (cover genitals)

Indications for Exchange transfusion
1. Cord Bilirubin is 5 mg/dl or more
2. Cord Hb is 10 g/dl or less
3. Signs of Bilirubin encephalopathy, irrespective of Total Bilirubin levels
4. In AAP Normogram chart - Total Bilirubin value is above the curve corresponding to the baby's age of gestation at birth
We do not own any copyright for this image taken through Google search



Candidate for exchange transfusion at day 1:
If Hb <10 g% and Bilirubin >5 mg/dl

Is failure to phototherapy, an indication for Exchange transfusion?
No!

What blood is given in exchange transfusion?
ABO incompatibility - give O +ve blood
Rh incompatibility - give O -ve blood

Method used for Exchange transfusion:
Push pull technique
Umbilical vein catheter used to exchange blood

Adverse effects of exchange transfusion
  1. Cardiac arrest
  2. Wrong blood
  3. Electrolyte imbalance
  4. Sepsis - leads to umbilical infection - leads to Extrahepatic portal hypertension

Other treatments for Neonatal Jaundice: (Temporary measures)
  1. 1-2 doses of Immunoglobulin
  2. Albumin transfusion to bind bilirubin