Neonatal Jaundice: Symptoms, Causes & Treatment

Neonatal Jaundice (NNJ)

• Yellow coloration of skin and sclera in babies, caused by increased serum bilirubin (SB) levels, also known as hyperbilirubinemia.

Physiology of Bilirubin Metabolism

• Hemoglobin degrades into heme.
• Heme further degrades into iron, carbon monoxide, and biliverdin.
• Biliverdin converts to unconjugated bilirubin, which is fat-soluble.
• Unconjugated bilirubin binds with plasma albumin for circulation.
• Glucuronyl transferase detaches bilirubin from albumin.
• Bilirubin joins with glucuronic acid, creating conjugated bilirubin.
• Conjugated bilirubin is excreted into the intestine, where normal flora convert it to urobilin and then stercobilinogen in feces, or urobilinogen in urine.
• Conjugated bilirubin is hydrolyzed by beta-glucuronidase back to unconjugated bilirubin and reabsorbed.

Causes of NNJ

• Increased bilirubin production
• Reduced albumin binding capacity in the blood
• Feeding practices
• Impaired conjugation due to ineffective glucuronyl transferase activity in an immature liver
• Hypoxia, hypoglycemia, hypothermia, and acidosis
• Ineffective excretory mechanism for conjugated bilirubin

Types of Neonatal Jaundice

Physiological Jaundice

• The SB level should not exceed 250 umol/L and should never increase by more than 85 umol/L per day
• Never appears within the first 24 hours of life and the baby is clinically well, except for the jaundice
• Appears earlier, peaks, and subsides later in preterm infants
• Management includes early and adequate feeding, close observation of jaundice level, exclusion of other pathological causes, and reassurance

Pathological Jaundice

• Occurs within the first 24 hours of life or shows a rapid increase in SB level exceeding 85 umol/L per day
• A cause is hemolytic disease of the newborn

Rhesus Incompatibilities / Isoimmunisation

• Prevented by checking maternal Rh antibodies via Indirect Coombs' test and checking paternal Rh blood group.
• Anti-D immunoglobulin is administered at 28 and 34 weeks and following any sensitizing event
• Postnatal anti-D immunoglobulin prophylaxis should be given within 72 hours

ABO Incompatibilities

• Occurs when a mother with blood group O has a fetus with blood group A or B
• Anti-A and B antibodies are mostly IgM (which cannot cross the placenta), but IgG can cross
• Less severe than Rhesus incompatibilities

G6PD Deficiency

• A X-linked recessive disorder, more common in males
• Can be triggered by precipitating agents causing acute hemolysis
• Avoid aspirin, anti-malarial drugs, fava beans, and moth balls.
• Neonatal screening involves cord blood testing for G6PD
• Management involves keeping the baby away from known precipitating agents, advising breastfeeding mothers to avoid precipitating drugs or food, and providing reassurance and support
• It is a lifelong deficiency without a cure, and a warning card should be provided

Prolonged Jaundice

• Lasts for more than 14 days in term babies or more than 21 days in preterm babies
• Can be caused by inborn errors of metabolism, congenital hypothyroidism, or galactosaemia

Congenital Hypothyroidism

• May be related to impaired production of binding albumin or glucuronyl transferase
• Neonatal screening and early thyroxine replacement is important

Galactosaemia

• Deficiency in the specific enzyme converting galactose to glucose
• Treated with a lactose-free milk formula

Obstructive Jaundice

• Results from stasis of conjugated bilirubin, does not typically cause Kernicterus, pale stool, tea colored urine

Breastfeeding Jaundice

• Early onset breastfeeding jaundice (Days 2-4) results from infrequent or ineffective feeding, leading to dehydration and reduced bowel motility
• Encourage early and frequent breastfeeding with adequate support

Breast Milk Jaundice

• Onset at day 3-7, may persist up to 1 month, with a gradual decline over 2-3 months
• Infants are clinically asymptomatic except for the jaundice
• Rule out other causes, reassure, continue breastfeeding while closely monitoring bilirubin levels

Kernicterus

• A complication of NNJ where excessive free unconjugated bilirubin crosses the blood-brain barrier, depositing in the brain tissue and causing toxic effects
• SB levels are >340 umol/L
• Acute bilirubin encephalopathy presents with hypotonia and retrocollis-opisthotonos
• Chronic bilirubin encephalopathy results in permanent neurotoxicity, potentially leading to motor and speech issues or cerebral palsy

Transcutaneous Bilirubin Measurement

• Measurement is a screening tool, not diagnostic
• Forehead and sternum are measured by transcutaneous bilirubinometer

Total Serum Bilirubin

• Considered a diagnostic test and can be used in infants less than 35 weeks gestation

Phototherapy

• Catalyzes unconjugated bilirubin into water-soluble lumirubin, bypassing the immature liver and allowing excretion in bile/urine.
• Involves placing the baby naked in an incubator, eye protection, eye care, turning, ensuring adequate intake every 3 hours, close monitoring

Exchange Transfusion

• Involves double-volume transfusion while continuing phototherapy, especially for premature babies

Birth Asphyxia

• Newborn fails to initiate or sustain respiration, leading to hypoxemia, hypercapnia, and tissue ischemia
• Maternal factors include inadequate placental perfusion, such as pre-eclampsia toxemia, placenta previa, and placental abruption
• Fetal factors include intrauterine growth restriction (IUGR), prematurity, and meconium aspiration
• Labor complications include hypertonic uterine contraction, shoulder dystocia, and cord prolapse.
• Phases include hyperventilation (tachypnea) and gasping, which can lead to secondary apnea, which is resolved by assisted ventilation

APGAR Score in Asphyxia

• Score >7 indicates no asphyxia
• Score 4-7 indicates mild/moderate asphyxia
• Score <=3 indicates severe asphyxia, requiring active resuscitation and NICU

Initial Steps & Routine Care

• Warmth, Dry, Stimulate, Sniffing Position
• Suction mouth first, then nose, using 80-100mmHg

Ventilation and Oxygenation

• Auscultate Heart Rate by stethoscope, count 6s & multiply by 10
• Oximeter probe on right wrist/palm (pre-ductal saturation)
• Call for help & PPV (within 1 min)
• O2 10L/min, 21% if >=35wk, 30% if <35wk
• Oxygen blender: 20-40cm H2O
• Ventilation rate & pressure (PPV) @ 40-60 breaths/min; "Breath-2-3"
• Effective ventilation is indicated as: - Rising HR, increasing within 15s, - >100bpm within 30s - Visible chest movement
• Consider ECG when PPV (with oximetry)
• ET tube: - Size (<28wk=2.5, 28-34wk=3.0, >34wk=3.5
• In-situ indicator: Increasing HR, CO2 detector (evidence of exhaled CO2 in tube)

Chest Compression

• If HR <60bpm, despite effective PPV for 30s then provide chest compressions
• Position: firm support to back, neck slightly extended
• Location: Compressed at lower third of sternum
• Depth: 1/3 of AP diameter of chest
• Compression to ventilation ratio: 3:1 ("1 and 2 and 3 and breath"),
• Total 30 cycles (!20 events) / min
• Technique: 2 thumb technique

Administer Drugs/Volume expander

• Narcan 0.1mg/kg (C/I to opioid-addicted mother)

Infant Growth & Development

• Principle of growth and development:Continuity, Sequential, From head to downwards, From center of the body outwards, From simple to more complex
• Reflex: Rooting, Sucking, Palmar grasp
• Major Principles of introducing solid food: Gradual change from fluid to solid, From scanty amount to more, All types of nutrients

Birth Injuries

• Structural damage or functional deterioration of a newborn, secondary to a traumatic event that occurred during labor, delivery, or both

Predisposing factors of birth injuries

• Include maternal and fetal factors such as nulliparity, short stature, macrosomia, prematurity, malpresentation, and manipulation during labor

Skin and Superficial Tissue Injuries

• Include abrasions, punctures, lacerations, oedema, bruising, and petechiae.

Muscle Injury

• Torticollis (wry neck) involves tightening and shortening of the sternocleidomastoid muscle, causing the neck to twist to the affected side
• Educate passive muscle-stretching exercise
• Encourage moving neck to less preferred side
• Surgical intervention if persisted after 1 year old.

Explore neonatal jaundice, its causes like elevated bilirubin, and treatments such as phototherapy. Learn about bilirubin metabolism, the role of glucuronyl transferase, and factors affecting conjugation. Understand symptoms of acute bilirubin encephalopathy and the use of bilirubinometers.