Paeds LT 1.3 Neonatal jaundice.pdf

Lydia Lau [email protected] Associate Professor Common Neonatal Presentation Learning Objectives: 1. Understand what is neonatal jaundice 2. Assessment of jaundice 3. Phototherapy 4. General principles in management of neonatal jaundice Hyperbilirubinemia  Accumulation of excess bilirubin in...

Lydia Lau [email protected] Associate Professor Common Neonatal Presentation Learning Objectives: 1. Understand what is neonatal jaundice 2. Assessment of jaundice 3. Phototherapy 4. General principles in management of neonatal jaundice Hyperbilirubinemia  Accumulation of excess bilirubin in blood serum Bilirubin (uncongugated) is a breakdown product of haemoglobin Unconjugated bilirubin  Highly lipid soluble  Cross blood brain barrier  Kernicterus  Develop Cerebral Palsy due to damage to the basal ganglia  S/S: Lethargic, poor feeding, abnormal tone and posturing, high-pitch cry & irritability 3 Physiological jaundice  About 60% of healthy babies become clinically jaundice in the 1st week of life  >24-36 hours ; rate of rise 34 weeks, at least 24 hours of life, up to 14 days of life 6 Investigation  Serum Bilirubin level should be done when TcB is at or above indicated level as below  FBC, retic count and direct Coomb’s  U/E/Cr: to assist therapy for dehydration  Albumin: SB: albumin ratio 7 Phototherapy involves the exposure of as much of the baby’s skin as possible  to blue fluorescent lights, which emit wavelengths in the 430–490nm range.  Decreases the bilirubin level by enhancing the conversion of bilirubin in the exposed skin to a more easily excretable form  Bound to albumin, transported to liver, excreted into bile  Increasing the amount of skin exposure to blue lights can enhance bilirubin excretion  Ensure adequate hydration, at least more than 6 wet diapers  Observe urine and stool nature & colour  Check skin integrity 8  Excessive breakdown of RBC Fetal Hb: 18-20 g/dl Life span: 90 days Increased Unconjugated Bilirubin Immature liver to Phototherapy produce sufficient enzyme glucuronyl Convert to water- transferase for soluble bilirubin bilirubin Jaundice conjugation (Hyperbilirubinemia) = Unconjugated Bilirubin Conjugated Excreted via Bilirubin by Liver - Urine and Stool Bile 9 Single Blue Phototherapy  The exposure of one plane of body surface (e.g. either the baby’s front or back) to the phototherapy light  Regularly turning the baby helps to maximise the exposure of all surfaces (turning 2-3 hourly)  Keep baby warm using heat shield, check 4 hourly Temp, heart rate and respiration rate  Use eye covers to prevent damage to baby’s eyes, remove during feeding 10 Double Blue Phototherapy  The simultaneous exposure of two body surface planes to two separate sets of blue lights, i.e. both front and back.  Recommended if the SB level above double blue phototherapy criteria or if the rate of rise of SB is >5μmol/L/hr. Side effects  Increase insensible water loss; Temperature instability  Rashes; Diarrhoea; Retinal damage Exchange  Principles of exchange transfusion 11 Bili-blanket (fibreoptic light system) Fibre-optic The science of light transmission through very fine, flexible glass or plastic fibers. BiliBed (fibreoptic light system) 12 Low risk factors: physiological jaundice High risk factors: Preterm; haemolytic jaundice; sepsis; dehydration 13 Feeding:  Feeding can be continued; nil by mouth if the baby needs exchange transfusion  Increase feeds by at least 10% over the usual expected intake  Continue breastfeeding  If not near or at exchange transfusion level, the baby can be taken off the lights for up to 30 mins to breastfeed  Once the ‘off phototherapy’ level has been reached and the baby has completed at least 24 hours of phototherapy  Parental and caretaker education:  Importance of follow up especially for babies discharged before age 48 hours  Give thorough breastfeeding advice  Teach mothers and caregivers the signs of dehydration 14  Medical cause: infection (URTI, GE, UTI, conjunctivitis, otitis media, meningitis,  Surgical cause: HI, trauma, intussusception, IO, pyloric stenosis, hernia,  Significant positive history or physical finding that suggest physical illness (Poor feeding, decreased feeding, vomiting, fever are especially important  Any features suggestive of NAI or injury  Abnormal FBC, UFEME, AXR  Parental anxiety and inability to cope or poor parent-craft 15 Department of Emergency Medicine. Clinical Guidelines (December 2018 Edition). KK Women’s and Children’s Hospital. P 86-87. Pillitteri, A. (2014). Maternal & Child Health Nursing Care of the Childbearing & Childrearing Family (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Silbert-Flagg, J. & Pillitteri, A. (2018). Maternal and Child Health Nursing. (8th ed.). Philadelphia: Lippincott Williams & Wilkins. 16