Multidisciplinary Neonatal Jaundice Promoting multiprofessional education and development

Multidisciplinary Neonatal Jaundice Promoting multiprofessional education and development in Scottish maternity care Quality Education for a Healthier Scotland

Neonatal Jaundice Definition = Total serum bilirubin (SBR) > 85 µmol/L. Quality Education for a Healthier Scotland Multidisciplinary

Why is it important? • Common • Worrying for parents and / or staff • Condition and treatment • Sign of underlying disease • Can cause neurological problems. Quality Education for a Healthier Scotland Multidisciplinary

Where does bilirubin come from? Quality Education for a Healthier Scotland Multidisciplinary

Causes Multidisciplinary • Benign • Physiological • Breast milk and breastfeeding • Pathologic. Quality Education for a Healthier Scotland

Multidisciplinary Quality Education for a Healthier Scotland

Physiological Jaundice Multidisciplinary Features: • Elevated unconjugated bilirubin • SBR generally peaks @ 85 -100 µmol/L on day 3 -4 and then declines to adult levels by day 10 • Asian infants peak at higher values (110 µmol/L ) • Exaggerated physiological (up to 290 µmol/L). Quality Education for a Healthier Scotland

Physiological Jaundice Multidisciplinary Asian infant Breastfed infant Non-breastfed infant Quality Education for a Healthier Scotland

Physiological Jaundice Increased rbc’s Shortened rbc lifespan Immature hepatic uptake and conjugation Increased enterohepatic circulation. Quality Education for a Healthier Scotland Multidisciplinary

Breast Milk Jaundice • Elevated unconjugated bilirubin • Prolongation of physiological jaundice • May be second peak @ day 10 • Average max SBR = 170 -205 µmol/L • SBR may reach 376 -410 µmol/L • ? Milk factor. Quality Education for a Healthier Scotland Multidisciplinary

Pathologic Jaundice • Features • • Jaundice in first 24 hrs Rapidly rising SBR • • • > 85 µmol/L per day SBR > 290 µmol/L. Categories • • • Increased bilirubin load Decreased conjugation Impaired bilirubin excretion. Quality Education for a Healthier Scotland Multidisciplinary

1. Increased Bilirubin Load Elevated unconjugated bilirubin • Haemolytic Disease • Non-haemolytic Disease. Quality Education for a Healthier Scotland Multidisciplinary

Multidisciplinary Quality Education for a Healthier Scotland

Multidisciplinary Quality Education for a Healthier Scotland

2. Decreased Bilirubin Conjugation Elevated unconjugated bilirubin • Genetic Disorders • Hypothyroidism. Quality Education for a Healthier Scotland Multidisciplinary

3. Impaired Bilirubin Excretion - usually later Elevated conjugated bilirubin o> 35 µmol/L or > 20% of SBR • Biliary Obstruction • Important to diagnose by 4 weeks • Infection • Metabolic Disorders • Chromosomal Abnormalities • Drugs. Quality Education for a Healthier Scotland Multidisciplinary

Diagnosis and Evaluation Multidisciplinary • Physical Examination • Jaundice visible when bilirubin reaches 85 µmol/l • Milder jaundice generally confined to face and upper chest • Downward extension generally signifies increasing bilirubin values. Quality Education for a Healthier Scotland

Diagnosis and Evaluation • Laboratory • Blood test • Indirect measurements • Transcutaneous. Quality Education for a Healthier Scotland Multidisciplinary

Risk Factors for increased Hyperbilirubinemia • Jaundice in first 24 hrs • Visible jaundice prior to discharge • Previous jaundiced infant • Gestation 35 -38 wk. Multidisciplinary • Exclusive breastfeeding • Asian race • Bruising, cephalohaematoma • Male sex. AAP, Subcommittee on Neonatal Hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics 2001; 108. Quality Education for a Healthier Scotland

Treatment Multidisciplinary • Underlying Cause • Where one is identified • Fluids and Nutrition • Phototherapy. Quality Education for a Healthier Scotland

Phototherapy Multidisciplinary • Mechanism • Forms • Breastfed infants are slower to recover • Rebound hyperbilirubinemia is rare Average increase is 17 µmol/L. • Quality Education for a Healthier Scotland

Treatment Multidisciplinary Quality Education for a Healthier Scotland

Treatment Multidisciplinary • Underlying Cause • Where one is identified • Fluids and Nutrition • Phototherapy • Monitoring and follow up • ? Repeat hearing checks • ? Hb checks for late anaemia. Quality Education for a Healthier Scotland

Exchange Transfusion Mechanism: removes bilirubin and antibodies from circulation • Most beneficial to infants with haemolysis • Generally never used until after intensive phototherapy attempted. • Quality Education for a Healthier Scotland Multidisciplinary

Kernicterus Multidisciplinary What is it? • Bilirubin induced toxicity to Basal Ganglia and brainstem nuclei. Increase in cases beginning in early 1990 s • At least partially related to early hospital discharge. Quality Education for a Healthier Scotland

Multidisciplinary Any questions? Quality Education for a Healthier Scotland

Summary Multidisciplinary • Jaundice is common and “normal” • Recognition of at risk infant • Assessment - clinical and biochemical • Treatment. Quality Education for a Healthier Scotland