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Neonatal Jaundice

Neonatal Jaundice. Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University. Introduction. Jaundice is quite common in newborns Full term infants: at least 50% Preterm infants: over 80%. Introduction continued. When?

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Neonatal Jaundice

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  1. Neonatal Jaundice Dezhi Mu MD/PhD Department of Pediatrics, West China Second University Hospital, Sichuan University

  2. Introduction Jaundice is quite common in newborns Full term infants: at least 50% Preterm infants: over 80%

  3. Introduction continued When? in the first week of life Where? skin and sclera What ? blood bilirubin concentrations is ≥5mg/dl.

  4. Introduction continued

  5. RBC、Heme Albumin Y Z Bilirubin Metablism Reticuloendothelial 1.Bilirubin 2. Bilirubin-Albumin Complex Cytoplasmic 3.Conjugated bilirubin Y Y Z Z UDPGT 4. Intestine -glucuronidase ENTEROHEPATIC CIRC Urobilinogen Fecal bilirubin

  6. The metabolic characteristics of bilirubin in newborns: 1. Bilirubin production 8.8mg/Kg/d in newborns 3.8mg/Kg/d in adults 2. Bilirubin-albumin complex formation a. preterm infants b. acidosis

  7. The metabolic characteristics of bilirubin continued 3. Bilirubin metabolism in hepatocyte a. Hepatic uptake of bilirubin, Y, Z protein b. Bilirubin conjugation: UDPGT (uridine diphosphate glucoronosyl transferase) 4. Enterohepatic circulation

  8. Bilirubin toxicity 1. Conjugated bilirubin water-soluble 2. Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy (kernicterus)

  9. Manifestations Evaluation of jaundice: 1. By eyes: face: 5mg/dl ( 85μmol/L ) abdomen: 10-15mg/dl limbs: 15-20mg/dl 2. By transcutaneous measurement : used for screening 3. By serum levels : standard

  10. 8.1mg/dl Skin color of different levels of jaundice Face 14.3mg/dl 22.5mg/dl Abdomen Limbs

  11. Manifestations continued Classification: Physiological Jaundice Pathological Jaundice

  12. Manifestations continued Physiological jaundice1. Cause: relevant to bilirubin metabolism 2. Appears 2-3 days (>24h of age) peaks 4-5days fades <2 week (term infants) <4 weeks (preterm infants)

  13. Manifestations continued Physiological jaundice3. Bilirubin level < 12.9mg/dl (full term infants) <15mg/dl (preterm infants) 4. Bilirubin accumulates <5mg/dl/d 5. General condition is good 6. Treatment: early feeding, help pass meconium from the bowels

  14. Manifestations continued • Pathological Jaundice 1. Appears earlier (first 24 hours of life) 2. Peaks >12.9mg/dl (full term infants) >15mg/dl (preterm infants) Fades >2 weeks (term infants) >4 weeks (preterm infants) 3. Accumulates >5mg/dl/d 4. Direct bilirubin >2mg/dl 5. Jaundice recurrence

  15. Hemolytic disease of newborn Hemolytic disease: ABO: 85.3% Rh : 14.6% MN : 0.1%

  16. Hemolytic disease of newborncontinued ABO incompatibility the mother: type O the infant: type A or B Rh incompatibility the mother:Rh (−) the infant: Rh (+) D, E, C, d, e, c

  17. Clinical Manifestations ABO Rh 1.Jaundice : mild severe 2-3 day 24 h 2.Anemia:mild severe (3-6 weeks) heart failure 3.Hepato- rare common splenomegaly

  18. Clinical Manifestations continued Bilirubin Encephalopathy & Kernicterus • warning stage • convulsion stage • recovery stage • sequelae stage

  19. Laboratory tests: 1. Blood type incompatibility 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1) Hemoglobin level : 2) Reticulocytes: 3) Nucleated RBC:

  20. Laboratory tests continued Antibody test 1) Direct Coombs test (+) confirm 2) Antibody release test (+) confirm 3) Free antibody test (+) judge

  21. Treatments 1) Phototherapy 2) Exchange transfusion 3) Internal Medicine

  22. Treatments continued 1. Phototherapy Indications of phototherapy : Unconjugated bilirubinemia Bilirubin level >12mg/dl Light source: Spectral outputs 425 to 475nm

  23. Treatments continued 1. Phototherapy

  24. Treatments continued Before After 1. Phototherapy

  25. Treatments continued Side effects of phototherapy : a. fever b. diarrhea c. skin rash d. bronze baby syndrome (conjugated bilirubin>4mg/dl)

  26. Treatments continued Rash bronze baby syndrome Side effects of phototherapy :

  27. Treatments continued 2. Exchange Transfusions: a. Severe hemolytic disease b. Refractory to phototherapy

  28. Treatments continued Aims of transfusions: a. Remove antibodies b. Remove bilirubin c. Correct anemia

  29. Treatments continued Indication of transfusions: one of the follows 20mg/dl >4mg/dl, Hb<120g/L 0.7mg/dl/h Kernicterus

  30. Treatments exchange transfusions Source of the blood mother newborns For Rh: Rh ABO incompatibility For ABO: “AB” plasma “O” cells incompatibility packed RBC

  31. Treatments exchange transfusions Volume 150-180ml/kg (twice as much as the blood volume of a newborn) Method Through peripheral blood vessels

  32. Treatments exchange transfusions Bilirubin 22.7mg/dl

  33. Treatments exchange transfusions Exchange transfusion Radial artery (out) Dorsalis pedis vein (in)

  34. Treatments continued 3. Pharmacological agents: a. Phenobarbital Effects: Uptake, Conjugation b. Albumin c. IVIG d. Probiotics

  35. Preventions For ABO incompatibility: No For Rh incompatibility 300 μg of human anti-D globulin within 72 h of delivery

  36. Case analysis : 24 h old male infant, gravida 1, para 1. Apgar scores: 8 at 1 min Mother: blood type “O”, Father: “AB” PE: icterus appeared on face and trunk skin liver edge 3cm palpable spleen tip

  37. Case analysis continued Lab tests: Hb:13g/dl, reticulocyte count : 7% Blood smear: nucleated RBC Blood type: A, Rh-positive Serum bilirubin: 12.9mg/ml Direct Coomb’s test: weakly positive Question: what’s the risk factor?

  38. Thank you and Welcome to become a pediatrician ! Email: mudz@scu.edu.cn Tel : 028-85503185 (O)

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