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NEONATAL HYPERBILIRUBINEMIA

NEONATAL HYPERBILIRUBINEMIA. Neonatal Jaundice. Learning Objectives: Define hyperbilirubinemia. Differentiate between physiological and pathological jaundice. Causes of hyperbilirubinemia. Discuss the pathophysiology of hyperbilirubinemia.

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NEONATAL HYPERBILIRUBINEMIA

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  1. NEONATAL HYPERBILIRUBINEMIA

  2. Neonatal Jaundice • Learning Objectives: • Define hyperbilirubinemia. • Differentiate between physiological and pathological jaundice. • Causes of hyperbilirubinemia. • Discuss the pathophysiology of hyperbilirubinemia. • Describe the most dangerous complication of hyperbilirubinemia. • therapeutic management. • Design plan of care for baby has hyperbilirubinemia.

  3. Neonatal Jaundice(Hyperbilirubinemia) • Definition: Neonatal Hyperbilirubinemiarefers to an excessive level of accumulated unconjugated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails. • Unconjugated bilirubin = Indirect bilirubin. • Conjugated bilirubin = Direct bilirubin.

  4. Neonatal Jaundice • In newborns, Jaundice occurs if the unconjugated bilirubin level is >5mg/dl.In adults jaundice appears if the bilirubin level >2mg/dl. • Occurs in 60% of term and 80% of preterm neonates • However, significant jaundice occurs in 6 % of term babies • 6-10% require phototherapy/ other therapeutic options.

  5. Hb → globin + haem 1g Hb = 34mg bilirubin Non – heme source 1 mg / kg Bilirubin metabolism Bilirubin Ligandin (Y - acceptor) Intestine Bilirubin glucuronidase Bil glucuronide Bil glucuronide β glucuronidase bacteria Bilirubin Stercobilin

  6. Bilirubin Production & Metabolism

  7. Clinical assessment of jaundice(Kramer’s staging) Area of body Bilirubin levels mg/dl(*17=umol) Face Zone-1: 4-6 Upper trunk Zone-2: 6-8 Lower trunk & thighs 8-16 Arms and lower legs Zone-3: 8-12 Palms & soles Zone-4 :12-14 Zone-5 :>15

  8. Physiological jaundice Characteristics • Appears after 24-72 hours • Maximum intensity by 3th-5th day in term & 7th day in preterm • Serum level less than 15 mg / dl • Clinically not detectable after 14 days • Disappears without any treatment Note: Baby should, however, be watched for worsening jaundice.

  9. Why does physiological jaundice develop? • Increased bilirubin load. • Defective uptake from plasma. • Defective conjugation. • Decreased excretion. • Increased entero-hepatic circulation.

  10. Pathological jaundice • Appears within 24 hours of age • Increase of bilirubin > 5 mg / dl / day • Serum bilirubin > 15 mg / dl • Jaundice persisting after 14 days • Stool clay / white colored and urine staining clothes yellow • Direct bilirubin> 2 mg / dl

  11. Causes of jaundice Appearing within 24 hours of age • Hemolytic disease of NB : Rh, ABO • Infections: TORCH, malaria, bacterial • G6PD deficiency

  12. Causes of jaundice Appearing between 24-72 hours of life • Physiological • Sepsis • Polycythemia • Intraventricular hemorrhage • Increased entero-hepatic circulation

  13. Causes of jaundice After 72 hours of age • Sepsis • Cephalhaematoma • Neonatal hepatitis • Extra-hepatic biliaryatresia • Breast milk jaundice • Metabolic disorders (G6PD).

  14. Breast feeding jaundice • In exclusively breast feed infants • Appears at 24-48 hrs of age • Peaks by 5-15 days • Disappears by 3rd week • Its related to inadequate B.F • T/t:Proper & adequate B.F

  15. Breast milk jaundice • In 2-4 % EBF babies • SBr>10mg/dl beyond 3rd-4th week • Should be differentiated from Hemolytic jaundice, hypothyroidism, G6PD def • T/t: Some babies may require PT Continue breast feeding Usually declines over a period of time

  16. Risk factors for jaundice JAUNDICE • J - jaundice within first 24 hrs of life • A - a sibling who was jaundiced as neonate • U - unrecognized hemolysis • N – non-optimal sucking/nursing • D - deficiency of G6PD • I - infection • C – cephalhematoma /bruising • E - East Asian/North Indian

  17. Diagnostic evaluation: • Normal values of unconjugated B. are 0.2 to 1.4 mg/dL. • Investigate the cause of jaundice.

  18. Therapeutic Management • Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity • Prevention of hyperbilirubinemia: early feeds, adequate hydration • Reduction of bilirubin levels: phototherapy, exchange transfusion, • Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.

  19. Babies under phototherapy Baby under conventional phototherapy Baby under triple unit intense phototherapy

  20. Prognosis • Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.

  21. Nursing considerations of Hyperbilirubinemia • Assessment: • observing for evidence of jaundice at regular intervals. • Jaundice is common in the first week of life and may be missed in dark skinned babies Blanching the tip of the nose

  22. Approach to jaundiced baby • Ascertain birth weight, gestation and postnatal age • Ask when jaundice was first noticed • Assess clinical condition (well or ill) • Decide whether jaundice is physiological or pathological • Look for evidence of kernicterus* in deeply jaundiced NB *Lethargy and poor feeding, poor or absent Moro's, or convulsions

  23. Thank You!

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