Neonatal Jaundice

Last updated 20.09.12 

 

Definition

-  Jaundice present in neonate

 

Features

-  Effects 50%+/- of newborns

-  Usually physiological

-  Usually occurs when SBR 85-120 mmol/L

-  If onset <48hrs old always pathological

-  If onset >48hrs old ?physiological

-  Persistant jaundice requires Ix

-  >1 week if term baby

-  >2 weeks if Prem

-  DDx Cholestatic jaundice

 

Risk Factors

-  Jaundice in first 48hrs

-  Blood group incompatability

-  Sibling requiring phototherapy

-  Cephalohaematoma or significant bruising

-  >10% weight loss

-  Family Hx red cell enzyme defect

-  Low Risk

-  >38/40, well, <10% weight loss, not at risk of haemolysis

-  At Risk

-  35-37+6/40, well, <10% weight loss, not at risk of haemolysis

-  >38/40, >10% weight loss, sleepiness or poor feeding

-  High Risk

-  >38/40, confirmed or likely haemolysis

-  >35/40, clearly unwell

-  35-37+6/40, confirmed or likely haemolysis, poor feeding, >10% weight loss

-  <35/40

-  At Risk for Haemolysis

-  Previous child with Ab mediated haemolytic disease of newborn

-  Family Hx of G6PD deficiency or RBC membrane or metabolic defects (Spherocytosis..)

-  Maternal positive antibody screen + positive cord blood Coombs to Anti-D, Anti-c or Anti-Kell

-  Visible jaundice in first 24hrs after birth

-  In utero haemolysis confirmed or presumed (fetal anaemia) with positive maternal antibody screen

-  SBR rising despite phototherapy

-  SBR above exchange level on first test

-  Unwell baby with sepsis, seizure, apnoea or unusual hypoglycaemia

 

Causes

-  Dehydration

-  Physiological

-  >48hrs old

-  Peaks day 3, resolves day 7+/-

-  Unconjugated

-  Dx of exclusion

-  Increased RBC production

-  Decreased conjugation & excretion

-  Increased enterohepatic circulation of billirubin

-  Breast Milk

-  Prolonged unconjugated

-  Peaks week 2, lasts up to 3 months

-  Resolves if breast feeding interrupted

-  Baby health & thriving

-  Haemolysis

-  Immune mediated: ABO or Rhesus incompatability (Haemolytic disease of newborn, isoimmunisation)

-  Meds

-  Sepsis or congenital infection

-  Hereditary: spherocytosis, G6PD deficiency, Pyruvate deficiency, Haemoglobinopathies..

-  Polycythemia: GDM, delayed cord clamping

-  Congenital hypothyroidism (? Unconjugated)

-  Neonatal hepatitis (CMV, Rubella, Hep A, B, C)

-  If jaundice persists exclude Cholestatic jaundice: Galactosaemia, biliary atresia..

 

Complications

-  Kernicterus (Bilirubin encephalopathy): CNS damage

-  Death

 

Associated S/S

-  Jaundice

-  Scleral icterus

-  More severe if palms & soles effected

-  Cephalocaudal progression

-  Neonates should be assessed every day whilst in hospital

-  Feeding: dehydration, starvation

-  Stool pattern: Hirschsprungs, pale stool

-  Vomiting: bowel obstruction, pyloric stenosis

-  Height & weight: IUGR, GDM (polycytehmia)

-  Plethora: polycythemia

-  Pallor: anaemia

-  Activity: sepsis

-  Petechiae, cephalohaematoma

-  Hepatosplenomegaly

-  Neuro Exam: kernicterus

 

Ix

-  SBR or TcB

-  Obvious jaundice in pale skinned babies below nipples or suspicion in dark skinned baby esp <24hrs

-  TcB not suitable for high risk, must do SBR

-  SBR daily if on Phototherapy

-  Compare level to charts for weight & gestation

-  Bilitool online calculator

-  Depth of jaundice poor guide to SBR

-  Elevated conjugated (>15%) consider hepatitis or cholestatic jaundice

-  Always abnormal

-  <48 hrs or SBR/TcB requiring phototherapy

-  FBE : haemolysis

-  Blood group

-  Coombs + elution test

-  Maternal blood group

-  CRP: DDx sepsis

- LFTs , conjugated Bilirubin

-  +/- BC

-  >48 hrs

-  ? physiological

-  +/- as above

-  +/- Urine: urinary reducing substances: galactosaemia

-  +/- G6PD: G6PD deficiency

-  +/- blood film & E5M: hereditary pherocytosis

Persistant jaundice (>2 weeks)

-  LFTs

-  SBR

-   Unconjugated (>85%): hypothyroidism, infection (UTI..), haemolysis, poor feeding, breast milk jaundice

-   Conjugated (always abnormal): requires further Ix: Cholestatic Jaundice

-  TFT: congenital hypothyroidism

-  +/- abdo US

 

Mx

-  Adequate calories & fluid

-  Lactaton support

-  +/- Abx if septic

-  SBR on Nomogram

-  Phototherapy (blue light)

-   Isomerisation (trans to cis) --> increased excretion

-   Once commenced clinically not reliable to determine jaundice

-   May cause dehydration

-   Daily SBR until 50mol/L below treatment threshold

-   Then repeat SBR each 2-3 days until peaked, expect peak 24-48hrs post cessation of phototherapy

-   Monitoring: hydration, temp, jaundice, kernicterus

-  Exchange transfusion (avoided if possible)

-  May cause long term portal hypertension

-  +/- IVIG

-  +/- Albumin

-  Mx by Risk Stratification

-  Low Risk & Nomogram requires no Rx

-  D/C <48hrs appropriate

-  Jaundice above nipples: R/V each 2-3 days until improved

-  Jaundice below nipples: community R/V w bilirubin check

-  At Risk/High Risk

-  D/C <48hrs not recommened

-  Paediatric R/V

-  Ongoing TcB or SBR until levels falling or phototherapy reached

 

 

 

References

 

SA Perinatal Practice Guidelines, Chapter 83: Neonatal Jaundice, 02/08/10

RCH NET Neonatal Handbook: Jaundice

Bilitool online calculator