Neonatal Jaundice

What sample is needed for Neonatal Jaundice?

1. The blood of the neonate is needed.
2. In difficult cases, it may get blood from the femoral vein.
3. Blood can be obtained from the finger or the heel prick.

How will you define the importance of neonatal jaundice?

1. Neonatal jaundice appears in the early days of the newborn.
2. If jaundice persists beyond 14 days, it indicates some pathological cause.
   1. This may be a hemolytic disease of the newborn that starts in utero and causes jaundice, anemia, and hepatosplenomegaly in mature infants.
3. The degree of severity of the disease ranges from mild anemia to mental retardation, brain damage, and kernicterus or stillbirth.
4. The early diagnosis and the significance of unconjugated hyperbilirubinemia are the potentials for developing Kernicterus.

How will you define Kernicterus?

Definition of kernicterus:

1. Kernicterus is the bilirubin staining of the central nervous system and basal ganglia with death or permanent neurologic or mental abnormalities.
   1. This disease was first studied in the 1950s, and Rh-induced hemolytic anemia was supposed to be the cause.
2. 20 mg/dL of the unconjugated bilirubin in mature newborns or 15 mg/dL in premature newborns leads to kernicterus.

What are the causes of kernicterus?

1. Acidosis.
2. Respiratory distress.
3. Very low birth weight.
4. Infections.
5. In these babies, kernicterus may develop at 15 mg/dL level, and few babies may develop this syndrome as low as 9 to 10 mg/dL of unconjugated bilirubin.

What are the signs and symptoms of kernicterus?

1. It causes neurotoxicity.
2. There is lethargy and gradual progress in opisthotonus and seizures.
3. 70% of the affected neonates die within the first week.
4. The rest will have severe brain damage.
5. This can be prevented by blood exchange transfusion and phototherapy.

How will you treat kernicterus?

1. Some physicians start phototherapy at 15 mg/dL bilirubin level.
   1. Phototherapy converts unconjugated bilirubin into soluble, nontoxic bilirubin isomers.
2. Blood transfusion exchange will be given in severe hemolytic anemia crises.

What are the types of neonatal jaundice?

1. Physiologic jaundice.
2. Pathologic jaundice.
3. Neonatal jaundice may be:
4. Unconjugated hyperbilirubinemia:
   1. Physiologic jaundice.
   2. Hemolytic disease.
   3. Breast milk hyperbilirubinemia.
5. Conjugated hyperbilirubinemia:
   1. Idiopathic neonatal hepatitis.
   2. Biliary atresia.

What are the causes of neonatal jaundice?

1. Hemolytic disease of the newborn.
2. Bacterial sepsis.
3. Toxoplasma infection.
4. Cytomegalovirus.
5. G-6PD deficiency.
6. Extensive bruising.
7. Other minor causes are:
   1. Breastfeeding.
   2. Race.
   3. H/O maternal smoking.
   4. H/O prematurity.

How will you discuss the Physiologic jaundice?

1. This is a benign type of jaundice.
2. This results from the insufficient hepatocyte enzyme, so unconjugated bilirubin is increased.
3. This jaundice appears in the first 2 to 3 days.
   1. It is pathological jaundice if it goes to 10 to 12 mg/dL on the first day.
4. Bilirubin rarely goes above 5 mg/dL per day.
   1. 90% is unconjugated.
5. The peak level lasts 4 to 5 days, and serum bilirubin level is around 5 to 6 mg/dL.
   1. This jaundice lasts for roughly 2 weeks.
6. This is treated by phototherapy (450 nm light source).
   1. Light converts bilirubin to a stable, nontoxic isomer.

How will you discuss the Pathologic jaundice?

1. The most common cause is the hemolytic disease of the newborn (HDN).
2. There is severe hyperbilirubinemia.
3. The blood-brain barrier is not well developed, so unconjugated bilirubin can cross this barrier.
4. The damage to the brain is called Kernicterus.
5. In kernicterus, there is yellowness of the subthalamic nucleus, hippocampus, thalamus, putamen, cerebellar nuclei, cranial nerves, and globus pallidus.
6. Differentiating points from physiologic jaundice are:
   1. The appearance of jaundice within the first 24 hours of birth.
   2. The persistent rise in the bilirubin is beyond one week.
   3. Persistent jaundice beyond 10 days.
   4. Bilirubin level exceeding 12 mg/dL.
   5. If there is a single-day rise of 5 mg/dL.
   6. Conjugated bilirubin may exceed 2 mg/dL.

Neonatal Jaundice: Mechanism of Neonatal jaundice

Criteria of pathological jaundice:

What is the differential diagnosis of neonatal jaundice?

1. Jaundice appearing in the first 24 hours suggests:
   1. Hemolytic disease of the newborn, Erythroblastosis fetalis.
   2. Sepsis.
   3. Concealed hemorrhage.
   4. TORCH infection.
2. Jaundice appearing between 3 to 7 days of birth suggests:
   1. Bacterial infections like urinary tract,
3. Jaundice appearing after one week of birth suggests:
   1. Bacterial sepsis.
   2. Extrahepatic biliary atresia.
   3. Cystic fibrosis.
   4. Breast milk jaundice.
   5. Congenital absence of bile duct.
   6. Neonatal hepatitis. Galactosemia.
   7. Hemolytic anemia (G6PD deficiency and hereditary spherocytosis).

How will you treat Neonatal Jaundice?

1. Phototherapy may be considered when the bilirubin level is:
   1. Above 10 mg/dL before 12 hours of birth.
   2. Above 12 mg/dL before  18 hours of birth.
   3. Above 14 mg/dL before 24 hours of birth.
   4. Phototherapy converts unconjugated bilirubin into a molecule that can be excreted without conjugation.
   5. Phototherapy is not good for conjugated hyperbilirubinemia.
2. Blood exchange transfusion is considered when the bilirubin level exceeds 20 mg/dL.

Questions and answers: