Neonatal Jaundice Breast Milk Jaundice, Phototherapy
Feb 16, 2023
Neonatal jaundice is an important topic for the NEET PG exam in pediatrics as it is a common condition affecting over 60% of newborns and is a leading cause of hospital readmission in the first 2 weeks of life.
Jaundice in newborns can be a sign of underlying diseases such as hemolytic anemia, infection, or liver dysfunction, and early recognition and treatment are essential to prevent severe complications such as kernicterus, which can lead to permanent brain damage.
Let's learn about this commonly tested topic in the NEET PG exam.
Overview
Clinical jaundice in neonates: At bilirubin level >5 mg / dL. Very common in neonates
Physiological jaundice
Pathological jaundice
It is clinical jaundice, which never appears in first 24 hrs
May appears in first 24 hrs
Always unconjugated
Urine does not stain diaper
May be conjugated or unconjugated.
Pale stools, high coloured urine
Icterus- does not involve palm and soles
Palm & sole may be stained yellow
Clinical jaundice does not persist beyond 3 weeks
May persist for longer time
Breastfeeding jaundice
It is due to inadequate breastfeeding
Rx: Adequate & frequent breastfeeding
Breast milk jaundice
Jaundice due to certain substances present in breast milk like pregnanediol or FFA that interferes with conjugation of bilirubin. Breastfeeding should be continued, it is withheld only when bilirubin level goes >20 mg/dL
Etiology of unconjugated hyperbilirubinemia
Increased production bilirubin
Decreased conjugated of bilirubin
Can be due to haemolytic causes like Erythroblastosis fetalis or haemolytic ds of new born – m/c
Hereditary spherocytosis
G6PD deficiency
Crigler-Najjar syndrome (due to deficiency of UDPGT that conjugate bilirubin)
Conjugated hyperbilirubinemia: When level of conjugated bilirubin >2 mg /dL or >20% of total bilirubin
Etiology of conjugated hyperbilirubinemia
Non obstructive
Obstructive
Infections:
TORCH
-Congenital TB
Metabolic causes
α-1 antitrypsin deficiency
Cystic fibrosis
Tyrosinemia
Galactosemia
Hereditary fructose Intolerance
Intrahepatic
Extrahepatic
Congenital Hepatic fibrosis
Caroli disease
PFIC
Alagille syndrome
Dubbin J. syndrome
Rotor syndrome
Stones
Strictures in CBD
EHBA (Extrahepatic Biliary Atresia: M/C)
For diagnosis of EHBA: Screening test of choice is HIDA scan
Surgery of choice: Kasai procedure
Good prognosis, if procedure is done at <8 weeks of age
Bad prognosis, if procedure is done at >8 weeks of age
Clinical assessment of Neonatal Jaundice
Done by Modified Kramer’s rule. Jaundice in neonates have cephalocaudal progression
Not reliable in preterm babies or neonates who have already received phototherapy - Transcutaneous bilirubinometer or serum bilirubin is done in those cases.
Kernicterus (CNS manifestation of Hyperbilirubinemia)
Part of the brain most commonly involved: Basal ganglia. Type of cerebral palsy most commonly seen due to neonatal jaundice: Extrapyramidal type
Features of Acute Bilirubin encephalopathy
Early stages: Hypotonia, lethargy, poor feeding
Late stages: Hypertonia, Fever, Opisthotonic Posture, Coma, Seizures & Death
Features of chronic bilirubin encephalopathy: SADMUM
SNHL
Athetosis
Dental enamel changes
Mental Retardation
Upward gaze palsy
Rx:
Phototherapy
Exchange transfusion in cases of severe jaundice
IvIg - In case of Erythroblastosis fetalis
Phototherapy
Most effective wavelength of light: 460-490 nm. Most important mechanism: Structural isomerisation
Other methods:
Photoisomerization
Photo oxidation
Minimum irradiance recommended: 30 µW/ cm2/ nm. Measured by lux meter
Ways to increase the effectiveness of phototherapy
Increase exposed surface area of baby
Decrease distance between baby & phototherapy unit
Use of LED lights
Adverse effects of phototherapy - Skin colour of baby becomes darker therefore called as bronze baby syndrome
Watery diarrhoea
Dehydration
Hypocalcemia
Retinal toxicity
Gonadal toxicity / mutation
Impaired maternal child bonding
Indication of phototherapy in a neonate
Cut off levels in otherwise healthy term babies.
Age
For phototherapy
For exchange transfusion
24-48 hrs of life
>15 mg /dl
>20 mg/dl
48-72 hrs
>18 mg /dl
>25 mg /dL
>72 hrs
>20 mg/dL
>25mg/dL
Preterm babies
1% of birth weight (in gm)
PT cut off +5
Indication of exchange transfusion in neonates with Rh incompatibility done if cord blood bilirubin is - >5 mg/dL, Cord blood Hg - <10 gm/dL
Most common cause of neonatal mortality in India:
Prematurity & related complications: M/C
Sepsis
Birth asphyxia & birth trauma
Congenital abnormalities
Common cause of Under-5 mortality in India:
Prematurity related complications: M/C
Pneumonia
Diarrhea
Injuries
Malaria
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