Neonatal Jaundice Breast Milk Jaundice, Phototherapy

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/NExT 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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