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D F h H i H b ll hDr Farhaana Husainy HasbullahKlinik Kesihatan Bukit Payong
29/1/2012
Content Introduction
What is jaundice? What is jaundice? What can go wrong? Causes of jaundiceCauses of jaundice Factors affecting severity
ManagementManagement History Examination Treatment
Prolonged Jaundiceg J
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Introduction Estimated 75 % of babies develop jaundice within the first week of birthfirst week of birth
Majority are physiological jaundiceO h d h l i l Others are due to pathological causes
25‐30% of babies require clinical intervention
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What is jaundice?j Apparent clinically when level of serum bilirubin rises above 85mmol/labove 85mmol/l
Physiological jaundice is a reflection of bilirubin load to the liver and rate of hepatic excretion (liver to the liver and rate of hepatic excretion (liver maturity)
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What can go wrong in jaundiceg g j Kernicterus
Hi h t lit High mortality Cerebral PalsyH i l Hearing loss
Paralysis of upward gazeD l d l i Dental dysplasia
Occurs when the elevated bilirubin causes brain cell death
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Causes of Neonatal Jaundice Physiological jaundice & Idiopathic jaundiceH l i d ABO Rh i i i i G6PD Haemolysis due to ABO or Rh isoimmunization, G6PD deficiency, drugsP l h i Polycythaemia
Sepsis e.g. UTI Breasfeeding jaundice Breastmilk jaundicej
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Breastfeeding jaundice v sBreastfeeding jaundice v.sBreastmilk jaundicej
Breastfeeding jaundiceI d t b tf di lti i d h d ti Inadequate breastfeeding resulting in dehydration
Breastmilk jaundiced b b lk Caused by certain enzymes in breastmilk eg
glucoronidase,pregnanendiolA i t d ith l d j di Associated with prolonged jaundice
Doesn’t harm babyDON’T STOP BREASTFEEDING DON’T STOP BREASTFEEDING
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Factors affecting severity ofFactors affecting severity of jaundicej
DehydrationL i h l f bi h Large weight loss after birth
Cephalohematoma Infant of diabetic mother Acidosis Asphyxia Intestinal obstructionIntestinal obstruction
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Historyy AgeP i i f i h NNJ k i G6PD Previous infants with NNJ, kernicterus, G6PD
Mother’s blood group Gestation Presence of abnormal symptoms : difficulty in feeding, feeding intolerance and temperature
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Physical Examinationy General ConditionP ll f h l h hi Pallor, presence of cephalohematoma, petechiae, hepatosplenomegalyC h l d l i f i f j di Cephalo‐caudal progression of severity of jaundice
Intensity of yellow discoloration in skin and mucosa
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Screening of NNJ using KramerScreening of NNJ using Kramer Chart
Area of Body Range of Indirect l bBilirubin
(mmol/l)Head and Neck 68‐135 I
Upper Trunk
35
85‐204 II
Lower Trunk and thighs
A d l l
136‐272 III
Arms and lower legs
Palms and soles
187‐306
>306
IV
V
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Jaundice may be detected by blanching detected by blanching the skin with pressure of the thumb and noting the thumb and noting the color of underlying skin
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When to refer to hospital?When to refer to hospital? (When to worry? ) CPG MOH 2003( y ) Onset of jaundice within 24 hours of lifeS J di l/l Severe Jaundice > 340 umol/l
Jaundice up to level of sole of feet Rapid rise of serum bilirubin > 85umol/l/hour Family history of significant hemolytic disease or kernicterus
Clinical signs suggesting other disease e.g. sepsisg gg g g Jaundice below umbilicus (Refer to Local policies for phototherapy threshold (Photo level) )p py
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Phototherapy LevelpyHours of Life Low Risk
(>38w + well)Medium Risk
(>38w + Risk Factor)( )
High Risk(35‐37w + Risk
)(35‐37w + well) Factor)D1 (24H) 150 120 85
D2(48H) 205 170 135D2(48H) 205 170 135
D3 (72H) 255 205 170
D4 (96H) 290 240 190
>D4 >96 H 310 255 205
Risk Factors :Risk Factors :1. Isoimmune Hemolytic Disease (ABO/Rhesus) 5. G6PD2. Asphyxia 6. Significant lethargy3 Temperature 7 Sepsis3. Temperature 7. Sepsis4. Acidosis 8. Albumin < 3g/dl
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Phototherapypy
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Exchange transfusiong
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Prolonged Jaundiceg Visible jaundice that persists beyond 14 days of life in term or 21 days in a preterm babyterm or 21 days in a preterm baby
Causes of Prolonged neonatal jaundiceConjugated Hyperbilirubinemia
(Direct Bilirubinemia)Unconjugated Hyperbilirubinemia
(Indirect Bilirubinemia)Neonatal Hepatitis Syndrome Septicemia or UTIp y p
Biliary Atresia Hemolysis
Choledochal Cyst Breast milk jaundice
Septicemia or UTI Hypothyroidism
Congenital Galactosemia
M t b li Di d ( l t i )Metabolic Disorder (e.g. galactosemia)
Post TPN29/1/2012
Initial Management of ProlongedInitial Management of Prolonged Jaundice
Child unwell or
Child well
Child unwell or pale stool
Initial Investigations :Serum BilirubinSerum T4 TSH Admit for Investigate at
OPD
Serum T4, TSHUrine FEME and C&SG6PD if not done yetFBC Retic Count FBP
Admit for investigations and treatment
FBC, Retic Count, FBP
If it is conjugated/obstructive (direct bilirubinemia) jaundice, admit29/1/2012
Reference CPG Management of Jaundice in Healthy term Newborn Ministry of Health 2003Newborn, Ministry of Health 2003
Paediatric Protocols for Malaysian Hospital 2005
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