Jaundice
Learning objectives
After completion of this session the participant should be able to:
- Describe physiological and pathological jaundice, including prolonged jaundice
- Describe how to evaluate jaundice including assess its severity
- Describe the management of jaundiced NYI
More than 50% of normal newborns and 80% of preterm infants have some jaundice. Jaundice may be normal or abnormal and the healthcare worker needs to be familiar with its management.
Physiological
- Appears after 48 hours Maximum
- By 4th and 5th day in term and 7th day in preterm
- Generally, disappears without any treatment but some NYI will require phototherapy for physiological jaundice.
Pathological
- Starting on the first day of life
- Associated with fever
- Deep jaundice: palms and soles
- Possible causes
- Haemolysis
- Congenital Infection
- Neonatal sepsis
Prolonged/ pathological
- Jaundice lasting for longer than 14 days in term infants and 21 days in preterm infants.
- Stool clay coloured and urine dark yellow
- Possible causes
- Hypothyroidism
- Neonatal Hepatitis
- Biliary atresia
Evaluation for aetiology on history
Birth weight, gestation and postnatal age
- Assess clinical condition (well or ill) lethargy, poor feeding, sepsis, urinary tract infection, foul smelling amniotic fluid, maternal fever
- Birth asphyxia(5 min Apgar of 7 or less)
- Onset of jaundice before 24 hours of age
Family history of significant haemolytic disease
Previous sibling received phototherapy
Failure of phototherapy to lower the total serum bilirubin (TSB)
Consider jaundice of prematurity<
- Sepsis often causes jaundice
- Birth asphyxia is often associated with jaundice
- Incompatibility between mothers and babies blood, may cause severe haemoglobinopathy
Evaluation for aetiology on examination
Assessment of severity of jaundice
Assess the level of jaundice clinically: blanching reveals the underlying colour. Neonatal jaundice first becomes visible in the face and forehead and gradually becomes visible on the trunk and extremities. This can be used to decide clinically when the baby should be treated. If possible confirm with a transcutaneous bilirubinometer or a serum bilirubin
Also assess for features of acute bilirubin encephalopathy, also called kernicterus and for dehydration which is commonly associated.
The bilirubinometer is useful to measure transcutaneous serum bilirubin but not widely available. It should be used on the chest and the forehead (which is not directly exposed to the phototherapy) and whichever value is highest should be used.
Investigations
Infection screen – infection must be excluded in any baby who is unwell and jaundiced or has risk factors for sepsis do LP, blood culture, urinalysis.
Blood grouping and Rh status (both baby and mother), Coombs test if available, PCV, VDRL
Treatment
The treatment for jaundice is phototherapy plus treating the underlying cause, for example sepsis.
Whilst on phototherapy:
Baby’s eyes should be covered with gauze pad.
Check bilirubin level daily if possible.
Turn baby 2 hourly.
Monitor signs of dehydration.
Ensure the baby is feeding well – top up with EBM via cup or NGT if necessary.
Encourage mother- child bonding,
When to stop phototherapy
Continue phototherapy until the serum bilirubin level is lower than the threshold range or until the jaundice is limited to area 1 in preterm infants and areas 1+2 in term infants. wall chart for phototherapy
Prolonged Jaundice
Jaundice lasting longer than 14 days in term or 21 days in preterm infants is abnormally prolonged.
If the baby’s stools are pale or the urine is dark, refer the baby to a central hospital for further management including doing both direct and indirect serum bilirubin level, ultrasound and thyroid function tests