Jaundice and Phototherapy (Chapter 13)

Learning Objectives

After completion of this chapter 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.

Introduction

More than 50% of normal newborns and 80% of preterm infants become jaundiced and the healthcare worker needs to be familiar with diagnosis and management. The number of newborns requiring treatment for jaundice can be reduced by keeping the baby with the mother allowing for more frequent breastfeeding and increasing bilirubin excretion in the stools.

Physiological	Pathological	Prolonged/ pathological
Appears after 48 hours of life. Maximum by 4^th and 7^th day. Generally, disappears without any treatment but some NYI will require phototherapy.	Starting on the first day of life; may have fever. Deep jaundice: palms and soles.	Jaundice lasting for longer than 14 days in term infants and 21 days in preterm infants.
	Possible causes Haemolysis Neonatal sepsis Congenital infection	Possible causes Hypothyroidism Neonatal hepatitis Biliary atresia (pale stool and dark yellow urine)

Evaluation for Aetiology in History

History	Diagnosis
Birth weight Gestation Postnatal age	Consider jaundice of prematurity
Fever Sleepy, lethargy Poor feeding Change in cry – high-pitched or reduced crying Mother: urinary tract infection, foul smelling amniotic fluid, maternal fever	Neonatal sepsis often causes jaundice
Birth asphyxia (5 min Apgar of 7 or less)	Birth asphyxia is often associated with jaundice
Onset of jaundice before 24 hours of age Family history of significant haemolytic disease Previous sibling received phototherapy Failure of phototherapy to reduce the jaundice	Incompatibility between mothers and baby’s blood, may cause severe haemoglobinopathy. (ABO incompatibility and Rhesus disease)

Evaluation for Aetiology on Examination^★

Examination	Diagnosis
Prematurity	Jaundice of prematurity
Temperature instability CNS signs e.g. lethargy	Possible meningitis or sepsis
Cephalohaematoma or significant bruising
Petechiae, hepato-splenomegaly	Congenital infection

^★A baby may have more than one diagnosis.

Assessment of Severity of Jaundice

Assess the level of jaundice clinically: blanching reveals the underlying colour. Neonatal jaundicefirst becomes visible on 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. The Kramer scale is used to clinically assess the severity of jaundice depending on the age in days and maturity of the baby. It is not as accurate as a serum bilirubin level or transcutaneous bilirubin reading. If possible, confirm with a transcutaneous bilirubinometer or a serum bilirubin. The bilirubinometer is used to measure serum bilirubin and much more accurate than a clinical assessment.

Also assess for: features of acute bilirubin encephalopathy (kernicterus) , and dehydration with which jaundice is commonly associated.

Investigations

Infection screen – infection must be excluded in any baby who is unwell and jaundiced or has risk factors for sepsis. Perform a LP, blood culture and urine dipstick.
Blood grouping and Rh status (both baby and mother).
Coombs test if available.
PCV or FBC.
Syphilis testing/VDRL – on mother and baby.
LFTs (transaminases, total serum bililubin and direct bililubin)

Treatment

The treatment for jaundice is phototherapy plus treating the underlying cause, for example sepsis.

Exchange transfusion will be needed if bilirubinlevels raise to a certain levels. See for cut-offs

Prevention of Jaundice

Allow skin to skin contact after delivery and early breast feeding within one hour of delivery.
Rooming in baby: i.e., baby stays with mother 24 hours per day and is breast feed on demand.
Separation of mother and child is avoided where possible.
Three hourly feeds with expressed breast milk when mother and child are separated.

E 11 Phototherapy Lights

Phototherapy should be commenced for neonates with:

Any visible jaundice on the day of birth
Jaundice extending below the umbilicus
Bilirubin level indicating need for treatment

See Phototherapy lights for more information.

Whilst on phototherapy:

Baby is naked except for a nappy and the baby’s eyes should be covered with gauze pad.
Check bilirubin level daily if possible.
Turn baby 2 hourly.
Monitor for signs of dehydration.
Ensure the baby is feeding well – top up with EBM via cup or NGT if necessary. Remember that the bilirubin needs to be excreted by passing stools.
Encourage mother-child bonding.

Prolonged Jaundice

Jaundice lasting longer than 14 days in term or 21 days in preterm infants is abnormally prolonged. This may be due to infection, hypothyroidism, hepatitis or biliary atresia.

If the baby’s stools are pale or the urine is dark, refer the baby to a central hospital for further investigation and management including checking both direct and indirect serum bilirubin levels, abdominal ultrasound scan and thyroid function tests. These babies are best diagnosed and treated early for better outcomes