neonatal%20jaundice
NEONATAL JAUNDICE
Jaundice that appears in a newborn <24 hour old is most likely nonphysiologic and needs further evaluation.
Jaundice typically presents on the 2nd-3rd day of life. It is usually first seen on the face and forehead then progresses caudally to the trunk and extremities.
Visible jaundice in the feet may be an indication to check bilirubin level.
Visual estimation of bilirubin level is often inaccurate and unreliable.
Danger signs in a newborn infant with jaundice includes changes in brainstem evoked auditory potentials, changes in muscle tone, seizures and altered cry characteristics.
The presence of any of the danger signs require prompt attention to prevent kernicterus.

Principles of Therapy

  • Consider TSB levels, infant’s age in hour & presence of risk factors to determine need for therapy

Indications for treating neonatal jaundice

  • When TSB level exceeds the threshold in the nomogram
  • A TSB level >25 mg/dL (428 µmol/L) at any time is a medical emergency & indicates prompt hospital admission & initiation of treatment
  • For preterm infants, initiation of phototherapy or exchange transfusion depends on the gestational age
  • Gestational Age

    (weeks)

    Phototherapy

    Exchange Transfusion

    TSB (µmol/L)

    TSB (mg/dl)

    TSB (µmol/L)

    TSB (mg/dl)

    <28

    86

    >5

    188-239

    11-14

    28-29

    103-137

    6-8

    205-239

    12-14

    30-31

    137-171

    8-10

    222-274

    13-16

    32-33

    171-205

    10-12

    257-308

    15-18

    >34

    205-239

    12-14

    291-325

    17-19

Pharmacotherapy

IV immunoglobulin (IVIG)

  • In an infant with isoimmune hemolytic disease, administration of IVIG is recommended if the TSB is rising in spite of intensive phototherapy or the TSB level is within 2-3 mg/dL of the exchange transfusion level
  • May reduce the need for exchange transfusions in Rh & ABO hemolytic disease
  • Has been shown to decrease RBC destruction & limit the rate of increase in bilirubin levels in infants with Rh & ABO isoimmunization

Tin-mesoporphyrin

  • This drug prevents or treats hyperbilirubinemia by inhibiting production of heme oxygenase

Clofibrate

  • May help lower bilirubin levels in term infants with hyperbilirubinemia by increasing bilirubin elimination, when used in combination with phototherapy
  • Further studies are needed to further prove the efficacy of Clofibrate in neonatal jaundice

Phenobarbitone

  • Has shown potential for reducing bilirubin levels by stimulation of hepatic enzymes
  • There are limited studies proving Phenobarbitone’s safety & efficacy for the management of neonatal jaundice

Non-Pharmacological Therapy

Phototherapy

  • Phototherapy creates water soluble bilirubin isomers which are excreted in the bile & urine, resulting in lower serum bilirubin levels & decreased risk of bilirubin-induced neurotoxicity
  • Has been shown to be most effective in very small preterm infants & least effective in severely growth retarded full-term infants
  • Conventional phototherapy in the hospital should consist of irradiance in the blue-green spectrum (400-500 nm) of at least 15 µW/cm2/nm that is delivered to as much of the infant’s surface as possible
    • The wavelength at the blue-green spectrum lets light penetrate the skin well & be maximally absorbed by bilirubin
    • The most effective light sources for phototherapy are special blue fluorescent tubes or specially designed light-emitting diode light
    • Light tubes should be placed as close to the infant as possible (30-50 cm from the infant)
    • The infant should be placed in the supine position, naked except for diapers to expose maximum body surface area, & eyes should be covered
  • Intensive phototherapy, which consists of at least 30 µW/cm2/nm, should be started when TSB levels reach 3 mg/dL (51 µmol/L) above the level of conventional phototherapy or when TSB levels continuously increase by >0.5 mg/dL/hour (8.5 µmol/L/hour)
  • Additional body surface area exposure may be achieved by lining the bassinet with aluminum foil or a white cloth
  • Infant’s eyes should be properly protected during phototherapy to prevent retinal damage
  • Fluid supplementation is not given routinely but is based on infant’s weight loss, urine output & urine specific gravity
  • Complications from phototherapy are rare
    • Grayish-brown discoloration of the urine, serum & skin may develop in infants with cholestatic jaundice (bronze baby syndrome)
    • Severe blistering & photosensitivity in infants may occur in infants with congenital erythropoietic porphyria
  • Sunlight exposure as a substitute for phototherapy is not recommended because sunburn is a serious danger given that exposure of a large body surface area is required
  • A decrease of 30-40% in the initial bilirubin level may be expected 24 hour after start of phototherapy in infants >35 week age of gestation
  • In infants with extremely high bilirubin levels, a decline of at least 0.5-1 mg/dL may be expected in the first 4-8 hour of phototherapy
  • A continuing rise in bilirubin levels despite phototherapy usually means that hemolysis is present
  • Frequency of TSB monitoring depends on previous measurements
  • TSB level in mg/dL

    Repeat TSB

    ≥25

    2-3 hour

    20 to 25

    3-4 hour

    14 to <20

    4-5 hour

    Continues to decrease

    8-12 hour

    <14

    Discontinue phototherapy & consider repeat TSB after 24 hour

Adapted from: Moerschel SK, Cianciaruso LB, Tracy LR. A practical approach to neonatal jaundice. Am Fam Physician. 2008; 77:1255-1262.

  • The TSB level for discontinuing phototherapy depends on the age at which phototherapy was started & the cause of the hyperbilirubinemia

Exchange transfusion

  • Exchange transfusion is recommended when an infant’s TSB level exceeds the threshold set in the nomogram (>5 mg/dL [85 µmol/L] above exchange transfusion level) or when TSB >25 mg/dL (428 µmol/L)
  • Exchange transfusion should be done immediately in any infant with jaundice & signs of acute bilirubin encephalopathy which include hypotonia or hypertonia, opistothonus, fever, poor feeding & lethargy, even if the TSB level is falling
  • In almost all cases, exchange transfusion is performed only when phototherapy fails to keep the bilirubin level below the exchange transfusion level
  • Trained staff should perform the procedure in a neonatal intensive care unit
  • Intensive phototherapy is recommended in preparation for an exchange transfusion
  • Complications of exchange transfusion include infection, thromboembolization, hemolysis of transfused blood, acidosis, serum electrolyte abnormalities, bradycardia & vasospasm
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
Elaine Soliven, 17 Aug 2017
Probiotic supplementation during the first 6 months of life does not reduce the incidence of eczema or asthma later in childhood, according to the randomized controlled TIPS* study.