NEONATAL JAUNDICE

 NEONATAL JAUNDICE

This is condition in neonates characterized by yellow discoloration of the skin, sclera and mucous membrane. It develops when there is an excessive bilirubin level in the blood stream. When there is increased rate of haemolysis of RBC or decreased conjugation, there are high amounts of free bilirubin in circulation leading to jaundice.

BILIRUBIN METABOLISM

When RBC’s are broken down by haemolysis, they produce heme and globulin. The heme part produces bilirubin and iron. Unconjugated (indirect) bilirubin is fat soluble hence has to be converted to water soluble form (conjugated/ direct bilirubin) by process of conjugation for it to be excreted. Conjugation of bilirubin occurs in the liver and thus it has to be transported to the liver by binding to transport protein, albumin. On arrival to the liver, bilirubin detaches itself from the albumin.

Conjugation is done by glucoronlytransfares in which bilirubin is added to glucoronic acid to become bilirubinDiglucoronide that is water soluble. Excretion of the bilirubin is done through the biliary system into the intestine. While in the intestine, it is converted to stercobilinogen by the gut normal flora and excreted in stool. Some of it is absorbed from the gut and becomes urobilinogen which is excreted in urine.

If conjugation process is interfered with, there will be accumulation of unconjugatedbilirubin leading to hyper bilirubinaemia and jaundice. This bilirubin may cross the BBB and cause brain damage, a condition known as kernicterusthat is characterized by seizure, hyper-tonicity, lethargy, and stiff neck with hyper extended head.

TYPES OF JAUNDICE

PHYSIOLOGICAL JAUNDICE

This type of jaundice affects both preterm and term babies in the first few days of life. It is apparent with the signs on the third day when the unconjugatedbilirubinlevels in serum is 25-125 mmol/L. In term babies , it never appears before 24 hrs of life but it can be in pre terms and the serum levels never exceeds 200mmol/L. it is also self limiting in  term babies.

Causes

ü Excessive haemolysis of RBCs greater than conjugation rate.

ü Glucoronyltransferase enzyme deficiency

ü  Increased enterohepaticreabsorption

ü Decreased albumin binding capacity thus less bilirubin is transported to the liver for conjugation.

Nursing management

ü Admit the baby into NBU and assess the general condition.

ü Start early and frequent breastfeeding for it provides glucose to the liver cells and also encourages bowel colonization with normal flora which is important in formation of stercobilinogen for excretion in stool. It also leads to increased gut motility leading to faster excretion of bilirubin. Feeding also enhances enzyme production and conjugation.

ü Closely monitor serum bilirubin levels at 12 -24 hrs interval.

ü If bilirubin levels takes time to clear, put the baby on phototherapy.

PATHOLOGICAL JAUNDICE

This type of jaundice appears within 24 hrs of life and is not self- limiting thus may persist for long. There is rapid rise in serum bilirubin. It includes both obstructive and haemolytic jaundice.

Causes

They include pathological disorders that increasebilirubin production, reduces transportation to and fro the liver or reduced rate of conjugation.

1. Increased haemolysis –Rhesus and ABO incompatibility, G6PD enzyme deficiency, bacterial septicaemia.

2. Non- haemolytic causes of increased unconjugatedbilirubin –CNS hemorrhage, cephalohaematoma, polycythaemia, exaggerated enterohepatic circulation of bilirubin due to fuctionalileus.

3. Decreased rate of conjugation –Criggler Nagar syndrome, Gilbert’s syndrome

4. Hepatotoxic drugs

5. Billiary obstruction that prevents transport of conjugated bilirubin to GIT for excretion

6. Reduced bilirubin binding sites to the albumin.

7. Malnutrition

8. Increased reconversion of conjugated to unconjugatedbilirubin if it stays in the GIT for long.

Nursing management

ü Assess the baby to determine the degree of jaundice.

ü Do investigation on serum bilirubin levels and Hb.

ü Start the baby on phototherapy.

ü Order for blood exchange transfusion if necessary.

Complication of neonatal jaundice

ü Retinal damage due to lights used in treatment

ü Anemia

ü Hyperthermia associated with phototherapy.

ü Hypocalcaemia

ü Kernicterus

NB:read more on  obstructive and haemolytic jaundice

 

 TREATMENT MODALITIES OF NEONATAL JAUNDICE

 There are three main modalities namely;

v Phototherapy

v Blood exchange transfusion

v Protoporphyrins

 phototherapy

Phototherapy prevents bilirubin levels from going high enough to cross BBB and cause kernicterus

Mechanism of action

Blue florescent light at a given wave length is absorbed by the unconjugatedbilirubin in the skin and superficial capillary and is converted into conjugated bilirubin which is water soluble and can be excreted in stool and urine.

Indications

v Pre term with jaundice appearing after 48 hrs and bilirubin levels are 260 -265 mmol/L

v Pre term with weight less than 1500g and bilirubin levels are 85 -114 mmol/L

v  Pre term with weight more than 1500g and bilirubin levels are 114-165 mmol/L

Care of the baby on phototherapy

ü Expose the whole body of the baby to increase surface area exposed to light

ü Keep turning the baby 2hrly to expose all parts to the fluorescent light.

ü Ensure the airway of the baby is patent by extending the head.

ü Cover the eyes of the babyto prevent damage by direct ray of lights.

ü When breastfeeding the eyes are unpadded to encourage eye contact with the mother.

ü Provide intermittent phototherapy i.e. 6 hrs on and 6 hrs off but may be continous.

ü Give phototherapy for 2-3days and assess the serum bilirubin levels twice or three times a day NB. Greatest reduction in bilirubin levels will be in the first 24 hrs of phototherapy.

ü Observe the eyes for weeping or discharge.

ü If phototherapy is continous, give extra fluids to prevent dehydration and maintain accurate input output charts.

ü Change linen frequently because opening of bowels is increased(loose stool)

ü Observe the feeding and sleeping behavior of the baby.

ü Observation e.g. temperature to rule out hyperthermia and skin colour to monitor the progress.

ü Top tail the baby to maintain hygiene.

Side effects

v Loose stool due to rapid instinal transit

v Dehydration

v Hyperthermia

v Visual deprivation

v Poor feeding

v Fragility

v Lethargy

v Irritability

v Hypocalcaemia