Neonatal Jaundice (Hyperbilirubinemia)

Neonatal jaundice (Hyperbilirubinemia)
Student name: Fatima Abu Hamdah

Student number: 22112580
Course name: pediatric clinical
Instructor name: Nashed Fashafsheh
Outline :
 Define hyperbilirubinemia/jaundice.
 Types of bilirubin.
 Physiological jaundice.
 Mechanism of physiological jaundice
 How is bilirubin metabolized ?
 What causes hyperbilirubinemia ?
 signs and symptoms of jaundice
 Diagnosis of hyperbilirubinemia
 Treatment for hyperbilirubinemia
Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is
characterized by jaundice, a yellowish discoloration of the skin, sclera, mucous membranes and nails.
Incidence of neonatal jaundice:
• Term: Occurs in 60%

• Preterm: 80% of preterm neonates
Bilirubin: is the orange yellow pigment of bile formed by the break down of RBC.
Catabolism of 1 g of hemoglobin produced 34 mg of bilirubin
Destruction of RBCs result in HEME and GLOBIN.
HEME: is converted to unconjugated bilirubin.
GLOBIN: is a protein used by the body.
Types of bilirubin
Unconjugated bilirubin(Indirect) Conjugated bilirubin(Direct)
Bind to albumen Conjugated with glucoronic acid

Fat soluble Water soluble
Can cross blood brain Excreted in urine and stool
Toxic in high level to brain Not toxic
Physiological jaundice
*Appears after 24 hours.

* Total bilirubin rises by less than 5 mg/di per day.
* Maximum intensity by 4th-5th day in term & 7th day in preterm.
* Serum level less than 15mg / dl.
* Clinically not detectable after 14 days Physiological Jaundice.
Mechanism of physiological jaundice
Bilirubin levels rise in newborn by three mechanisms:

1. over production of bilirubin because of excessive destruction of RBC due to higher
concentration of RBC, and Shorter life span which is 70 - 80 days in contrast to 120 days in
older child and adults.
2. Decreased removal of bilirubin due to the Liver ability to conjugate bilirubin is not high
due to low liver enzyme (glucouronyl transferase enzyme).
3. Increased reabsorption (enterohepatic circulation).
How is bilirubin metabolized ?
* The unconjugated bilirubin is water insoluble (fat soluble) & measured as indirect bilirubin.
* Bilirubin binds to albumin in plasma for transport to the liver (1 g of albumin binds 8.5 mg of bilirubin in
a newborn).
* once in the liver, bilirubin detaches from albumin and enters hepatocyte.
* Within hepatocyte, with the aid of glucuronyl transferase enzyme, bilirubin is conjugated OR CONVERTED
TO glucuronic acid to produce a highly soluble substance.
* The converted bilirubin is referred as conjugated bilirubin, and is measured as direct bilirubin, and is
water soluble.
* Most conjugated bilirubin is excreted through the bile into the small intestine and eliminated in the
stool.
* bacteria in the neonatal intestine convert bilirubin to urobilinogen
and stercobilinogen, which are excreted in urine and stool and
usually limit bilirubin reabsorption.
* Delayed passage of meconium, which contains bilirubin, also may

contribute to the enterohepatic recirculation of bilirubin.
* Delayed feeding & delayed passages of meconium and absence of

intestinal flora can result in that Some bilirubin may converted back to
the unconjugated bilirubin by intestinal beta- glucuronidase, may be
reabsorbed (enterohepatic recirculation).
What causes hyperbilirubinemia ?
 Physiologic jaundice. Physiologic jaundice occurs as a "normal" response to the baby's
limited ability to excrete bilirubin in the first days of life.
 Breast milk jaundice. About 2% of breastfed babies develop jaundice after the first week. It
peaks about 2 weeks of age and can persist up to 3 to 12 weeks. Breast milk jaundice is
thought to be caused by a substance in the breast milk that increases the reabsorption of
bilirubin through the intestinal tract.
 Breastfeeding failure jaundice. It is caused by failure to successfully establish
breastfeeding, resulting in dehydration, decreased urine production and
accumulation of bilirubin. Late preterm infants, those who are born between 34
weeks and 36 weeks, are more susceptible to this problem because they do not
have the coordination and strength to maintain a successful breastfeeding.
However, it is also very common in full-term newborns and usually gets better
once breastfeeding is established.
 Jaundice from hemolysis. Jaundice may occur with the breakdown of red blood
cells due to hemolytic disease of the newborn (Rh disease), or from having too
many red blood cells that break down naturally and release bilirubin.
 Jaundice related to inadequate liver function. Jaundice may be related to

inadequate liver function due to infection or other factors.
signs and symptoms of jaundice
Yellow coloring of the baby's skin (usually beginning on

the face and moving down the body) .
 Poor feeding or lethargy.
Fever.
Dark urine.
Wight loss.
Chills.
Stomach pain.
Jaundice is seen first in the sclera and head and
proceeds in a cephalocaudal direction.
Diagnosis of hyperbilirubinemia
* Total Serum Bilirubin (TSB) with direct

(conjugated) and indirect (unconjugated) portions
* blood group and (Coomb’s test)
• albumin, hemoglobin & hematocrit
• investigations for sepsis if clinically unwell
Non invasive monitoring
Transcutaneous bilirubinometry TcB

• Screening tool in nursery
• Accuracy : with 2-3mg/dl
• Sternum-forehead sites: multiple reading
Treatment for hyperbilirubinemia
Phototherapy: Since bilirubin absorbs light, jaundice and increased bilirubin levels usually
decrease when the baby is exposed to special blue spectrum lights. Phototherapy may take
several hours to begin working and it is used throughout the day and night. Different
techniques may be used to allow all of the skin to be exposed to the light. The baby's eyes
must be protected and the temperature monitored during phototherapy. Blood levels of
bilirubin are checked to monitor if the phototherapy is working.
Fiber-optic blanket: Another form phototherapy is a fiber-optic
blanket placed under the baby. This may be used alone or in
combination with regular phototherapy.
Exchange transfusion: Exchange transfusion increase the red

blood cell count and lower the levers of bilirubin. An exchange
transfusion is done by alternating giving and withdrawing
blood in small amounts through a vein or artery. Exchange
transfusions may need to be repeated if the bilirubin levels
remain high.
Adequate hydration with breastfeeding or pumped breast milk. The American Academy
of Pediatrics recommends that, if possible, breastfeeding be continued. Breastfed babies
receiving phototherapy who are dehydrated or have excessive weight loss can have
supplementation with expressed breast milk or formula.
Treating any underlying cause of hyperbilirubinemia, such as infection.

References:
Medical-Surgical Book
https://www.ncbi.nlm.nih.gov/books/NBK470290/
https://www.mayoclinic.org/diseases-conditions/infant-jaundice/symptoms-causes/syc- 20373865
https://www.cedars-sinai.org/health-library/diseases-and-conditions---
pediatrics/h/hyperbilirubinemia-in-the-newborn.html

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Neonatal jaundice (Hyperbilirubinemia)

Student name: Fatima Abu Hamdah

• Term: Occurs in 60%

Unconjugated bilirubin(Indirect) Conjugated bilirubin(Direct)

Bind to albumen Conjugated with glucoronic acid

*Appears after 24 hours.

Bilirubin levels rise in newborn by three mechanisms:

* Delayed passage of meconium, which contains bilirubin, also may

* Delayed feeding & delayed passages of meconium and absence of

 Jaundice related to inadequate liver function. Jaundice may be related to

Yellow coloring of the baby's skin (usually beginning on

* Total Serum Bilirubin (TSB) with direct

Transcutaneous bilirubinometry TcB

Exchange transfusion: Exchange transfusion increase the red

Treating any underlying cause of hyperbilirubinemia, such as infection.

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