Neonatal Jaundice (NNJ)

Pathological jaundice | Physiological jaundice | Prolonged jaundice

Definition
• Pathological jaundice occurs within 24 hours of life
• Prolonged jaundice: visible jaundice (or serum bilirubin >85 µmol/L) that persists beyond 14 days in life in term infant or 21 days in preterm infant

Implications
• Unconjugated bilirubin → deposited in basal ganglia → kernicterus

Risk stratification
1st rule: Gestational age
2nd rule: Risk factors
– Isoimmune haemolytic disease (mother blood group O+ve / mother Rhesus negative)
– G6PD deficiency
– Neonatal encephalopathy
– Neonatal asphyxia
– Sepsis

NOTE: Presence of >1 risk factor will NOT further increase the risk!! Examples:
– 38 weeks + G6PD deficiency = Medium risk
– 38 weeks + G6PD deficiency + Mother O+ve = Medium risk (not high risk)

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Re-stratification of risk
Upgrading: from low to medium risk // from medium to high risk
Downgrading: from high to medium risk // from medium to low risk

Example:
37 weeks + Mother O+ve = high risk
Later on results of baby’s ABO is O+ve, direct Coombs test negative
Re-stratified into medium risk

Neonatal jaundice surveillance
• Transcutaneous bilirubinometry ( TCB )

Neonatal jaundice workup
• Total serum bilirubin (TSB)
• Full blood picture or Full blood count
• Reticulocytes
• Patient’s ABO + RhD
• Patient’s direct Coombs test

• Trace mother’s blood group

**Not all NNJ require ABO & Coombs test, unless suspicious of ABO incompatibility

Other investigations
• G6PD
• Blood C&S, urine C&S if infection/sepsis suspected

Neonatal jaundice (inpatient) monitoring
• TCB or TSB

1. Phototherapy
• ‘Intensive phototherapy’ = ‘double phototherapy’

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2. Exchange transfusion
ET guideline for babies ≥35 weeks gestation
• Indications of ET:
–> Signs of acute bilirubin encephalopathy (ABE), or
–> TSB >85 µmol/L above ET level
–> TSB rises to ET levels despite intensive phototherapy


3. IV Immunoglobulin (IVIG)

Causes
(i) Conjugated hyperbilirubinaemia (>25 µmol/L)
• Biliary tree abnormalities e.g. biliary atresia
• Neonatal hepatitis
• Metabolic disorders e.g. alpha-1 antitrypsin deficiency, citrin deficiency

(ii) Unconjugated hyperbilirubinaemia
• Haemolytic anaemia e.g. G6PD deficiency, congenital spherocytosis
• Hypothyroidism
• Infection, e.g. UTI , TORCHES
• High GI obstruction e.g. pyloric stenosis

Signs & symptoms e.g.
• Pale stool
• Poor weight gain
• Pallor
• Hepatosplenomegaly

Prolonged jaundice workup
• Total serum bilirubin (+direct & indirect)
• FBC + reticulocytes // FBP
• Liver function test
• Thyroid function test
• UFEME ± Urine C&S

• Trace G6PD screening taken at birth

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Other Ix
• TORCHES
• HBsAg, Anti-HCV
• Alpha I antitrypsin

Imaging
• USG HBS