1. Dr.Hisham Ahmed,M.D,MRCS.Eng Asst.Professor of General & Pediatric Surgery B.U.H2015

2.   Physiologic jaundice is the normal elevation of unconjugated bilirubin in healthy neonates. It usually manifests in the 1 st week of age.  In white and black infants the peak level of bilirubin is ~ 6mg/dl at 72 hours of age. In Asian infants the bilirubin level peaks later (3-5 days) at a higher level (~12mg/dl).  In preterm neonates, the level is ~12 mg/dl on the 5 th day of life. What is NPJ?

3.   Phase one  Term infants - jaundice lasts for about 10 days with a rapid rise of serum bilirubin up to (12 mg/dL).  Preterm infants - jaundice lasts for about two weeks, with a rapid rise of serum bilirubin up to (15 mg/dL).  Phase two  bilirubin levels decline to about (2 mg/dL) for two weeks, eventually mimicking adult values.  Preterm infants - phase two can last more than one month.  Exclusively breastfed infants - phase two can last more than one month This pattern of hyperbilirubinemia has been classified into two functionally distinct periodshyperbilirubinemia

4.   Rh incompatibility  Enzyme defects i.e. G6PD deficiency, pyruvate kinase deficiency, hexokinase deficiency, congenital porphyria.  Structural defects; hereditary spherocytosis, hereditary elliptocytosis, sickle cell disease.  Increased RBCs mass i.e. polycythemia Etiology;

5.   Decreased hepatic uptake e.g. Gilbert syndrome (unconjugated hyperbilirubinemia).  Decreased conjugation e.g. Crigler- Najjer syndrome I/II (conjugated hyperbilirubinemia); Lucey-Driscoll syndrome; hypothyroidism; pyloric stenosis.  Increased Enterohepatic circulation breast feeding, breast milk Cont.

6.   Blood type/Rh  Coombs’ test ( Direct Anti-globulin Test i.e. DAT).  CBC  Total and direct bilirubin level.  LFT, PT and PTT if direct hyperbilirubinemia is present. Basic laboratory work-up of healthy newborn with increased unconjugated hyperbilirubinemia

7.  MANAGEMENT; The American Academy of Pediatricians (AAP) published the following guidelines for phototherapy and exchange transfusion in 1994. Total bilirubin levels are expressed in mg/dl. AGEPHOTOTHERAPY EXCHANGE TRANSFUSION+ INTENSIVE PHOTOTHERAPY 1-2 days ≥ 15≥ 25 3 days ≥ 18≥ 30 >3 days ≥ 20≥ 30 N.B; Jaundice in a newborn ≤ 24 hours of age is considered pathologic and requires at least a total serum bilirubin level and possibly other laboratory tests for detection of hemolysis or other disease process

8.  What is the difference between breast-feeding jaundice and breast- milk jaundice? Breast feeding jaundice Breast milk Jaundice  Early onset  Caused by the baby not getting enough milk and is not related to breast milk jaundice.  Adequate amounts of breast milk increase a baby’s bowel movements, which help to wash out the buildup of bilirubin.  late onset (jaundice that persists after physiologic jaundice subsides)  Results from chemical changes in the milk that increase Enterohepatic circulation.  Tends to be genetic and run in families. N.B; up to 4% of all breastfed infants have a serum bilirubin concentration> 10 mg/dl at 3 weeks of age.

9.  What is the rule of thumb? It’s a notoriously inaccurate rule used to roughly estimate the approximate bilirubin level; BODY PART BILIRUBIN LEVEL (mg/dl) Face 6 Neck to the umbilicus 9 Umbilicus to knees 12 Knees to ankles 15 Hands and feet >15

10. Does NPJ affect the decision for Circumcision?

11.   T.Bilirubin level less than 10mg /dl+ normal BT & CT+ negative DAT in a generally health baby……. DO Circumcision.  T.Bilirubin level 11-15mg /dl+ normal BT & CT+ negative DAT……. DO Circumcision.  T.Bilirubin level 15mg/dl or more postpone circumcision until jaundice is clinically and laboratory resolved( even if the other mentioned parameters are normal).  T.Bilirubin level normal + abnormal BT&CT + negative DAT….. postpone circumcision, and correct the bleeding diathesis.  ALL parameters are normal except DAT positive postpone circumcision and investigate for auto-immune hemolytic anemia. Protocol for neonatal circumcision

12.   AAP, "Circumcision Policy Statement". Peds, Mar 103(3):686-693, 1999.Circumcision Policy Statement  Elder, J. "Circumcision". BJU Int, Jun 99(6): 1553-1564, 2007.  Eroglu, E, et al. "Buried penis after newborn circumcision". J Urol, Apr 181(4): 1841-1843, 2009.Buried penis after newborn circumcision  Hutcheson, JC. "Male neonatal circumcision: indications, controversies, and complications". Urol Clin N Amer, Aug 31(3): 461-467, 2004.Male neonatal circumcision: indications, controversies, and complications  Lerman, SE and JC Liao. "Neonatal circumcision". Ped Clin N Amer, 48(6):1539- 1557, 2001.  Niku, SD, et al. "Neonatal circumcision". Uro Clin N Amer, 22(1): 57-65, 1995.  http://www.circumcision.net/jaundice.htm References

13. You