1. Neonatal Jaundice Dezhi Mu MD/PhD
Department of Pediatrics, West China Second University Hospital, Sichuan University

2. Introduction Jaundice is quite common (5mg/dl).
Full term infants: at least 50%
Preterm infants: over 80%
Elevated blood bilirubin levels: 97%

3. Introduction continued
When?
in the first week of life
Where?
skin , mucosa and white of eye
How many?
blood bilirubin concentrations is
≥5-7mg/dl.

4. Introduction continued

5. Why Jaundice occurred?
Producing
Excreting

7. Bilirubin Metabolism:
1. RBC: Heme bilirubin (UCB)
2. Blood: carried by bound to albumin
3. Liver: uptaken : Y protein, Z protein
conjugated: UDPGT
excreted： to the biliary system
4. Intestine: stercobilins
-glucuronidase enterohepatic
circulation

8. The metabolic characteristics of bilirubin in newborns:
1. Bilirubin production
8.8mg/Kg/d in newborns 3.8mg/Kg/d in adults
2. Bilirubin-albumin complex formation
a. preterm infant;
b. acidosis

9. The metabolic characteristics of bilirubin continued
3. Bilirubin metabolism of hepatocyte
a. Hepatic uptake of bilirubin
b. Bilirubin conjugation:
UDPGT (uridine diphosphate
glucoronyl transferase)
c. Defective bilirubin excretion
ability to bile system
4. Enterohepatic circulation

10. Bilirubin toxicity 1. Conjugated bilirubin water-soluble
2. Unconjugated bilirubin
lipid-soluble
bilirubin-encephalopathy
（kernicterus）

11. Clinical Manifestations
Jaundice appears
When:
at any time during the neonatal period
Where:
from face chest
abdomen feet

12. Manifestations continue
Evaluation of jaundice :
1. By eyes: face, 5mg/dl ( 85μmol/L );
abdomen, 10-15mg/dl;
feet, 15-20mg/dl ;
2. By transcutaneous measurement :
used for screening
3. By serum levels : standard

13. Manifestations continue
Classification:
Physiological Jaundice
Pathological Jaundice

14. Manifestations continue
Physiological jaundice : 1. General state is well
2. Appears 2-3days (>24h of age)
peaks < 12.9mg/dl (full term infants) <15mg/dl (preterm infants)
fades <2 week (term infants)
<4 weeks (preterm infants)
3. Accumulates <5mg/dl/d
4. Direct bilirubin <2mg/dl

15. Manifestations continue
Pathological Jaundice
1. Appears earlier (first 24 hours of life)
2. Peaks >12.9mg/dl (full term infants) >15mg/dl (preterm infants)
Fades >2 weeks (term infants)
>4 weeks (preterm infants)
3. Accumulates >5mg/dl/d
4. Direct bilirubin >2mg/dl
5.Jaundice recurrent

16. Common causes of pathological jaundice
1. Unconjugated bilirubinemia:
a. hemolytic diseases:
ABO, Rh incompatibility
b. G-6-PD deficiency;
c. Breast milk jaundice

17. Causes of pathological jaundice continue
2. Conjugated bilirubinemia:
a. Neonatal hepatitis
b. Biliary obstruction (cholestatic jaundice)
biliary atresia,
common bile duct stenosis
c. Congenital metabolic diseases
α-1 antitrypsin deficiency

18. Hemolytic disease of newborn
ABO: 85.3%
Rh : 14.6%
MN : 0.1%

19. Hemolytic disease of newborn continued
ABO incompatibility
the mother: type O
the infant: type A
or B
Rh incompatibility
the mother： Rh（-）
the infant: Rh（+）D,E,C,d,e,c

20. Pathogenesis

21. Pathophysiology Red blood cell breakdown Hyperbilirubinemia Anemia
Jaundice
Liver
Spleen
Heart, other organs
Hydrops
Kernicterus
Seizures etc.

22. Clinical Manifestations:
ABO Rh
1.Jaundice : mild severe
1-2 day h
2.Anemia: mild severe
(3-6 weeks) heart failure
3.Hepato rare common
splenomegaly

23. Complication Kernicterus: Phase 1: decreased alertness Hypotonia
Poor feeding
Phase 2: Hypertonia,
Retrocollis, opisthotonus
Phase 3: Hypotonia

24. Laboratory tests: 1. Blood type incompatibility
2. Hyperbilirubinemia :
Unconjugated bilirubin level
3. Hemolytic tests
1). Hemoglobin level : low
2). Reticulocytes:10–15%
3). Nucleated RBC

25. Laboratory tests continued
Antibody test
1). Direct Coombs test (+) confirm
2). Antibody release test (+) confirm
3). Free antibody test (+) judge

26. Treatments 1). Phototherapy 2). Exchange transfusion
3). Internal Medicine

27. Treatments continued During pregnancy
1. Intrauterine blood transfusion
2. Early delivery

28. Treatments continued After birth 1. Phototherapy
Principle : photon of light
Three photochemical reactions:
1). Structure isomer
2). Geometric isomer
3). Photo-oxidation
Photoproducts excretion: w/o conjugation

29. Treatments continued Indications of phototherapy : Light source:
Unconjugated bilirubinemia
Bilirubin level >12mg/dl
Light source:
Spectral outputs 420 to 500nm

30. Treatments continued Side effects of phototherapy : a. diarrhea
b. fever
c. skin rash
d. bronze baby syndrome
(conjugated bilirubin>4mg/dl)

33. Treatments continued 2. Exchange Transfusions:
a. Severe hemolytic disease
b. Refractory to phototherapy

34. Treatments continued Aims of transfusions: a. Remove antibodies
b. Remove bilirubin
c. Correct anemia

35. Treatments continued Indication of transfusions: one of the follows
20mg/dl (340 μmol/L)
>4mg/dl,Hgb<120g/L, edema
0.7mg/dl/h
Kernicterus

36. Treatments exchange transfusions
Source of the blood
mother newborns
For Rh: Rh ABO
incompatibility
For ABO: “AB” plasma “O” cells
incompatibility packed RBC

37. Treatments exchange transfusions
Potential complications:
a. Infection
b. Necrotizing enterocolitis NEC
c. Thromboembolic complications

38. Treatments continued 3. Pharmacological agents: a. Phenobarbital
Effects: Uptake, Conjugation
Excretion
b. Albumin
c. IVIG

39. Preventions For ABO incompatibility: No For Rh incompatibility
300 μg of human anti-D globulin
within 72 h of delivery.

40. 1.Unconjugated bilirubinemia:
a. Hemolytic diseases:
ABO, Rh incompatibility
b. G-6-PD deficiency;
c. Breast milk jaundice

41. 1.Unconjugated bilirubinemia:
b. G-6-PD deficiency;
male, jaundice, enzyme activity
c. Breast milk jaundice
causes: unclear, -glucuronidase
follows physiologic jaundice: 4-7 d
breast feeding
persist for several weeks.

42. Conjugated bilirubinemia:
a. neonatal hepatitis
b. biliary obstruction (cholestatic jaundice)
biliary atresia,
common bile duct stenosis
c. congenital metabolic diseases
α-1 antitrypsin deficiency

43. Case analysis : 24 old male infant, gravida1,para 1.
Apgar scores: 8 at 1 min
Mother: blood type “O”
PE: icterus appeared on
face and trunk skin
liver edge 1cm
palpable spleen tip

44. Case analysis continued
Lab tests:
Hgb:13g/dl, reticulocyte count : 7%
Blood smear: nucleated RBC
Blood type: A, Rh-positive
Serum bilirubin: 12.9mg/ml
Direct Coomb’s test: weakly positive
Question: what’s the risk factor ?

45. Department of Pediatrics
Thank you! Questions？