1. بسم الله الرحمن الرحيم Jaundice in the newborn DR Husain Alsaggaf

2. Jaundice in the newborn Clinical jaundice appear at SB 5 mg/dl Clinical jaundice appear at SB 5 mg/dl 25% to 50% of term newborns have clinical jaundice. 25% to 50% of term newborns have clinical jaundice. Jaundice may caused by serious illness or lead to keriniectrus. Jaundice may caused by serious illness or lead to keriniectrus. 75% of bilirubin comes from haemoglobin and 25% from other sources 75% of bilirubin comes from haemoglobin and 25% from other sources

3. Neonatal jaundice physiologicalpathological conjugated Intrahepatic Hepatic injures infectious metabolic Neonatal hepatitis Paucity of hepatic ducts Extrahepaitc unconjugated

4. Physiological jaundice Start after the first 24hours. Start after the first 24hours. Peak in the fourth or fifth day {not >12 mg/dl} in term babies and not more than 15 mg/dl in premature Peak in the fourth or fifth day {not >12 mg/dl} in term babies and not more than 15 mg/dl in premature The baby is well. The baby is well. Clear in week in term and two weeks in premature. Clear in week in term and two weeks in premature. Bilirubin is unconjucated. Bilirubin is unconjucated. The rise is not more than 0.5 mg /h The rise is not more than 0.5 mg /h

5. Causes of physiological jaundice High haemoglobin Decrease RBC life span. Increase enterohepatic circulation. Defective conjugation. Decrease hepatic excretion

6. Pathological jaundice Unconjucated High Hg mass Haemolysis. Blood group incompqatability.(RH.A BO.) Red cell membrane defect (spherocytosis) Heamoglobinopathy. Haemolytic agents (vit k3.oxytocin) Infection E.coli septicaemia

7. Causes of unconjucated hyperbiliruniemia Liver cell membrane defect (GILBRET). Liver cell membrane defect (GILBRET). Defective conjugation. Defective conjugation. Jaundice of prematurity. Jaundice of prematurity. Breast milk jaundice. Breast milk jaundice. Hypothyroidism. Hypothyroidism. Hereditary(crigler-najjar). Hereditary(crigler-najjar). Other conditions Pyloric stenosis,infant of diabetic mother, down's syndrome Other conditions Pyloric stenosis,infant of diabetic mother, down's syndrome

8. Investigation of unconj- hyberbilirubinneamia Split biliurubin. Blood groups and Rh. coomb’s test. CBC and reticulocyte. G-6-P-D estimation Blood film and osmotic fragility test. TFT and urine for reducing substance.

9. Causes of conjugated hyberbilirubineamia Hepatitis: CMV.toxoplasmosis.rubella.herpes.giant cell,Hep A and b,syphilis,E coli. Hepatitis: CMV.toxoplasmosis.rubella.herpes.giant cell,Hep A and b,syphilis,E coli. Metabolic: Galctosemia,Tyroseanemia,Fructoseamia. Metabolic: Galctosemia,Tyroseanemia,Fructoseamia. Cystic fibrosis. Cystic fibrosis. Alpha one anti trypsin deficiency. Alpha one anti trypsin deficiency. Gauchers and neimman pick Gauchers and neimman pick Biliary Artesia (intrahepatic and extrahepatic) Biliary Artesia (intrahepatic and extrahepatic) Choldoccal cyst. Choldoccal cyst. T.P.N T.P.N

10. Investigation of conjugated hyperbiliruniemia L.F.T L.F.T PT.PTT. PT.PTT. Urine for glucose and reducing substance. Urine for glucose and reducing substance. Serum and urine amino acid determinations. Serum and urine amino acid determinations. TORCH serology. TORCH serology. Ultrasound. Ultrasound. Liver scan Liver scan Duodenal aspiration. Duodenal aspiration. Liver biopsy. Liver biopsy.

11. Approach To neonatal jaundice History. History. FH of aneamia,spleenomegaly. FH of aneamia,spleenomegaly. Jaundice in other sibling (breast milk jaundice.Rh disease) Jaundice in other sibling (breast milk jaundice.Rh disease) FH of liver disease (galactoseamia,alpha-one- antitrypsin difficiency,cystic fibrosis, Gilbert and crigler- najjar) FH of liver disease (galactoseamia,alpha-one- antitrypsin difficiency,cystic fibrosis, Gilbert and crigler- najjar) Maternal illness during pregnancy (TORCH and diabetes). Maternal illness during pregnancy (TORCH and diabetes). Maternal drugs.(sulfanomide Maternal drugs.(sulfanomide Labour and delivery(Truma,oxytocin,delay ed clamping of the cord,prematurity. Labour and delivery(Truma,oxytocin,delay ed clamping of the cord,prematurity. Infant history. Infant history. Feeding (breast milk jaundice). Feeding (breast milk jaundice). Poor feeding. Poor feeding. Vomting(sepsis pyloric stenosis,galactosemia Vomting(sepsis pyloric stenosis,galactosemia

12. Examination Small for date(polycythemia, in-utroinfection. Small for date(polycythemia, in-utroinfection. Premature Premature Extravagated blood(briuses,cephaloheamatoma). Extravagated blood(briuses,cephaloheamatoma). Pallor(heamolytic anaemia and extravagated blood) Pallor(heamolytic anaemia and extravagated blood) Cherioretinitis,cataract,(congenital infection,galactoseamia) Cherioretinitis,cataract,(congenital infection,galactoseamia) Petechia rash (congenital infection,galactoseamia) Petechia rash (congenital infection,galactoseamia) Hepatospleenomegaly(heamolytic anaemia,congenital infection, liver diseases) Hepatospleenomegaly(heamolytic anaemia,congenital infection, liver diseases)

13. Management Prevention: Prevention: Rh incompatibility----- Anti D Rh incompatibility----- Anti D Syphlis---Pencilline Syphlis---Pencilline Specific therapy: Specific therapy: Septicaemia---- Antibiotic. Septicaemia---- Antibiotic. Surgery------------ Ex hepatic biliary Artesia. Surgery------------ Ex hepatic biliary Artesia. Galctose withdrawal for galactoseamia. Galctose withdrawal for galactoseamia.

14. Management of unconjucated hyberbilirubineamia

15. Phototherapy Wave length 450-460 --  Reduce bilirubin To harmless compound excreted in the urine. Wave length 450-460 --  Reduce bilirubin To harmless compound excreted in the urine. Complication: Complication: Retinal damage, nasal obstruction, mild diarrhea,dehydration, bronzed baby syndrome Retinal damage, nasal obstruction, mild diarrhea,dehydration, bronzed baby syndrome

16. Exchange Transfusion Indicated when bilirubin reach toxic level. Indicated when bilirubin reach toxic level. Mortality1% Mortality1% Remove bilirubin,antibodies,correct anaemia. Remove bilirubin,antibodies,correct anaemia. Double blood volume is used 85 ml /kg Double blood volume is used 85 ml /kg COMPLICATION. COMPLICATION. Infection,acidosis,Cad iac failure, Electrolytes imbalance. Infection,acidosis,Cad iac failure, Electrolytes imbalance.

17. Phenobarbitone This act as enzyme inducer which increase amount of glucoreny transferase and protein z. This act as enzyme inducer which increase amount of glucoreny transferase and protein z. Used in crigler najjar Used in crigler najjar

18. Kernicterus Yellow staining of nuclear centres of the brain Yellow staining of nuclear centres of the brain Due to high level of indirect bilirubin. Due to high level of indirect bilirubin. Bilirubin cause neural loss. Bilirubin cause neural loss. Bilrubin inhibit cell respiration, protein synthesis,glucouse metabolism. Bilrubin inhibit cell respiration, protein synthesis,glucouse metabolism. Poor feeding and lethargy-  fits,rigidity  spacsticty  deafnes,athetosis Poor feeding and lethargy-  fits,rigidity  spacsticty  deafnes,athetosis