1. Dr.Abdulaziz Alsoumali Intern Alyamamh hospital Pediatric rotation
Jaundice
Dr.Abdulaziz Alsoumali
Intern
Alyamamh hospital Pediatric rotation

2. Content Definition of jaundice Background & Epidemiology
Bilirubin metabolism
Classifications of jaundice
Causes of neonatal jaundice
Diagnosis
Treatment

3. Jaundice
Definition:

4. Definition Yellow discoloration of : - The skin
- The conjunctival membrane (sclera)
Jaundice is not a disease
Bilirubin
Over the sclera
But a sign of increases bilirubin level

5. Background & Epidemiology
Over 50% of all newborn infants become visibly jaundiced.
About 80% of pre-term newborn infants become jaundiced.
The red cell half life span of newborn infants is (70 days)
Hepatic bilirubin metabolism is less efficient in the
first few days of life.

6. Bilirubin metabolism

7. Classification A) Unconjugated Hyperbilirubinemia
Hemolysis & Recticuloycytosis No Hemolysis
(+) Coombs test
ABO & Rh incompatibility
Autoimmune SLE
Idiopathic acquired hemolytic anemia
Coombs test
RBC enzyme defect (G6PD)
RBC membrane defect (spherocytosis)
Gilbert syndrome
Physiologic jaundice
Breast milk jaundice
Breast feeding
Crigler-Najjar syndrome
Hypothyrodisim
Pyloric stenosis
SLE: systemic lupus erthematous

8. Classification B) Conjugated Hyperbilirubinemia
Obstructive Infectious Metabolic
Biliary atresia
Choledochal cyst
Cholelithiasis
Bile duct stenosis
Tumor/neoplasia
Spontanoeus bile duct perforation
Bile-mucus plug
Hepatitis
Cytomegalovirus
Herpes simplex 1,2,6
Epstein-Barr virus
Measles
Varicella
Bacterial sepsis
Cholecystitis
Wilson disease
Alpha-1 antitrypsin deficiency
Galactosemia
Cystic fibrosis
Dubin-Johnson
Rotor syndrome
D.D. of jaundice in childhood !!

9. Classification B) Conjugated Hyperbilirubinemia
Idiopathic Autoimmune
e.g. Idiopathic neonatal hepatitis
e.g. Autoimmune chronic hepatitis
Sclerosing cholangitis

10. Causes of neonatal jaundice

11. Diagnosis (Clinical Assessment)
Jaundice appears clinically --> the bilirubin level reaches about 80 μmol/L
Kramer recognised the cephalocaudal progression of jaundice with increasing total serum bilirubin levels and divided the baby into 5 zones, with a total serum bilirubin level measurement associated with each zone. This is known as Kramer’s rule (see Figure 1) and has traditionally been used to visually assess the severity of jaundice
Kramer’s rule is inaccurate on a baby who has already commenced phototherapy.1 Visual estimation of bilirubin levels can lead to errors,2,3 especially in darkly pigmented babies.

12. Complications Permanent damage --> Kernicterus
- Athetoid cerebral palsy
- developmental delay
- hearing deficit
- dental dysplasia
- Permanent upward gaze
(Parinaud’s sign)
Acute bilirubin encephalopathy refers to the acute manifestations of bilirubin toxicity1 seen in the first few weeks after birth.2 Initial signs include1 : • lethargy • hypotonia and poor suck progressing to: o hypertonia (opisthotonos and retrocollis) o high pitched cry and eventually to: ƒ seizures and coma Kernicterus is the pathogenic diagnosis characterised by bilirubin staining of the brain stem nuclei and cerebellum, but has also come to refer to chronic bilirubin encephalopathy.1 Clinical findings include1 : • athetoid cerebral palsy with or without seizures • developmental delay • hearing deficit • oculomotor disturbances including paralysis of upward gaze (Parinaud’s sign) • dental dysplasia • intellectual impairment

13. Complications Initial signs include: - lethargy Reversible damage
--> Acute bilirubin
encephalopathy
Initial signs include: - lethargy
- hypotonia
- poor suck, progressing to
- hypertonia
(opisthotonos&retrocollis)
- High pitched cry
Postmortem brainstem and cerebellum
showing kernicterus with yellow bilirubin staining of
There is no bilirubin level known to be safe or which
will definitely cause kernicterus. In rhesus haemolytic
disease, it was found that kernicterus could be prevented
if the bilirubin was kept below 340 μmol/L
(20 mg/dl
brainstem nuclei (arrows).
, kernicterus is the yellow staining of specific areas of brain tissue in the neonate secondary to accumulation of unconjugated bilirubin. Bilirubin staining is seen most commonly in the basal ganglia (particularly the globus pallidus), subthalamic nuclei, and hippocampus and multiple cranial nerve nuclei (facial, cochlear, oculomotor, and vestibular nuclei).

14. Treatment Phototherapy Exchange transfusion
Complications:
Loose stools
Erythematous macular rash
Overheating --> leading to dehydration
Bronze baby syndrome
Exchange transfusion
- no response with phototherapy
- reaches the threshold of the transfusion
Light (wavelength 450 nm) from the blue–green band of the visible spectrum converts unconjugated bilirubin into a harmless water­soluble pigment excreted pre­ dominantly in the urine.
(light (wavelength 450 nm) from the
blue-green band)

15. NICE guidelines ....

18. Take home message

19. Literatures
Up to date
Tom Lissauer, Graham Clayden. Illustrated textbook of Pediatrics, 4th edition
NELSON, Essentials of pediatrics
Queensland Maternity and Neonatal Clinical guideline
NICE guidelines for neonatal jaundice

20. Questions !!