1. Quality Education for a Healthier Scotland Multidisciplinary Neonatal Jaundice Promoting multiprofessional education and development in Scottish maternity care

2. Quality Education for a Healthier Scotland Multidisciplinary Neonatal Jaundice Definition = Total serum bilirubin (SBR) > 85 µ mol/L.

3. Quality Education for a Healthier Scotland Multidisciplinary Why is it important? Common Worrying for parents and / or staff Condition and treatment Sign of underlying disease Can cause neurological problems.

4. Quality Education for a Healthier Scotland Multidisciplinary Where does bilirubin come from?

5. Quality Education for a Healthier Scotland Multidisciplinary Causes Benign Physiological Breast milk and breastfeeding Pathologic.

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7. Quality Education for a Healthier Scotland Multidisciplinary Physiological Jaundice Features: Elevated unconjugated bilirubin SBR generally peaks @ 85-100 µ mol/L on day 3-4 and then declines to adult levels by day 10 Asian infants peak at higher values (110 µ mol/L ) Exaggerated physiological (up to 290 µ mol/L).

8. Quality Education for a Healthier Scotland Multidisciplinary Physiological Jaundice Asian infant Breastfed infant Non-breastfed infant

9. Quality Education for a Healthier Scotland Multidisciplinary Physiological Jaundice Increased rbc’s Shortened rbc lifespan Immature hepatic uptake and conjugation Increased enterohepatic circulation.

10. Quality Education for a Healthier Scotland Multidisciplinary Breast Milk Jaundice Elevated unconjugated bilirubin Prolongation of physiological jaundice May be second peak @ day 10 Average max SBR = 170-205 µ mol/L SBR may reach 376-410 µ mol/L ?Milk factor.

11. Quality Education for a Healthier Scotland Multidisciplinary Pathologic Jaundice Features Jaundice in first 24 hrs Rapidly rising SBR > 85 µ mol/L per day SBR > 290 µ mol/L. Categories Increased bilirubin load Decreased conjugation Impaired bilirubin excretion.

12. Quality Education for a Healthier Scotland Multidisciplinary 1.Increased Bilirubin Load Elevated unconjugated bilirubin Haemolytic Disease Non-haemolytic Disease.

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15. Quality Education for a Healthier Scotland Multidisciplinary 2. Decreased Bilirubin Conjugation Elevated unconjugated bilirubin Genetic Disorders Hypothyroidism.

16. Quality Education for a Healthier Scotland Multidisciplinary 3. Impaired Bilirubin Excretion - usually later Elevated conjugated bilirubin o> 35 µ mol/L or > 20% of SBR Biliary Obstruction Important to diagnose by 4 weeks Infection Metabolic Disorders Chromosomal Abnormalities Drugs.

17. Quality Education for a Healthier Scotland Multidisciplinary Diagnosis and Evaluation Physical Examination Jaundice visible when bilirubin reaches 85 µ mol/l Milder jaundice generally confined to face and upper chest Downward extension generally signifies increasing bilirubin values.

18. Quality Education for a Healthier Scotland Multidisciplinary Diagnosis and Evaluation Laboratory Blood test Indirect measurements Transcutaneous.

19. Quality Education for a Healthier Scotland Multidisciplinary Risk Factors for increased Hyperbilirubinemia Jaundice in first 24 hrs Visible jaundice prior to discharge Previous jaundiced infant Gestation 35-38wk. Exclusive breastfeeding Asian race Bruising, cephalohaematoma Male sex. AAP, Subcommittee on Neonatal Hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics 2001;108.

20. Quality Education for a Healthier Scotland Multidisciplinary Management of Unconjugated Hyperbilirubinemia (Term) ≥ 500≥ 430≥ 340≥ 290>72 ≥ 500≥ 430≥ 310≥ 25549-72 ≥ 430≥ 340≥ 255≥ 20525-48 ≤24 Exchange transfusion and intensive phototherapy Exchange transfusion if phototherpay fails Phototherapy Consider Phototherapy Bilirubin Level ( µ mol/L) Age (hr) AAP, Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Pediatrics 1994; 94(4 Pt 1):558-565.

21. Quality Education for a Healthier Scotland Multidisciplinary Treatment Underlying Cause Where one is identified Fluids and Nutrition Phototherapy.

22. Quality Education for a Healthier Scotland Multidisciplinary Phototherapy Mechanism Forms Breastfed infants are slower to recover Rebound hyperbilirubinemia is rare Average increase is 17 µ mol/L.

23. Quality Education for a Healthier Scotland Multidisciplinary Treatment

24. Quality Education for a Healthier Scotland Multidisciplinary Treatment Underlying Cause Where one is identified Fluids and Nutrition Phototherapy Monitoring and follow up ? Repeat hearing checks ? Hb checks for late anaemia.

25. Quality Education for a Healthier Scotland Multidisciplinary Exchange Transfusion Mechanism: removes bilirubin and antibodies from circulation Most beneficial to infants with haemolysis Generally never used until after intensive phototherapy attempted.

26. Quality Education for a Healthier Scotland Multidisciplinary Kernicterus What is it? Bilirubin induced toxicity to Basal Ganglia and brainstem nuclei. Increase in cases beginning in early 1990s At least partially related to early hospital discharge.

27. Quality Education for a Healthier Scotland Multidisciplinary Kernicterus Causes of kernicterus Idiopathic – 32% G6PD Deficiency – 32% Bruising – 10% Infection – 7% Crigler-Najjar syndrome – 3%.

28. Quality Education for a Healthier Scotland Multidisciplinary Any questions?

29. Quality Education for a Healthier Scotland Multidisciplinary Summary Jaundice is common and “ normal ” Recognition of at risk infant Assessment - clinical and biochemical Treatment.