INTRODUCTION Jaundice can be detected clinically when the level of bilirubin in the serum rises above 85 mol/l (5mg/dl).

CAUSES OF NEONATAL JAUNDICE Haemolysis due to ABO or Rh-isoimmunisation, G6PD deficiency, microspherocytosis, drugs. Physiological jaundice. Cephalhaematoma, subaponeurotic haemorrhage. Polycythaemia. Sepsis septicaemia, meningitis, urinary tract infection, intra-uterine infection. Breastfeeding and breastmilk jaundice. Gastrointestinal tract obstruction: increase in enterohepatic circulation.

Approach to an infant with jaundice History Age of onset. Previous infants with NNJ, kernicterus, neonatal death, G6PD deficiency. Mothers blood group (from antenatal history). Gestation: the incidence of hyperbilirubinaemia increases with prematurity. Presence of abnormal symptoms such as apnoea, difficulty in feeding, feed intolerance and temperature instability. Physical examination General condition, gestation and weight, signs of sepsis, hydration status. Signs of kernicterus: lethargy, hypotonia, seizure, opisthotonus, high pitch cry. Pallor, plethora, cephalhaematoma, subaponeurotic haemorrhage. Signs of intrauterine infection e.g. petechiae, hepatosplenomegaly.

INVESTIGATIONS Total serum bilirubin G6PD status Others as indicated: Infants blood group, maternal blood group, Direct Coombs test (indicated in Day 1 jaundice and severe jaundice). Full blood count, reticulocyte count, peripheral blood film Blood culture, urine microscopy and culture (if infection is suspected)

MANAGEMENT

Indications for referral to hospital: Jaundice within 24 hours of life. Jaundice below umbilicus (corresponds to serum bilirubin 200-250 mol/L). Jaundice extending to soles of feet: Urgent referral, may need exchange transfusion ! Family history of significant haemolytic disease or kernicterus. Any unwell infant with jaundice. Prolonged Jaundice of >14 days. - Refer infants with conjugated hyperbilirubinaemia urgently to a hospital. - Infants with unconjugated hyperbilirubinaemia can be investigated and referred only if the jaundice does not resolve or a definitive

TREATMENT Avoid sunlight exposure due to risk of dehydration and sunburn. Phototherapy Phototherapy lights should have a minimum irradiance of 15 W/cm2/nm. Measure intensity of phototherapy light periodically using irradiance meters. Intensive phototherapy implies irradiance in the blue-green spectrum of at least 30 W/cm2/nm measured at the infants skin directly below the center of the phototherapy unit. Position light source 35-50 cm from top surface of the infant (when conventional fluorescent photolights are used). Expose infant adequately; Cover infants eyes. Monitor serum bilirubin levels as indicated. Monitor infants temperature 4 hourly to avoid chilling or overheating. Ensure adequate hydration and good urine output. Monitor for weight loss. Adjust fluid intake (preferably oral feeds) accordingly. Routine fluid supplementation is not required with good temperature homeostasis. Allow parental-infant interaction. Discontinue phototherapy when serum bilirubin is below phototherapy level. Turn off photolights and remove eyepads during feeding and blood taking. Once the baby is on phototherapy, visual observation as a means of monitoring is unreliable. Serum bilirubin levels must guide the management.

In infants without haemolytic disease, the average increase of bilirubin level in rebound jaundice after phototherapy is < 1 mg/dl (17 mol/L). Hospital discharge need not be delayed to observe for rebound jaundice, and in most cases, no further measurement of bilirubin is necessary.

115

NEONATOLOGY
ADDITIONAL NOTES

Failure of phototherapy has been defined as an inability to observe a decline in bilirubin of 1-2 mg/dl (17-34 mol/L) after 4-6 hours and/or to keep the bilirubin below the exchange transfusion level. Do an immediate exchange transfusion if infant shows signs of acute bilirubin encephalopathy (hypertonia, retrocollis, opisthotonus, fever, high pitch cry) or if TSB is 5 mg/dL (85 umol/L) above exchange levels stated above.
Use total bilirubin level. Do not subtract direct or conjugated bilirubin. During birth hospitalisation, ET is recommended if the TSB rises to these levels despite intensive phototherapy. Infants who are of lower gestation will require

INTRAVENOUS IMMUNOGLOBULINS (IVIG) High dose intravenous immunoglobulin (IVIG) (0.5 - 1 gm/kg over 2 hours) reduces the need for exchange transfusions in Rh and ABO hemolytic disease. Give as early as possible in hemolytic disease with positive Coombs test or where the serum total bilirubin is increasing despite intensive phototherapy. Dose can be repeated in 12 hours if necessary. If exchange transfusion is already indicated, IVIG should be given after ET.

MEASURES TO PREVENT SEVERE NEONATAL JAUNDICE Inadequate breast milk flow in the first week may aggravate jaundice. Supportive measures should be there to promote successful breastfeeding. Supplementary feeds may be given to ensure adequate hydration, especially if there is more than 10% weight loss from birth weight. Interruption of breastfeeding in healthy term newborns is discouraged and frequent breast-feeding (at least 8-10 times/24 hours) should be continued. Supplementing with water or dextrose water does not lower bilirubin level. G6PD status should be known before discharge. Observe infants with G6PD deficiency, for 5 days if not jaundiced and longer with moderate jaundice. Infants of mothers with blood group O and with a sibling who had severe neonatal jaundice should be observed for at least the first 24 hours of life. If phototherapy in infants with hemolytic diseases is initiated early and discontinued before the infant is 3 - 4 days old, monitor for rebound jaundice and adequacy of breast feeding within the next 24-48 hours.

FOLLOW-UP All infants discharged < 48 hours after birth should be seen by a healthcare professional in an ambulatory setting, or at home within 2-3 days of discharge. For infants with risk factors for severe neonatal jaundice, early follow up to be arranged to detect rebound jaundice after discharge. Infants with serum bilirubin > 20 mg/dl (340 mol/L) and those who require exchange transfusion should be followed for neurodevelopmental outcome. Do a Hearing assessment (using BAER, not OAE) at 0-3 months of corrected age. Infants with hemolytic diseases not requiring ET should be closely followed up for anaemia until the risk of ongoing hemolysis is minimal.