1、Neonatal JaundiceDezhi Mu MD/PhDDepartment of Pediatrics, West China Second University Hospital, Sichuan UniversityIntroduction Jaundice is quite common (5mg/dl). Full term infants: at least 50% Preterm infants: over 80% Elevated blood bilirubin levels: 97%Introduction continued When? in the first w
2、eek of life Where? skin , mucosa and white of eye How many? blood bilirubin concentrations is 5-7mg/dl. Introduction continued Producing Excreting Why Jaundice occurred?Bilirubin Metabolism:1. RBC: Heme bilirubin (UCB) 2. Blood: carried by bound to albumin3. Liver: uptaken : Y protein, Z protein con
3、jugated: UDPGT excreted： to the biliary system 4. Intestine: stercobilins -glucuronidase enterohepatic circulationThe metabolic characteristics of bilirubin in newborns: 1. Bilirubin production 8.8mg/Kg/d in newborns3.8mg/Kg/d in adults 2. Bilirubin-albumin complex formation a. preterm infant; b. ac
4、idosis 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 The metabolic characteristics of bilirubin continuedBilirubin
5、toxicity 1. Conjugated bilirubin water-soluble 2. Unconjugated bilirubin lipid-soluble bilirubin-encephalopathy （kernicterus）Clinical Manifestations Jaundice appears When: at any time during the neonatal period Where: from face chest abdomen feetEvaluation of jaundice :1. By eyes: face, 5mg/dl ( 85m
6、ol/L ); abdomen, 10-15mg/dl; feet, 15-20mg/dl ;2. By transcutaneous measurement : used for screening3. By serum levels : standardManifestations continue Classification: Physiological Jaundice Pathological Jaundice Manifestations continue Physiological jaundice : 1. General state is well 2. Appears 2
7、-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 12.9mg/dl (full term infants) 15mg/dl (preterm infants) Fades 2 weeks (term infants) 4 weeks (preterm infants)3. Accumul
8、ates 5mg/dl/d4. Direct bilirubin 2mg/dl5.Jaundice recurrent Manifestations continueCommon causes of pathological jaundice1. Unconjugated bilirubinemia: a. hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice 2. Conjugated bilirubinemia: a. Neonatal hepatitisb. Bi
9、liary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. Congenital metabolic diseases -1 antitrypsin deficiencyCauses of pathological jaundice continueHemolytic disease of newbornHemolytic disease: ABO: 85.3%Rh : 14.6%MN : 0.1% Hemolytic disease of newborn continuedABO
10、 incompatibility the mother: type O the infant: type A or B Rh incompatibility the mother： Rh（-） the infant: Rh（+）D,E,C,d,e,cPathogenesisPathophysiologyRed blood cell breakdownHyperbilirubinemiaJaundiceKernicterus Seizures etc.Anemia1. Liver 2. Spleen3. Heart, other organs4. Hydrops Clinical Manifes
11、tations:ABO Rh1.Jaundice : mild severe 1-2 day 24 h2.Anemia: mild severe (3-6 weeks) heart failure3.Hepato- rare commonsplenomegaly ComplicationKernicterus: Phase 1: decreased alertnessHypotoniaPoor feeding Phase 2: Hypertonia, Retrocollis, opisthotonus Phase 3: Hypotonia1. Blood type incompatibilit
12、y 2. Hyperbilirubinemia : Unconjugated bilirubin level 3. Hemolytic tests 1). Hemoglobin level : low 2). Reticulocytes:1015% 3). Nucleated RBCLaboratory tests: Antibody test1). Direct Coombs test (+) confirm 2). Antibody release test (+) confirm3). Free antibody test (+) judgeLaboratory tests contin
13、ued1). Phototherapy 2). Exchange transfusion3). Internal MedicineTreatments During pregnancy 1. Intrauterine blood transfusion 2. Early deliveryTreatments continued After birth 1. Phototherapy Principle : photon of light Three photochemical reactions: 1). Structure isomer 2). Geometric isomer 3). Ph
14、oto-oxidationPhotoproducts excretion: w/o conjugationTreatments continuedIndications of phototherapy :Unconjugated bilirubinemia Bilirubin level 12mg/dl Light source: Spectral outputs 420 to 500nmTreatments continuedSide effects of phototherapy : a. diarrhea b. fever c. skin rash d. bronze baby synd
15、rome (conjugated bilirubin4mg/dl)Treatments continued2. Exchange Transfusions: a. Severe hemolytic disease b. Refractory to phototherapy Treatments continuedAims of transfusions:a. Remove antibodiesb. Remove bilirubinc. Correct anemiaTreatments continuedIndication of transfusions: one of the follows
16、a.20mg/dl (340 mol/L)b.4mg/dl,Hgb120g/L, edema c.0.7mg/dl/hd.KernicterusTreatments continuedSource of the blood mother newbornsFor Rh: Rh ABOincompatibility For ABO: “AB” plasma “O” cells incompatibility packed RBC Treatments exchange transfusionsPotential complications:a. Infectionb. Necrotizing en
17、terocolitis NECc. Thromboembolic complicationsTreatments exchange transfusions3. Pharmacological agents:a. Phenobarbital Effects: Uptake, Conjugation Excretionb. Albuminc. IVIGTreatments continuedPreventionsFor ABO incompatibility: NoFor Rh incompatibility 300 g of human anti-D globulin within 72 h
18、of delivery.1.Unconjugated bilirubinemia: a. Hemolytic diseases: ABO, Rh incompatibility b. G-6-PD deficiency; c. Breast milk jaundice1.Unconjugated bilirubinemia:b. G-6-PD deficiency; male, jaundice, enzyme activityc. Breast milk jaundice causes: unclear, -glucuronidase follows physiologic jaundice
19、: 4-7 d breast feeding persist for several weeks. Conjugated bilirubinemia:2.Conjugated bilirubinemia: a. neonatal hepatitis b. biliary obstruction (cholestatic jaundice) biliary atresia, common bile duct stenosis c. congenital metabolic diseases -1 antitrypsin deficiencyCase analysis :24 old male i
20、nfant, gravida1,para 1. Apgar scores: 8 at 1 minMother: blood type “O”PE: icterus appeared on face and trunk skin liver edge 1cm palpable spleen tipCase analysis continuedLab tests:Hgb:13g/dl, reticulocyte count : 7%Blood smear: nucleated RBCBlood type: A, Rh-positiveSerum bilirubin: 12.9mg/mlDirect Coombs test: weakly positiveQuestion: whats the risk factor ?Thank you! Questions？Department of Pediatrics
