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Okay, good evening, everyone. Uh Thank you for joining us and welcome to the third part of our neonatal themed webinar week. Um This evening, we have wonderful presentation on Neonatal Jaundice. Um um And it is my pleasure to introduce Doctor Purohit who will be taking us all through this and share in her experience working on a neonatal unit um Throughout the presentation, as always, please feel free to contribute answers in the chat or if you have any questions at all, we'll both be keeping an eye on it. Um And we'll do our best to answer any questions you have. OK, over to you. Thank you. So, yes, hi, everyone. I'm Aisha. I'm currently an F Y two on my GP rotation. Um But my last rotation was in a tertiary Nick You Center. So up in Burnley, um which was really interesting experience um very niche, but really enjoyed it. So, yeah, I'm just going to talk a bit about neonatal jaundice today. Um I hope it's useful for some of you. Um And these are basically the things that we're gonna cover. So I'm going to talk about what Neonatal jaundice is and the causes for neonatal jaundice. We'll also have a look through the signs and symptoms as well as investigations um that you would do and how you treat and manage neonatal jaundice as well as complications. Um I'll also have a like a small kind of focus at the end on something that's quite rare but is also really important within um like neonatal jaundice as a topic. So go to the next slide. So what is neonatal jaundice? So joined is as we know, very similar in adults. It's basically yellow discoloration of the skin and this is due to um the accumulation of billy Ruben in the tissues. So you might see discoloration in the sclera in the skin in mucous membranes. Um and all over the body basically, um especially like the soles of babies is something that I found was really important to look at because sometimes there were some babies we saw who literally would just have joined us in their souls. So um important to look out for things like that. So 50 to 70% of terminates have joined this. So it's very common. Um And 80% of preterm babies have joined this within their first week of life. Your bilirubin levels would be higher in a neonate compared to an adult. And, and that is because um newborn babies have a higher concentration of red blood cells and their red blood cells have a shorter lifespan compared to adults. Um Most cases of neonatal jaundice are physiological. Um and you can kind of split it into two sections. So it's early jaundice, which is defined as jaundice. Backers in babies that are less than 24 hours old, but also prolonged jaundice as well. And by those two sort of topics, you can decide how you're going to treat and manage that kind of case. So this is just a schematic of what happens um in terms of when babies become jaundice. So if you just click again, James, so um your red blood cells, they're broken down and that causes the release of uncontradicted, Billy Ruben into the blood. And some of this is bound to album in which is we some which we, we call us free. Um And this is what crosses the blood brain barrier, which is important in neonatal jaundice because the blood brain barrier in babies is not as well formed as saying adults. So this is really important which we'll learn about later on. So this uncomplicated Billy Ruben um then becomes conjugated in the liver. And this conjugated. Billy Ruben is excreted in two ways one way through the urine, which is what gives our urine, the pigment that it has and also um through the gastrointestinal system where it's re absorbed within the small intestine as well. So it's just a bit of a physiology. So jaundice that occurs within the 1st 24 hours of life is considered pathological. That's really important So anytime you see a baby who has joined us and they're less than 24 hours old, that is something that is really important to be aware of babies that are breast feeding, they're more likely to have jaundice than babies that are bottle fed. Um And I think this is to do with, I think proteins in the breast milk that basically are more difficult for the liver to break down. Um due to the immaturity of the liver in the babies. So prolonged jaundice that can be harmless, but also it can be an indication of severe liver disease. And like I say, that's something that we'll focus on a bit later. Um So your fetal red blood cells, they are broken down more rapidly than normal red blood cells as we were saying. And so this causes an increased release of Billy Ruben, which is why Julie neonatal jaundice is so common and normally babies would excrete Billy Ruben by the placenta. But obviously, once they're born, there's no more placenta for them to excrete Billy Ruben by. So, um this can cause us the babies to have a rise in there, Billy Ruben shortly after birth. So you might see in babies that are say two days old that they still have a mild yellowing of the skin or the squarer, but this usually can resolve by 10 days' time or so. So, like I said, very important point, jaundice is that in the 1st 24 hours. Life is always pathological. So it's really important to think of reasons as to why this could occur. And here's just some examples there. So early onset jaundiced, we'll talk about that first. So there's many reasons why this could occur. Um They might have blood group incompatibility. There might be hemolytic disease of the newborn or another really important thing is sepsis. So these babies will um need to be screened. So they'll need to have like full blood count, white blood cells checked. Um like platelets might be low. Um They also need to have um they're like lactate, venous blood samples and then you need to treat them for sepsis. So usually we would start antibiotics um at the same time, like we take blood culture and then we'll start the antibiotics. Um The baby might have liver disease, obviously, we don't know anything about them before they've been born. So that's something to keep in mind as babies are born as well. They obviously, if they're born, say bye. Um Well, both means like if they're born by Cesarean, it might be traumatic if they're born via like normal vaginal delivery, they're obviously being squashed. And so say they used four steps to deliver baby, they might cause um like bruising and cephalohematomas, which can also cause obviously breakdown of the red blood cells and therefore also an increased risk of jaundice. So that's also something to keep in mind. Babies might have different metabolic disorders and also glucose, six phosphate, dehydrogenize, deficient deficiency. And that's something also that's really important to um to look out for. So, there are many risk factors to um developing neonatal jaundice. So the most common ones are babies that have a low birth weight. Um So ones that are usually premature or small for dates, babies that are breast fed, as I said before, um, babies that have a previous sibling that had neonatal jaundice that required voter therapy. They're more at risk of getting jaundice as well. Um Babies whose mothers have gestational diabetes or um type two diabetes prior to being pregnant, they also are at higher risk of developing jaundice. Um males, those that are um of Asian descent as well have had significant bruising like I mentioned before, like a scalp hematoma as well. Um And those with significant weight loss and decreased oral intake. Um I don't know whether it's the same across all um trust, but our trust would say anything uh for 10% weight loss. Um when babies were readmitted, that's something that we would be really, really concerned about. And these are the babies that we would want to kind of focus on so that they don't become dehydrated when they're re admitted with jaundice. So this is a very typical kind of case that we would have. Um So a baby was born at 38 weeks. Um Maternal history wise, it was mom's first pregnancy and she had no other past medical history herself during the pregnancy, there was no problems. All scans were normal and baby was born by normal vaginal delivery. There was no complications with the delivery. Um baby cried at birth. Uh The app gahr was nine throughout. So, you know, absolutely fine. Um However, baby was noticed by the midwifery team that they were jaundiced at 24 hours old, but they were sent home. So this is quite common. They might have some mild jaundice, but they can be sent home. This mum specifically chose to breastfeed the baby. But 48 hours later, the baby was brought back through E D because they were becoming more and more jaundiced and they weren't breastfeeding and they were lethargic. So a baby that is not feeding well and a baby that is a lot more floppy than it than normal, we would be really concerned about and they're babies that would get re admitted back into the ward. So when we examined this baby, there was significant jaundice throughout the whole body. Um they were yellow from head to toe, neurological e they were very normal normal reflexes, um including the morrow reflex and the sucking reflex as well. Um And when they had their blood stone, the billy Ruben was significantly raised, go to the next one. So some of the signs and symptoms that we would look for in a baby who is joined, this is obviously do they are, they visibly jaundice. So sometimes it starts in the forehead in the face, but it can become visible on the trunk as well. And like I say, in the soles of the feet, you've also got to look at because babies might become jaundiced only from there. So it's really important to have a good look throughout the whole of baby. Um You want to look for neurological symptoms as well. So how is their tone? Is it normal? Are they moving about? Well, um are they hypertonic, have they got head lag? Have they had seizures any muscle spasms? Because this is really important due to one of the main complications of um letting the billy Ruben rise too high. Um Hepatosplenomegaly is something that you can also look for. Obviously, it can be quite difficult in a neonate to assess the size of their liver and spleen because they have such a small abdomen anyway. Um but usually by palpating, you, you, you sometimes can feel the liver. But I guess if you think that it is and I guess as you get more experience examining babies, but by feeling, once you felt like a big liver, you, you kind of know what that that feels like and it takes quite a lot of the abdomen. Um and I think it can feel quite hard as well in comparison to say bowel. So if that's taking up a lot of the abdomen, you know, the baby might have um some sort of liver problem which as we mentioned before is important in um neonatal jaundice. They might also have Patiki eye um as well as microcephaly. Um and usually something like that might be picked up on a antenatal scan. Um microcephaly particularly is associated with hemolytic anemia. Um So another thing as well is babies could have pale stools and dark urine. Um and mostly these are associated with the the infections such as rubella and CMB, go to the next slide. So this is just a schematic, which I think is really important because obviously, we see babies from all different backgrounds and it can be very difficult to realize whether a baby is jaundiced or not, especially like the amount of babies that you see and they might only have, you know, on their hands, it might just be slightly jaundiced. Um So it can be really difficult to kind of work out. Is this baby joined? This? Is it not? Um but we have a lot of different ways in which we can tell in terms of um you know, through investigations. So if you do suspect that a baby might be slightly joined this, it's there's no harm in in checking whether there Billy Ruben level is high um or not to be honest, next life. So as I was just saying, you can use um well, you can, you can check a transcutaneous Billy Ruben level, which is what a lot of the midwifery team would do especially at our hospital before kind of taking the baby's bloods and checking the serum Billy Ruben that way. So often, if the midwives would suspect that babies were um, you know, particularly drawn this looking, they would do a transcutaneous billy Ruben, which is kind of done through this Zapper that is um like the temperature probes that you can like a matte people's heads and they can use that to see how, whether they've got a raised Billy Ruben and whether they require phototherapy or hopefully not, but exchange transfusion as well. Um You can obviously take babies bloods and check for a serum billy Ruben level. And while you're doing this, it's also important to check for the full blood count as well as the blood film. The blood film can tell us whether babies have something like poly polycythemia or hemolytic anemia, which tells us an underlying course for their jaundice. Um and as well checking their white blood cells and the platelets because um this can indicate whether a baby septic or not as well as well as infection markers too. We also could if you're suspecting that it might be actually a prolonged jaundice and they, you know, it's important to check the conjugated bilirubin levels because then we can find out if it's actually a hepatobiliary cause um rather than a physiological cause that's, you know, not as worrying and may not require urgent management and it's also important to check the blood type of both mom and baby to look for whether there's recess incompatibility or not as well. We'll also do A D C T so direct Coombs test and this can tell us whether there's him all icis. Um We should also look at the thyroid function um as well as blood in urine cultures if you suspect that there's an infection and obviously, we would treat this with antibiotics. Oh And like I said before, there's um glucose six phosphate, that's also something that can present it neonatal neonatal jaundice can present um as the kind of clinical feature of this deficiency. So, um yeah, you can also check for glucose six phosphate dehydrogenase levels. So this, I think this should be something that is kind of throughout different neonatal departments across um the UK. And this is basically just a graph that we use to plot the levels of Billy Ruben. And it tells us whether the baby needs to start through to therapy or whether they need to start exchange transfusion. Um We hope that hopefully it won't go past that line, but um you can play uh my trust, we would plot the transcutaneous level. And then judging by whether or not how high it was or how close to the phototherapy line is, you can kind of make a trend and you can how long you should kind of expect it to take for a baby to kind of cross the line is you can kind of tailor when you're going to take the bloods again to check whether or not they do need to start phototherapy because some babies you might see that it is going up, but then it might just um kind of plateau off. So actually they, they don't need phototherapy. Um So this is a really useful graph to use and you get them for different gestations if they're premature. And, and it just gives you the days from birth along the bottom and then the level of Billy Ruben on the side. So you can then just plot and work out whether you need to start treatment or not. So, in terms of management, um so as we saw in the previous slide, there's phototherapy, which you can use to treat jaundice levels. And um what phototherapy does is it's basically uses light energy to cause a reaction that causes the Billy Ruben to become less lipophilic and more easily excreta ble. So because there's so much Billy Ruben that the babies can't break down. So by the photos therapy, light energy allows for this to occur. So this may means that it creates this breakdown, these breakdown products that don't need to be conjugated in the liver because the liver as it's so immature can't handle the amount of Billy Ruben that there is that needs conjugating. So it's really important when babies have phototherapy to remove all their clothes, they usually just in a nappy and we give them little eye patches as well. Um And they can just lie underneath the lights. Sometimes babies will have double phototherapy depending on how high the levels are. So that will be like two light blocks that are kind of over the top of the incubator. And babies can just have um like double phototherapy. That way you can also use a biliblanket. I'm not sure if this is available everywhere, but this is quite beneficial because I would say that one of the things that I found a lot of mums were quite, you know, upset about was that the babies would have been separated from them if they're in the incubator all the time having their phototherapy. So often if babies were being taken out of the incubator quite a lot, it would take a while for the jaundice levels to go down. And so we would sometimes give the mom's a Billy blanket so they could have a blanket underneath the baby while they were say breast feeding or holding the baby. We wouldn't use that as the mainstay of treatment from a phototherapy perspective. But it was quite useful to have for, for some um for some cases and obviously throughout phototherapy, you, you monitor the Billy Ruben really closely. So you'll keep them on the phototherapy for as long as you can a period of time. And you know, the more they're under the lights, the quicker it will be for the Billy Ruben to um, you know, be excreted and then the quicker the baby is back with mom and on the way home, hopefully. Um So normally we would give the phototherapy some time to start working. So we would check the bilirubin level um from the blood just through a heel prick 12 hours after they started phototherapy. And then following that, we would kind of wait and see what that level is if that level comes back and it's below the line of phototherapy. Um For us, we would say about 100 kind of um as the level that we would want it to come down by before we stopped phototherapy. I think it's either 50 to 100 is what we would go by um to stop the phototherapy. And then following that, we would do a rebound, Billy Ruben that we would measure 12 to 18 hours after stopping to see whether the levels are going back up again. And sometimes they would shoot up in which case they'd have to go back on phototherapy. But a lot of the time it might just plateau out or it'll be on the decline. So it kind of lets you use that as like whether or not you're starting treatment again or how you're gonna manage from then on. So this is just a picture of a baby having phototherapy. So they've got these little I patches over the top and you know the under the lights in the incubator for as long as go to the next slide. Thank you. Um So the other line on that graph was for exchange transfusion and you know, by um checking, especially if babies are in hospital, I would say we would want to make sure that they are having checks enough by the midwives and my mom to kind of notice whether or not they are becoming a little bit more yellow and if they're not feeding so well or they've had a significant weight loss before they're discharged. Um You know, if, if it was from like a neonatal jaundice point of view, we would hope that they wouldn't get to this exchange transfusion line. But sometimes babies do get to the exchange transfusion level. And in that case, you know, the what that means is that the blood of the babies literally needs to be removed and replaced with blood that is like fresh donor blood to just do an X direct exchange of the blood. Basically. So often you do a double volume exchange. So you that allows Billy Ruben to kind of come out of the brain. And then we don't have as many neurological complications for for when the Billy Ruben has become at such a high level. Um if there are signs of encephalopathy, then you must start the exchange transfusion immediately. So this will be things like whether babies hypertonic, yeah, hypertonic, whether they're arching have they got high pitched cry and this can even happen when the Billy Ruben levels are falling as well. So it's really important following exchange transfusion to continue on with photo therapy as well to keep measuring the serum Billy Ruben and watch it hopefully fall. Um And also, you know, use those graphs that we've got to basically manage. Do we keep going with the exchange transfusion or do we need to now just move on to phototherapy basically. So one of the main complications of um having too high a Billy Ruben level or unconjugated bilirubin level, sorry. Um is clinic to Rhys, which is basically when that unconjugated Billy Ruben goes through the blood brain barrier. So your levels of that Billy Ruben become so high and there is not enough albumin for the to bind to the Billy Ruben to not make it free as such. And so that really excess Billy Ruben will cross the blood brain barrier and become toxic to the tissue in the brain as well as the spinal cord. And because babies don't have a mature blood brain barrier, um this is why it happens or it can happen more often than we don't see that in adults that obviously we, you know, in adult medicine, see patients that are really, really yellow, but it hasn't actually penetrated through their brain um causing neurological side effects. So, you know, this is why it's really important to notice our babies becoming more or having more of these neurological complications. Um and it can cause both short term and long term neurological dysfunction and it in babies who are preterm as well as those that are have, have the risk factors that we discussed before. Um Those babies are also known to have um like lower levels of the bilirubin will cause connect to us in those babies. So um yeah, it's important to keep those things in mind. So these babies will often present with being really irritable. They'll have a high pitched cry. Um They can often present with a fever as well, have increased muscle tone. Um And they do this kind of characteristic arching of the neck um as well as the trunk. So they'll kind of be like this sort of shape. Um but they might also have a decreased tone as well in their arms and the morrow reflex will be abnormal, but we hope that we don't get to this, this point, which is kind of the point of those graphs really. So this is just um an MRI that shows the build up of the Billy Ruben within the brain. So we can kind of see where I put this arrow. There's like a typical area as well as on the other side as well that shows where the Billy Ruben is built up in the brain. So it is rare connectors, especially in this country. Um But you know, unfortunately, there is no treatment for connect a risks that I know of. Um and often having that build up of the billy Ruben in the brain leads to um neurological dysfunction, particularly things like cerebral palsy, a paralysis of upward gaze. Babies may have hearing loss as well as um like intellectual deficits as well, which can present later on in life. Um So we can we try to prevent it early by giving aggressive phototherapy and exchange transfusion to avoid this from happening. Um And by doing that as immediately as we can, it will hopefully help prevent some of the neurological dysfunction too. So that was basically partly about like early onset jaundice. So, prolonged jaundice is another thing that can happen. So this is jaundice that occurs um for 14 days in babies who are born at term or 2, 21 days in preterm babies that are born before 37 weeks, gestation. Um breast milk jaundice is the most common cause of this, but it can also be caused by a humorless iss um decreased conjugation which can occur in like Gilbert's disease, conjugated hyperbilirubinemia um as well and investigations that we do which are really important are full blood count group in D C T, which like I said before, we do with the other one as well. And the management of this basically depends on your underlying cause. So it's important to try and work out why baby could have prolonged on this. So I just wanted to focus a little bit on the conjugated Billy Ruben. Um So this is basically when babies have an elevated um level of the conjugated Billy Ruben as opposed to the un conjugated Billy Ruben. And this is most likely due to impaired hepatobiliary function. So, we have different causes of um this conjugated hyperbilirubinemia. And these can be classified into different um different kind of causes, but there are loads, but I've just picked a few kind of important ones. So there could be obstruction of the flow of um vial and that could be due to biliary atresia, which is a surgical emergency. Um They could also have choledochal sis as well and um neonatal cholelithiasis iss they might have an infection such as CNV HIV, rubella toxoplasmosis, even UTI S as well or they might be septic. There can be also genetic causes that cause this conjugated hyperbilirubinemia, such a cystic fibrosis. Um and then there's other causes as well. So it might be idiopathic and the in it'll hepatitis as well as having parenteral nutrition induced cola stasis too. Psa biliary atresia is the most common cause of having conjugated hyperbilirubinemia in infants which your jaundiced in the neonate will present around 2 to 4 weeks of life and those babies will have pale stools um as well as jaundice. So it's important to obviously, babies, stools can be so varied, but they will literally be really pale. So it's always important to ask about stools and how babies passing stool, etcetera. What we would do is we'll do an ultrasound. So you can have a look at the biliary tree. See what's, what's going on there. And urgent surgery is the management of for bili biliary trees. Yeah. So just kind of summarize what we've talked about. So, neonatal jaundice, this is when there's a build up of Billy Ruben in the tissues. Um and usually you can have, I've put a level here of 85.5, but I think it varies amongst obviously gestation. Um and different charts basically, um it occurs in 50 to 70% of terminates. And most of these cases are physiological and joined us within the 1st 24 hours of life that is considered pathological and the treatment for um severe hyperbilirubinemia is phototherapy, but you also can um do exchange transfusion. Um And the most common, well, not most common, but the major complication of uncontradicted hyperbilirubinemia is connect a risk, which is one that I think is important too. Um No about and I know one that they like to always ask about in exams. So, yeah, which can cause neurological complications. For example, cerebral palsy and censor, sensorineural hearing loss. So, yeah, that's me. Thank you. Okay. Thank you very much. Does anybody have any questions at all? I feel like a very comprehensive run through of neonatal jaundice. Um But was there anything anyone like to clarify? Just give people a couple of minutes to formulate what they might want to ask. That was quite a lot of information. But it is something that you do see often, I would say in the nick you, um, a lot of jaundice babies and while you were working on the NICU as an F two, what, what kind of, uh, I guess the key things that you think you needed to know in your role. Yeah, I mean, neonatal life support, that's, that was something that we really needed to know because we would often be the ones going to deliveries. Um So that's something um I guess I would say if you do have a job coming up in the in etiology, use your reg use the consultants. Everyone is always so approachable because they know so much and they don't expect you to know much because they understand all you've done normally is like adult medicine and then even pediatrics is so small in medical school. So then to go and do neonatology, you know, it's even more niche, but just seize every opportunity because it is a really valuable experience because even in that GP for example, you'll have babies that coming in who have been discharged from an accu or you're doing the I P S, you know, things like that. So, yeah, it has been a really, really good job and you learn great communication skills because I have to communicate some really difficult things to parents who are going through such turmoil with tiny, tiny, you know. Um Yes, it's a great learning experience. Excellent. I'm glad you got lots from it and I'm sure everyone it seems that was in attendance. There's also managed to get loads from this presentation. Um Plus we're very lucky to have had a run through of neonatal life support just a couple of evenings ago. So if anyone missed out on that is uploaded onto youtube, but also the medal page given that we don't have any questions coming through, I will just pop a link to the feedback form. Um If you can just give us a couple of minutes of your time just to fill this in. Um It's really helpful because it firstly gives us evidence for our portfolios. But also we do go through it, we read it. We're trying to see how we can make these presentations and sessions the most useful for you guys. Um All of us as teachers and educators obviously want to do our best to improve um and make our sessions as useful as possible. Um And in your own interest, if you need any evidence for your uh portfolios, when you submit the feedback, you also get a certificate showing that you attended this talk. And then just before we go, I just want to remind everyone that our final part of the neonatal webinar series is tomorrow evening at the same time, 7 30. And I believe it's all things neonatal sepsis. Um So we will see you then. Thank you. Once again, Doctor Purohit. Thank you.