Neonatal Hyperbilirubinemia2009 Modified for Presention

7/29/2019 Neonatal Hyperbilirubinemia2009 Modified for Presention

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Neonatal

Hyperbilirubinemia


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Jaundice

Yellowish discoloration of skin +/- sclera ofnewborns due to bilirubin

Affects nearly all newborns Peak: 48-120 hours, typically 5-6 mg/dL,

usually does not exceed 17-18 mg/dL

Pathologic: TSB exceeds age (in hours)specific 95th percentile according to Bhutaninomogram


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Effects of

hyperbilirubinemia Bilirubin toxicity

Toxicity due to unbound (free) form

Focal necrosis of neurons and gliaAcute bilirubin encephalopathy

Chronic= kernicterus

Most often affects basal ganglia and

brainstem nuclei Movement disorders

Impaired upward gaze

Auditory abnormalities


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Effects

Bilirubin toxicityAt risk when TSB > 25-30 mg/dL

Premature and sick infants

Albumin level

Drugs- silfisoxazole, moxalactam, ceftriaxone

Acidosis

Near term (35-37) weeks

Breast fed Hemolytic disease

Discharge before 48 hours


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Manifestations

Phase one- 1st few days Lethargy, hypotonia, poor suck, high

pitched cry Phase two- end of 1st week

Irritable, hypertonia, retrocollis,opisthotonus

Phase three- after 1st week Stupor, coma, shrill cry


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Evaluation

Transcutaneous bilirubin

Total serum bilirubin

End-tidal carbon monoxide

Blood type, direct Coombs test

CBC, peripheral blood smear Reticulocytes, G6PD screen

Serum albumin


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Special circumstances

Jaundice in 1st 24 hours

Frequently due to hemolysis

Require immediate evaluation and closesurveillance

Other reasons for increased bilirubin

production Cephalohematoma, extensive bruising,

conjugation disorders


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Management

Phototherapy Mechanisms

Structural isomerization Photoisomerization

Photo-oxidation

Irradiance

Initiation if bilirubin exceeds the 95thpercentile for hour-specific TSBconcentration and risk category


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Risk categories-

phototherapy Lower risk: at least 38 weeks gestation, no risk

factors >12 mg/dL at 24 hours, >15 mg/dL at 48 hours, >18

mg/dL at 72 hours

Medium risk: at least 38 weeks with risk factors or35-38 weeks without risk factors >10 mg/dL at 24 hours, >13 mg/dL at 48 hours, >15

mg/dL at 72 hours

Higher risk: 35-38 weeks with risk factors >8 at 24 hours, >11 at 48 hours, >13.5 at 72 hours


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Management

Rate of decline of TSB

Irradiance

Surface area

Initial TSB

Discontinuation

TSB level below 95th percentile for age

Is less than 13 mg/dL


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Management

Exchange transfusion Hyperbilirubinemia unresponsive to

phototherapy Especially useful with immune-mediated

hemolysis Removal of circulating antibodies and

sensitized RBCs For TSB > 25 mg/dL

Presence of bilirubin neurotoxicity


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Risk categories-

exchange transfusion Lower risk: at least 38 weeks gestation, no risk factors

>19 mg/dL at 24 hours, >22 mg/dL at 48 hours, >24 mg/dL at72 hours

TSB/Albumin>8.0

Medium risk: at least 38 weeks with risk factors or 35-38weeks without risk factors >16.5 mg/dL at 24 hours, >19 mg/dL at 48 hours, >21 mg/dL at

72 hours TSB/Albumin>7.2

Higher risk: 35-38 weeks with risk factors >15 at 24 hours, >17 at 48 hours, >18.5 at 72 hours TSB/Albumin>6.8


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Summary

Assess for jaundice every 8-12 hours

Assess risk factors

If discharging, appropriate follow-up isnecessary

Treatment should be initiatedimmediately upon identifyingsignificant hyperbilirubinemia


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Approach to themanagement ofHyperbilirubinemia in

Term Newborn Infant


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2004 AAPGuidelines

Management of Hyperbilirubinemia in theNewborn Infant 35 or More Weeks ofGestation

Subcommittee on HyperbilirubinemiaPediatrics

2004; 114;297-316


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Prevention

Breastfeeding

Should be encouraged for most

women Separate AAP guidelines

8-12 times/day for 1st several days

Assistance and education

Avoid supplements in non-dehydratedinfants

Do not decrease level & severity ofhyperbili


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Prevention

Ongoing assessments for risk ofdeveloping severe hyperbilirubinemia

Monitor at least every 8-12 hours

Dont rely on clinical exam

Blood testing

Prenatal (Mom): ABO & Rh type, antibody

Infant cord blood Mom not tested, Rh (-): Coombs, ABO, Rh

Mom O or Rh (+): optional to test cord blood


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Laboratory investigation

Indicated (if bilirubin concentrations reachphototherapy levels) Serum total or unconjugated bilirubin concentration

Serum conjugated bilirubin concentration

Blood group with direct antibody test (Coombstest)

Hemoglobin and hematocrit determinations Optional (in specific clinical circumstances)

Complete blood count including manual differentialwhite cell count Blood smear for red cell morphology Reticulocyte count Glucose-6-phosphate dehydrogenase screen

Serum electrolytes and albumin or proteinconcentrations


20/36Co ri ht 2004 American Academ of Pediatrics

Subcommittee on Hyperbilirubinemia, Pediatrics 2004;114:297-316

Nomogram for designation of risk in 2840 well newborns at 36 or more weeks'

gestational age with birth weight of 2000 g or more or 35 or more weeks' gestational

age and birth weight of 2500 g or more based on the hour-specific serum bilirubin

values


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Risk Factors for SevereHyperbilirubinemia

Major risk factors

Predischarge bili in high-riskzone

Jaundice in 1st 24 hrs Blood group incomp with +

direct antiglobulin test, otherknown hemolytic disease (eg,

G6PD deficiency) Gestational age 3536 wk Previous sibling received

phototherapy Cephalohematoma or

significant bruising

Exclusive breastfeeding East Asian race

Minor risk factors

Bili in high intermed-risk zone Gestational age 3738 wk Jaundice before discharge Previous sibling with jaundice Macrosomia infant with

diabetic mother

Maternal age 25 Male

Decreased Risk Bili in low-risk zone

41 wks gestation Exclusive bottle feed Black race D/c from hospital > 72hrs


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Discharge

Assess risk Predischarge bili

Use nomogram to determine risk zone

And/or Assessment of risk factors

TSB Zone Newborns(%)

% with TSB>95th %

High risk 6 39.5High intermed 12.5 12.9

Low intermed 19.6 2.26

Low 61.8 0


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Discharge

Close follow-up necessary

Individualize based on risk

Weight, % change from BW, intake,voiding habits, jaundice

InfantDischarge

Should be Seenby

< 24 hours 72 hours

24-48 hours 96 hours

48-72 hours 120 hours


24/36Co ri ht 2004 American Academ of Pediatrics

Subcommittee on Hyperbilirubinemia, Pediatrics 2004;114:297-316

Algorithm for the management of jaundice in the newborn nursery


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Phototherapy

Mechanism: converts bilirubin to watersoluble form that is easily excreted

Forms Fluorescent lighting

Fiberoptic blankets

Goal is to decrease TSB by 4-5 mg/dL or

Documents

Neonatal Hyperbilirubinemia2009 Modified for Presention