neonatal hyperbilirubinemia n.
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Neonatal Hyperbilirubinemia. Jaundice. Yellowish discoloration of skin +/- sclera of newborns due to bilirubin Affects nearly all newborns Peak: 48-120 hours, typically 5-6 mg/dL, usually does not exceed 17-18 mg/dL

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jaundice
Jaundice
  • Yellowish discoloration of skin +/- sclera of newborns 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 Bhutani nomogram
effects of hyperbilirubinemia
Effects of hyperbilirubinemia
  • Bilirubin toxicity
    • Toxicity due to unbound (free) form
    • Focal necrosis of neurons and glia
      • Acute bilirubin encephalopathy
      • Chronic= kernicterus
      • Most often affects basal ganglia and brainstem nuclei
        • Movement disorders
        • Impaired upward gaze
        • Auditory abnormalities
effects
Effects
  • Bilirubin toxicity
    • At 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
manifestations
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
evaluation
Evaluation
  • Transcutaneous bilirubin
  • Total serum bilirubin
  • End-tidal carbon monoxide
  • Blood type, direct Coombs test
  • CBC, peripheral blood smear
  • Reticulocytes, G6PD screen
  • Serum albumin
special circumstances
Special circumstances
  • Jaundice in 1st 24 hours
    • Frequently due to hemolysis
    • Require immediate evaluation and close surveillance
  • Other reasons for increased bilirubin production
    • Cephalohematoma, extensive bruising, conjugation disorders
management
Management
  • Phototherapy
    • Mechanisms
      • Structural isomerization
      • Photoisomerization
      • Photo-oxidation
    • Irradiance
    • Initiation if bilirubin exceeds the 95th percentile for hour-specific TSB concentration and risk category
risk categories phototherapy
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 or 35-38 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
management1
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
management2
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
risk categories exchange transfusion
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 at 72 hours
    • TSB/Albumin>8.0
  • Medium risk: at least 38 weeks with risk factors or 35-38 weeks 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
summary
Summary
  • Assess for jaundice every 8-12 hours
  • Assess risk factors
  • If discharging, appropriate follow-up is necessary
  • Treatment should be initiated immediately upon identifying significant hyperbilirubinemia