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HYPERBILIRUBINEMIA IN TERM NEONATES Tanya Oberoi Pandya D.O., M.B.A. & Vishaan Pandya (Master’s In Colic, PhD in Poopology)
Definition • Infants >/= 35wks GA Total Serum Bilirubin >95th percentile for hours-of-age • Up to 60% of term newborns have clinical jaundice in the first week of life
Bilirubin • Final product of heme degredation • Insoluble in plasma (needs to be bound to albumin) • Has to go to liver to be conjugated • After liver, excreted in bile
Why Neonates? :( • Newborn Bilirubin Production: 6 to 8 mg/kg/day • Adult Bilirubin Production: HALF that! • Newborn: • Relative polycythemia • Increased RBC turnover
So What’s The Big Deal? KERNICTERUS!!!
Kernicterus • Neurologic consequences of unconjugated bilirubin deposition in brain • Damage & scarring of basal ganglia & brain stem
Kernicterus (Cont’d) • Unconjugated bilirubin > albumin binding capacity • Unconjugated bilirubin = Fat Soluble • Enters BBB • No specific level definitive for kernicturus • Be worried if Bilirubin level: • >25 in term baby WITHOUT hemolysis • >20 in term baby WITH hemolysis
Consequences of Kernicterus • Developmental delay • Motor delay • Sensorineural deafness • Mild mental retardation
Common Causes • Physiologic Jaundice • Breastfeeding Jaundice • Breastmilk Jaundice
Physiologic Jaundice • Occurs: >24hours of life, drop by week 1 of life • Increased bilirubin load d/t relative polycythemia • Shortened erythrocyte life span (80 days compared with the adult 120 days) • Immature hepatic uptake and conjugation processes • Increased enterohepatic circulation
Breastfeeding Jaundice • Occurs: 3-4 days of life • Due to insufficient milk production by mom or intake by baby; relative caloric deprivation in the first few days of life. • Decreased volume and frequency of feedings -->passive dehydration and the delayed passage of meconium
Breastfeeding Jaundice Management • Increase frequency of feedings to more than 10 per day • Formula supplement if infant has decline in weight gain, delayed stooling, and continued poor caloric intake • Breastfeeding should be continued to maintain breast milk production • Supplemental water or dextrose-water administration should be avoided, as it decreases breast milk production and places the newborn at risk for iatrogenic hyponatremia
BreastMILK Jaundice • Occurs later in life • Day 6 to 14 • Bili 12 to 20 • May stay high for 1-2 months
BreastMILK Jaundice Etiology • Unclear • Substances in maternal milk, such as alpha glucuronidases, and nonesterified fatty acids, may inhibit normal bilirubin metabolism • The bilirubin level usually falls continually after infant is 2 weeks old, but it may remain persistently elevated for 1 to 3 months.
BreastMILK Jaundice Management • Breastfeeding may be temporarily interrupted • Mother should continue to express breast milk to maintain production • With formula substitution, the total serum bilirubin level should decline rapidly over 48 hours,confirming the diagnosis • Breastfeeding may then be resumed.
Pathologic Jaundice • Anything OTHER THAN physiologic or breastfeeding or breastmilk jaundice!!
Pathologic Jaundice Features • Jaundice within 24 hours after birth • Rapidly rising total serum bilirubin concentration (increase of more than 5 per day), and a total serum bilirubin level higher than 17 in a full-term newborn • Other features of concern include prolonged jaundice • Evidence of underlying illness • Elevation of the serum conjugated bilirubin level to >2 mg per dL or more than 20% of the total serum bilirubin
Pathologic Jaundice Causes • Sepsis • Rubella • Toxoplasmosis • Occult hemorrhage • Erythroblastosis fetalis.
Pathologic Jaundice Workup • Fractionated serum bili (conjugated bili >2) • CBC with diff • Reticulocyte count • Blood type • Rh compatability • Coomb’s test • Peripheral blood smear • G6PD screen (if applicable) • Blood culture • UA, urine culture • TSH for hypothyroidism (on state screen) • Galactosemia (on state screen) • Cholestatic Jaundice (need to r/o biliary atresia if light colored stool, dark urine, urine with bilirubin, persistent jaundice >3wks)
Hyperbilirubinemia Signs • Skin yellowing • Not visible if bili <4 • Estimate level by degree of icterus • Face 5; upper chest, 10; abdomen, 12; palms and soles, >15 [soles = 20] • Pallor, petechiae, extravasated blood, excessive bruising, hepatosplenomegaly, weight loss, and evidence of dehydration.
Diagnosis • Jaundice in a term newborn fewer than 24 hours old is always pathologic • Based on rate of bilirubin level rise, risk of developing significant hyperbilirubinemia can be classified as low, intermediate, or high • If jaundice persists > 2 weeks in a formula-fed infant and >3 weeks in a breastfed infant, further evaluation is warranted
Diagnosis (cont’d) • Laboratory studies: • Fractionated bilirubin level • Thyroid studies • Evaluations for metabolic disorders • Evaluation for hemolytic disease • Assessment for intestinal obstruction.
Treatment • Phototherapy • Exchange Transfusion
Phototherapy • Use blue wavelengths of light to alter unconjugated bilirubin in the skin. • Bilirubin converted to less toxic water-soluble photoisomers • Excreted in the bile and urine without conjugation
75th Percentile 40th Percentile
When To Start Phototherapy? • TSB at 95th percentile • Although, may be facility dependent
Phototherapy Optimization • Ideal configuration: 4 special blue bulbs (F20T12/BB) placed centrally, with two daylight fluorescent tubes on either side • Power output of the lights (irradiance) is directly related to the distance between the lights and the newborn • Ideal light distance: 15 to 20 cm from the infant • Naked • Eye shields • For double phototherapy: a fiber-optic pad can be placed under the newborn (twice as effective as standard phototherapy)
Phototherapy Tid-Bits • If TSB levels approach or exceed the exchange transfusion line the sides of the bassinet, incubator, or warmer should be lined with aluminum foil or white material • If the total serum bilirubin does not decrease or continues to rise in an infant who is receiving intensive phototherapy, strongly suggests hemolysis • Infants who receive phototherapy and have an elevated conjugated bilirubin level (cholestatic jaundice) may develop the bronze-baby syndrome (brown discoloration)
Phototherapy Cessation • Decline avg at 1-2 points within 4-6 hours • Decline may be slow in breastfed than in formula fed • Can be stopped if <15 • Turn off lights and check for rebound in ~12 hours • Avg rebound ~1 point • Hospital discharge does not have to be held for rebound elevation
Phototherapy Complication • Burns • Dehydration • Retinal Damage • Thermoregulatory instability • Loose stools • Tanning of the skin
Hydration Assessment • Percentage of birth weight lost • Mucous membranes • Fontanelle • Skin turgor
Exchange Transfusion • Most rapid way of decreasing bilirubin • Removes partially hemolyzed and antibody-coated erythrocytes replacing them with uncoated donor RBCs that lack the sensitizing antigen
Exchange Transfusion Indication • Hemolytic disease • Severe anemia • Rapid rise in TSB level (>1 mg per dL per hour in less than six hours) • Considered in nonhemolytics where intensive phototherapy fails • If the total serum bilirubin level remains elevated after intensive phototherapy • If the initial bilirubin level is meets defined critical levels based on the infant's age (approx >20-25)
Exchange Therapy Complications • Air embolism • Vasospasm • Infarction • Infection • Death
Monitoring • Recheck bilirubin level every 12-24 hours • Consider neonatologist consult if Bilirubin >20 or pathologic causes suspected
Prevention • RhoGham in Rh negative moms • GA <12 weeks: 50mcg • GA >12 weeks: 300mcg • Universal Screening of ALL infants
**Quickie on Phototherapy Number** • >15 at <24 • >18 at 25-48 • >20 at >48