NEONATAL HYPERBILIRUBINEMIA.ppt

NEONATAL HYPERBILIRUBINEMIA

Julniar M TasliHerman Bermawi

Module: Neonatal Hyperbilirubinemia - Session 1

Module Overview: PurposeTo introduce to the student participants the knowledge, competencies and skills required to identify the etiology, diagnose and manage both unconjugated and conjugated hyperbilirubinemia in full term and preterm infants.


Module Overview: StoryNeonatal hyperbilirubinemia is an elevated serum bilirubin level in the neonate.The most common type is unconjugated hyperbilirubinemia, which is visible as jaundice in the first week of life.Although 60% of babies will develop jaundice, and most jaundice is benign, severe hyperbilirubinemia can cause serious permanent brain damage. The goal of this module is to teach student to identify, assess and manage neonatal hyperbilirubinemia.


Module Overview: Learning ObjectivesBroad OutlineStudent must:Understand the physiology of bilirubin metabolism in the neonate, and the difference between unconjugated and conjugated hyperbilirubinemiaIdentify neonatal hyperbilirubinemia and decide whether it is physiological or pathological.Obtain an accurate history and perform a physical examination in order to diagnose the etiology of hyperbilirubinemia.Identify laboratory tests needed for investigation.Manage unconjugated hyperbilirubinemiaDiagnose conjugated hyperbilirubinemia.


CLINICAL JAUNDICE60% of newbornVisible jaundice: serum bilirubin > 5 mg/ dl


Neonatal Jaundice: WHY WE WORRY bilirubin bilirubin encephalopathy KernicterusStage 1: lethargy, hypotonia, poor suckStage 2: fever, hypertonia, opisthotonusStage 3: apparent improvementSequelae: Sensorineural hearing loss Choreoathetoid cerebral palsy Gaze abnormalities


Kernicterus Neuropathologyyellow staining and neuronal necrosisbasal ganglia: globus pallidus subthalamic nucleuscranial nerve nuclei: vestibulocochlear oculomotor facial cerebellar nuclei


1970s - KERNICTERUS ELIMINATED 1990s - 125 CASES OF KERNICTERUS in the United States

2000s - ? Cases of kernicterus in Indonesia

A preventable tragedy


NEONATAL JAUNDICEMechanism Physiologic vs PathologicNon- physiologic jaundice: differential diagnosis Management


BILIRUBIN METABOLISMbiliverdin reductase haem oxygenase


Bilirubin metabolismHEME + GlobinBILIVERDINBILIRUBINAlbUCBLIVERCO(Heme Oxygenase)Conjugated bilirubinFree unconjugatedbilirubin


BILIRUBINUNCONJUGATED Indirect bilirubinWater- insolubleBound to albumin for transportFree component fat - solubleFree component TOXIC to brain CONJUGATED Direct bilirubinWater soluble

Not fat soluble

Not toxic to brain


BILIRUBIN TOXICITYUnconjugated bilirubin level > 20 mg/ dL? >25 mg/ dl? > 30 mg/ dL?

Gestational ageHemolysisOther illness: asphyxia, hypoglycemia, acidosis, sepsisDrugs displacing bilirubin from albumin binding sites


CLINICAL JAUNDICE60% of newbornVisible jaundice: serum bilirubin > 5 mg/ dl


Why do babies have jaundice in the first week of life? Increased bilirubin productionHigher turnover of red blood cellsDecreased life span of red blood cellsDecreased excretion of bilirubinDecreased uptake in the liverDecreased conjugation by the liverIncreased enterohepatic circulation of bilirubinBilirubin excretion improves after 1 week


PHYSIOLOGICAL JAUNDICE


Physiological JaundiceNote the natural history of physiologic jaundice in the full term newborn- onset after 24 hourspeaks at 3 to 5 daysdecreases by 7 days. Average full term newborn has peak serum bilirubin level of 5 to 6 mg/ dl. Exaggerated physiologic jaundice- when peak serum bilirubin is 7 to 15 mg/ dl in full term neonates.Always consider age of the baby and bilirubin level


Hour- specific bilirubin levelBilirubin level of 10 mg/ dl at 72 hours of age in a term newborn is probably physiological.Bilirubin level of 10 mg/ dl at 10 hours of age is NOT physiological, and needs immediate attention. (see natural history of physiological jaundice)


Serum Bilirubin levels in term and preterm infants


Jaundice in preterm neonatesOnset earlierPeaks laterHigher peakTakes longer to resolve- up to 2 weeksWhat level is physiologic?


Physiologic vs Non- physiologic hyperbilirubinemia


NON- PHYSIOLOGIC JAUNDICEOnset before 24 hours of ageRate of rise > 0.5 mg/ dl/ hourCutoff levels > 15 mg/ dl in term infant? > ? mg/ dl in preterm infant?Jaundice persisting > 8 days in term infant > 14 days in preterm infantOther signs of illness


HYPERBILIRUBINEMIA - CAUSES OVERPRODUCTION ( HEMOLYSIS)

Extravascular blood- hematomas, bruisesFeto- maternal blood group incompatibility Rh- mom / baby Rh+ O group mom / baby A or BIntrinsic red cell defects G-6-PD deficiency hereditary spherocytosisPolycythemia


NEONATAL JAUNDICE - case ( ref. MacDonald MG. Pediatrics 1995)

African- American male infant, birth weight 3.47kgNormal delivery 39 w gestation Discharged home at 24 hrs of ageJaundice and lethargy noted at 5 days of age LABS: Total serum bilirubin 37mg/ dL Peripheral blood smear normal, retic count 3.6% Mom O+, Baby O +, Coombs test negativeSeizures, apnea, opisthotonus during Exchange Tx13 months of age: profound hearing loss and hypotonia

G6PD DEFICIENCYX- Linked disorder (2- 6% carrier rate in Indonesia)enzyme protects red cell from oxidative damage>150 mutationsOnset of jaundice usually day 2- 3, peaks day 4 - 5Hyperbilirubinemia may be out of proportion to anemiamicrospherocytes/ bite cells/ normal blood pictureDiagnosis- enzyme assay baby and motherFalse negative test with reticulocytosisDNA analysis

HYPERBILIRUBINEMIA CAUSESUNDERSECRETION

PrematurityHypothyroidismInfants of diabetic mothersInherited deficiency of conjugating enzyme uridine diphosphate glucuronyl transferaseOther metabolic disorders


HYPERBILIRUBINEMIA CAUSESSecreted but reabsorbed from gut ENTEROHEPATIC CIRCULATIONDecreased enteral intakePyloric stenosisIntestinal atresia/ stenosisMeconium ileusMeconium plugHirschsprungs disease


OBSTRUCTIVE DISORDERS - direct hyperbilirubinemia CholestasisBiliary atresiaCholedochal cyst

Direct bilirubin > 2 mg/ dLTime of appearanceColor of stoolsColor of urine


HYPERBILIRUBINEMIA CAUSESMIXED

Bacterial sepsisIntrauterine infections: TORCHAsphyxia


Hyperbilirubinemia- diagnosisHistoryPhysical exam:gestational ageactivity/ feedinglevel of icteruspallorhepatosplenomegalybruising, cephalhematoma


Rapidly developing jaundice on Day 1

LikelyRhesus, ABO, or other hemolytic diseaseSpherocytosisLess likelyCongenital infectionG-6-P-D deficiency


RHESUS INCOMPATIBILITY

MOTHER Rh (-) + FATHER Rh (+) ANTI d ( IgG ) RBC 1st CHILD Rh (+) ANTI D + 2nd CHILD Rh (+) ANTI D ++ 3rd CHILD Rh (+) .. ANTI D +++ 4th CHILD Rh (+) .. ANTI D ++++

HAEMOLYSIS


ABO INCOMPATIBILITY

Substan AMOTHER blood group O + FATHER blood group A Agglutinin A ( IgG ) CHILD blood group A

IgG A + Atg A HAEMOLYSIS


Rapid Onset jaundice after 48 hours of ageLikelyInfectionG-6-P-D deficiency

UnlikelyRh, ABO, spherocytosis


Hyperbilirubinemia- diagnosisLaboratory testsBilirubin levels: total and directMothers blood group and Rh typeBabys blood group and Rh typeDirect Coombs test on babyHemoglobinBlood smearReticulocyte count


NEONATAL HYPERBILIRUBINEMIA MANAGEMENTHYDRATION - FEEDING PHOTOTHERAPYEXCHANGE TRANSFUSION

PhenobarbitalTin protoporphyrin


American Academy of PediatricsSubcommittee on HyperbilirubinemiaClinical Practice GuidelineManagement of Hyperbilirubinemia in the Newborn Infant 35 or more weeks of gestation

Pediatrics July 2004


Management of Hyperbilirubinemia in the Newborn Infant 35 or more weeks of gestation

Promote and support successful breast-feedingPerform a systematic assessment before discharge for the risk of severe hyperbilirubinemiaProvide early and focussed follow-up based on risk assessmentWhen indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe jaundice and possibly, kernicterus.


Feeding to Prevent and Treat Neonatal JaundiceMothers should breast feed their babies at least 8 to 12 times per day for the first several days

caloric intake / dehydration Jaundice

Supplementation with water or dextrose water will not prevent prevent or treat hyperbilirubinemia


Systematic Assessment for Neonatal Jaundice

Pregnant women - Blood group and Rh type If mom is Rh negative or O group: Babys cord blood group/ Rh type/ DATMonitor infant for jaundice at least every 8 to 12 hoursIf level of jaundice appears excessive for age, perform transcutaneous bilirubin or total serum bilirubin measurement


Clinical assessmentof severity of jaundice

Cephalocaudal progressionface 5 mg/ dl (approximately)upper chest 10 mg/ dl (approx)abdomen and upper thighs 15 mg/ dl ( approx)soles of feet 20 mg/ dl ( approx)Visual inspection may be misleading


Transcutaneous BilirubinometersUseful as screening device TcB measurement fairly accurate in most infants with TSB< 15mg/ dL.Independent of age, race and weight of newborn

Not accurate after phototherapy


Assess risk factors for significant jaundice

Blood group incompatibility with positive DAT Gestational age 35- 36 weeksExclusive breast feeding - first time momCephalhematoma or significant bruising Asian race Previous sibling had significant jaundice Jaundice in the first 24 hours of lifePredischarge bilirubin in the high risk zone


Hour Specific Serum BilirubinBhutani et al, Pediatrics 1999Predictive Ability of a Predischarge Hour Specific Serum Bilirubin for Subsequent Significant Hyperbilirubinemia in Healthy Term and Near - term Newborns.Serum Bilirubin levels predischarge in 13,003 babies Serum Bilirubin levels post- discharge in 2840 babiesRacially diverse - 5% AsianNomogram- 95th percentile for serum bilirubin level 24 hours: 8 mg/ dl (137 M/ L)48 hours: 14 mg/ dl (239 M/ L)72 hours: 16 mg/ dl ( M/ L)84 hours: 17 mg/ dl (290 M/ L)


Nomogram for designation of risk based on hour specific serum bilirubin levels at dischargeBhutani et al., Pediatrics 1999


Guidelines for phototherapy in infants 35 or more weeks gestationAmerican Academy of Pediatrics, July 2004


PHOTOTHERAPYNOT UV LIGHT @#$%*!

Light wavelength 450 to 460 nmBlue lamps: 425 to 475 nmCool white lamps: 380 to 700 nm

Spectral irradiance: 30 W / cm2 / nm


PHOTOTHERAPYNatural unconjugated bilirubin isomer: ZZZZ ZE( toxic, no conjugation need)

ZZ lumibilirubin

ZZ photooxidation productsPhotoisomerizationStructural isomerizationphotooxidation


Measuring Adequacy of Phototherapy


Intensive PhototherapyLight source: daylight, cool white, blue, special blue fluorescent tubes,tungten halogen lamps, fiberoptic blanket, gallium nitride light emitting diode.Distance from light: florescent lights should be as close as possible ( up to 10 cms from baby), halogen lights can cause overheatingSurface area: maximal, remove all clothes except diaper, may remove diaper tooIntermittent versus ContinuousHydration


Complications of phototherapySignificant complications very rareseparation of mother and babyincreased insensible water loss and dehydration in premature babyBronze- baby syndrome (in babies with cholestatic jaundice)


What decline in serum bilirubin can you expect with phototherapy ?Rate of decline depends on effectiveness of phototherapy and underlying cause of jaundice.With intensive phototherapy, the initial decline can be 0.5 to 1.0 mg/ dl/ hour in the first 4 to 8 hours, then slower. With standard phototherapy, expect decrease of 6% to 20% of the initial bilirubin level in the first 24 hours.


When should phototherapy be stopped? Depends on the age of the babyCause of the hyperbilirubinemia


Exchange Transfusion


Guidelines for Exchange Transfusion in Infants 35 or more weeks gestationAmerican Academy of Pediatrics, July 2004


Exchange TransfusionwastePartially packedRed Blood CellsDouble volume Exchange Transfusion2 X 85 mL/ kg


EXCHANGE TRANSFUSION - COMPLICATIONS cardiac failuremetabolic- hypoglycemia, hyperkalemia, hypocalcemia, citrate toxicity, air embolismthrombocytopeniabacterial sepsistransfusion transmitted viral diseasenecrotizing enterocolitisportal vein thrombosisMortality / permanent sequelae 1-12%

Phototherapy and Exchange Transfusion in VLBW infants (Cashore WJ, Clin Pediatr 2000)???


Weight (g)

Start phototherapy

(mg/ dl)

Consider exchange transfusion (mg/ dl)

500 - 750

5- 8

12- 15

750 - 1000

6 - 10

> 15

1000 - 1250

8 - 10

15 - 18

1250 1500

10 - 12

17 - 20

Guideline of phototherapy and exchange transfusion in low birth weight infant base on body weight

Total bilirubin [ mg/L ( umol/L)]

Birth weight ( gr ) Phototherapy Exchange transfusion

< 1500 5 8 ( 85 140 ) 13 16 ( 220 275 ) 1500 - 1.999 8 12 ( 140 200 ) 16 18 ( 275 300 ) 2000 2499 11 14 ( 190 240 ) 18 20 ( 300 340 )

Guideline of phototherapy and exchange transfusion in low birth weigt infant base on gestational age Total bilirubin [ mg/L ( umol/L)]

Gestational age Phototherapy Exchange transfusi health baby Exchane transfusion sick baby

36 14,6 ( 250 ) 17,5 ( 300 ) 20,5 ( 350 ) 32 8,6 ( 150 ) 14,6 ( 250 ) 17,5 ( 300 ) 28 5,8 ( 100 ) 11,7 ( 200 ) 14,6 ( 250 ) 24 4,7 ( 80 ) 8,8 ( 150 ) 11,7 ( 200 )


BREAST MILK JAUNDICE


TERIMAKASIH


NEONATAL HYPERBILIRUBINEMIA.ppt

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