JAUNDICE AND THE NEWBORN

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JAUNDICE AND THE NEWBORN

• Abbey Rupe, MD

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Objectives

• Definitions
• Prevention
• Risk factors
• Assessment
• Treatment

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What is jaundice?

• Hyperbilirubinemia
• Indirect/Unconjugated
• Direct/Conjugated
• Considered elevated if direct portion is gt20 of
  total bilirubin level
• Scope wont be discussed in this lecture

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Definitions

• Unconjugated
• Physiologic jaundice
• Most babies develop some jaundice
• Mean peak of 5-6 mg/dl between 60-72 hr of life
• Breast-feeding jaundice
• Decreased calories, increased enterohepatic
  circulation
• Breast-milk jaundice
• Prolonged after 2-3 weeks of age
• ?? Protein in breast milk that increases
  enterohepatic circulation

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Definitions

• Pathologic
• Jaundice appearing in first 24 h of life
• TSB gt 95th percentile for age
• TSB increasing at rate gt0.2 mg/dl/h or gt 5
  mg/dl/d
• Elevated direct component
• Jaundice persisting gt 2 weeks in full-term
  infants
• Exception breast-milk jaundice
• Severe hyperbilirubinemia
• Generally considered to be TB gt25-30

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Complications of untreated jaundice

• Bilirubin-induced neurologic dysfunction (BIND)
• Bilirubin crosses BBB and binds to brain tissue
• Risk increased when TB gt25-30
• Acute bilirubin encephalopathy (ABE)
• Initial phase lethargy, hypotonia, decreased
  movement, poor suck
• Intermediate phase stupor, irritability,
  increased tone (retrocolis and opisthotonos),
  fever
• Advanced phase deep stupor or coma, inability
  to feed, shrill cry, apnea, seizures
• potentially reversible!

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Complications

• Chronic bilirubin encephalopathy (kernicterus)
• Choreoathethoid cerebral palsy
• Sensorineural hearing loss
• Palsy of vertical gaze
• Dental enamel hypoplasia
• Up to 10 mortality
• Most (but no all) infants with kernicterus
  previously manifested symptoms of ABE

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Why do neonates become jaundiced?

• Increased bilirubin production
• More RBCs shorter RBC life span increased
  turnover and increased bilirubin
• Decreased bilirubin clearance
• Deficiency of UGT
• UGT activity at 7 days of age is approx 1 of
  adult
• Reaches adult levels around 14 days of age
• Increased enterohepatic circulation

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Pathologic jaundice--causes

• Rh or ABO incompatibility
• Enzyme deficiencies G6PD, pyruvate kinase
• Hemoglobinopathies
• Infection
• Increased RBC load
• Cephalohematomas, etc
• Polycythemia
• Infants of diabetic mothers

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Pathologic jaundice--causes

• Disorders of bilirubin clearance
• Crigler-Najjar, Gilbert
• Metabolic and endocrine
• Galactosemia, hypothyroidism
• Increased enterohepatic circulation
• Breast-feeding jaundice
• Conditions causing GI obstruction or decreased
  motility

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Risk factors for severe jaundice

• Major
• Predischarge bili in high-risk zone
• Observed jaundice in 1st 24 hours of life
• Blood group incompatibility w/ positive DAT
• Previous sibling required ptx
• Cephalotematoma or other significant bruising
• Exclusive breastfeeding (esp if not going well
  and weight loss is excessive)
• East Asian race

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Risk factors for severe jaundice

• Minor risk factors
• Predischarge bili in high-intermediate risk zone
• GA 37-38 weeks
• Jaundice observed before discharge
• Previous sibling with jaundice
• Macrosomic IDM
• Maternal age 25 years
• Male gender

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Risk factors for severe jaundice

• DECREASED risk
• Pre-discharge bili in low-risk zone
• GA 41 weeks
• Exclusive bottle feeding
• Black race
• Discharge from hospital after 72 hours

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Hyperbilirubinemia--prevention

• Pregnant women
• ABO and Rh testing
• Rhogam as indicated
• screen for isoimmune antibodies
• If mom is Rh- or ABO/Rh status unknown
• Check blood type, Rh, and DAT on neonate (cord
  blood)
• If DAT positive needs frequent (q6-12hr)
  checking of TSB

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Jaundice--prevention

• Newborn nursery
• Advise mothers to nurse 8-12 times per day for
  first several days
• Evaluate for jaundice every time vitals taken
  (q8-12 hr)

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Testing for jaundice

• Before discharge, ALL newborns should be assessed
  for jaundice (2004 AAP Practice Guideline)
• Visual assessment
• Need adequate ambient light or daylight
  fluorescent light
• Subjective and not recommended as lone assessment
• More difficult in darker-complected infants
• TSB (total serum bilirubin)
• Oftentimes drawn with metabolic screen
• TcB (transcutaneous bilirubin)
• Method implemented at SRHC in 2010

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Assessment tools

• AAP bilirubin nomograms
• Electronically
• UpToDate calculator
• BiliTool.org
• Online calculator
• App for iPhone or iPod touch
• Palm OS

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Phototherapy
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Using the nomograms

• Use total bilirubin (dont subtract direct
  component)
• Risk factors
• Isoimmune hemolytic disease
• G6PD deficiency
• Asphyxia
• Significant lethargy
• Temp instability
• Sepsis
• Acidosis
• Albumin lt 3.0 (if measured)

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Exchange transfusion
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Discharge and follow-up
Infant Discharged Should Be Seen By Age
Before age 24 hours old 72 hours old
Between 24 and 47.9 h 96 h
Between 48 and 72 h 120 h
Follow-up by a qualified health care
professional typically with PCP or mid-level
provider nurse/lactation specialist home
health nurse visit If follow-up cannot be
ensured, may be necessary to delay discharge
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Anticipatory Guidance

• Jaundice progresses head to toe, then as it
  resolves, disappears from toe to head
• Testing for jaundice blanch skin with finger
• Call if
• Jaundiced to belly button
• Not waking well for feeds or feeding poorly
• Decreased wet diapers
• Shrill cry

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Follow-up appointment

• Weight and change from BW
• Adequacy of po intake
• Pattern of voiding and stooling
• Presence or absence of jaundice
• /- checking bili level
• If predischarge bili was high-intermediate risk,
  I nearly always recheck a bili
• If predischarge bili was low-risk, I rarely do
• If predischarge bili was low-intermediate, I do
  if concerns present

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So . .. .youve reached LL.Now what?

• History and physical exam
• Laboratory testing
• Phototherapy
• Assess hydration

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Laboratory evaluation

• Approaching or at light level
• Direct and total bilirubin
• Blood type and DAT
• CBC
• Peripheral smear
• Consider retic count, G6PD, ETCOc
• Consider UA (for reducing substances) with
  culture, sepsis eval

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Lab evaluation

• Approaching exchange levels or not responding to
  phototherapy
• Retic, G6PD, albumin, ETCOc
• UA
• Sepsis eval
• Elevated direct (or conjugated) bilirubin
• UA and urine culture
• Evaluate for sepsis if indicated by history and
  physical exam

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TreatmentPhototherapy

• Mechanism of action
• Exposes skin to light of specific wavelength
  (425-475 nm/blue-green spectrum)
• Converts bilirubin to lumirubin
• Lumirubin is more soluble than bilirubin and is
  excreted without conjugation into the bile and
  urine

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Phototherapy options

• Bili blanket
• Home or hospital
• Bili bed
• Home or hospital
• Bank phototherapy
• Hospital only
• Home vs hospital
• Home is an option 2-3mg/dl below LL in infant
  with no risk factors and caregivers with ready
  access to medical care

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Treatment--phototherapy

• Techniquebank phototherapy
• Infant should wear diaper only, and diaper should
  be pulled down as much as possible to increase
  skin exposure
• baby sunglasses
• Ensure that banks of lights are at appropriate
  distance from infant
• Infant needs to remain under lights continuously,
  only to be taken out for feedings
• Can utilize biliblanket to continue some ptx
  during feeds

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Phototherapy

• phototherapy typically results in a decline of TB
  of 2-3 mg/dl within 4-6 hours
• Obviously, more lights faster decline
• Recheck TB within 2-6 hours of starting ptx
• Then, recheck every 6-12 hours, if TB is falling
• If doing home therapy, need to redraw daily
• Hospitalize if surpasses LL, excessive rate of
  rise, or other concerns develop

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Phototherapyside effects

• Generally considered safe
• Transient erythematous rashes
• Loose stools
• Hyperthermia
• Increased insensible water loss
• Possible retinal degeneration (hence the
  sunglasses)
• Parents/caregivers
• some models can cause HA and nausea
• Frustrating to not get to hold baby
• bronze baby syndrome
• If used on infant with cholestasis

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Managementassess hydration

• Maintaining adequate hydration and UOP is
  important
• Lumirubin excreted in urine gt stool
• Encourage breast or bottle feeding
• Lactation consult prn
• Supplement with EBM or formula in breastfed
  infants with excessive weight loss (gt12) or
  evidence of hypovolemia
• IVF if oral intake is inadequate

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Phototherapy . .. When to stop?

• No strict guideline
• when TSB lt13-14
• When TSB back to, or lower-than, level at which
  ptx was initiated
• Sometimes at lower level if started during NB
  stay and treatment initiated at lower LL

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Phototherapy . . . When to stop?

• checking for rebound
• TB will typically re-increase by small amount
  (typically lt1 mg/dl) after discontinuation of ptx
• DONT have to keep pt hospitalized to check for
  rebound, unless risk-factors present
• DO check in hospital or clinic the next day if
• ptx discontinued prior to 5-6 days old (may not
  have reached peak yet)
• Other concerns
• For nervous Nellies (like myself) night
  before anticipated discharge, check TSB.
  Continue ptx until 2 or 3am, then d/c. Check
  bili with AM labs, should see if significant
  rebound present

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If not improving

• Likely that hemolysis is occurring
• Increase banks
• Labs
• Retic, G6PD, albumin, ETCOc
• Sepsis eval
• UA and urine culture
• Add IVF
• Consult pediatrician /- neonatologist
• Exchange transfusion in NICU

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Lab evaluation

• Jaundice preset at 2-3 weeks
• Total and direct bili
• If direct bili elevated, evaluate for causes of
  cholestasis
• Check NB thyroid and galactosemia evaluate
  infant for signs/sx of hypothyroidism
• If indirect elevated and breast-fed, potentially
  breast-milk jaundice
• Option to give formula in place of breast milk
  x24 hours (controversial)

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?Sunny window?

• Technically. . .. NO
• Risk for sunburn
• Risk for hypo- or hyper-thermia