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Hijo de Sonia Marlene Sanchez HC 1043672mat 1059646 Hijo

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Title: Hijo de Sonia Marlene Sanchez HC 1043672mat 1059646 Hijo

1
Hijo de Sonia Marlene SanchezHC 1043672-mat-
1059646 Hijo

FI 19-06-03 (14.23)
FE20-06-03
Embarazo de 35 sem en madre de 37 años,con
ruptura prematura de membranas.
8 controles prenatales normales.
Grupo sanguineo mat. O
TParto y parto vaginales normales.

RN AT, Masculino APGAR 9-10/10
No tiene clasif . Materna en hoja RN.
Peso 2.520 gm, Talla 47 cm PC 32 cm
RN sano incomp. OA
Ictericia precoz, solic. Bilirrubinas
Hc 49, hb16, ret. 4.5 BI5.5, BD0,
Salida rec. Sol
Control CE
A
Cooms dir neg
Bilirr ind 9.1 mg /dl (20-06-03) a las 11.54

2
Hijo de Sonia Marlene SanchezHC 1043672-mat-
1059646 Hijo

Ingresa a Urgencias
26-06-03 (15,15)
Ictericia III, 2.4 kg,
Toman BD. 27 mg, BT 29 mg/dl, Se inicia
fototerapia.Ex Fisico Activo, succión busqueda.
SS autorización Exanguinotransfusión.

27-06-03 Valoración por docente no considera
exanguino.
BI 15mgfototerapia.
Salida 29-06-03

Brief Summary
GUIDELINE TITLE
Practice parameter management of
hyperbilirubinemia in the healthy term newborn.
BIBLIOGRAPHIC SOURCE(S)
American Academy of Pediatrics. Practice
parameter management of hyperbilirubinemia in
the healthy term newborn. Provisional Committee
for Quality Improvement and Subcommittee on
Hyperbilirubinemia. Pediatrics 1994 Oct94(4 Pt
1)558-65. 31 references
ADAPTATION
Not applicable Guideline was not adapted from
another source.
DATE RELEASED
1994 Oct (reviewed 2000)

MAJOR RECOMMENDATIONS
Evaluation
Maternal prenatal testing should include ABO and
Rh(D) typing and a serum screen for unusual
isoimmune antibodies.
A direct Coombs' test, a blood type, and an Rh(D)
type on the infant's (cord) blood are recommended
when the mother has not had prenatal blood
grouping or is Rh-negative.
Institutions are encouraged to save cord blood
for future testing, particularly when the
mother's blood type is group O. Appropriate
testing may then be performed as needed.
When family history, ethnic or geographic origin,
or the timing of the appearance of jaundice
suggests the possibility of glucose-6-phosphate
dehydrogenase deficiency or some other cause of
hemolytic disease, appropriate laboratory
assessment of the infant should be performed.
Total serum bilirubin level needs to be
determined in infants noted to be jaundiced in
the first 24 hours of life.
In newborn infants, jaundice can be detected by
blanching the skin with digital pressure,
revealing the underlying color of the skin and
subcutaneous tissue. The clinical assessment of
jaundice must be done in a well-lighted room.
Dermal icterus is seen first in the face and
progresses caudally to the trunk and extremities.
As the TSB level rises, the extent of
cephalocaudad progression may be helpful in
quantifying the degree of jaundice use of an
icterometer or transcutaneous jaundice meter may
also be helpful.
Evaluation of newborn infants who develop
abnormal signs such as feeding difficulty,
behavior changes, apnea, or temperature
instability is recommendedregardless of whether
jaundice has been detectedto rule out underlying
illness.

Follow-up should be provided to all neonates
discharged less than 48 hours after birth by a
health care professional in an office, clinic, or
at home within 2 to 3 days of discharge.
A report of dark urine or light stools should
prompt a measurement of direct serum bilirubin.
If the history (particularly the appearance of
the urine and stool) and physical examination
results are normal, continued observation is
appropriate. If jaundice persists beyond 3 weeks,
a urine sample should be tested for bilirubin,
and a measurement of total and direct serum
bilirubin obtained.

Treatment
Jaundice occurring before age 24 hours is
generally considered "pathologic" and requires
further evaluation. Although some healthy infants
appear slightly jaundiced by 24 hours, the
presence of jaundice before 24 hours requires (at
least) a serum bilirubin measurement and, if
indicated, further evaluation for possible
hemolytic disease or other diagnoses.
Phototherapy and/or exchange transfusion may be
indicated for rapidly rising total serum
bilirubin levels in the first 24 hours of life.
For the treatment of the 25- to 48-hour-old
infant, phototherapy may be considered when the
TSB level is gt12 mg/dL (210 µmol/L). Phototherapy
should be implemented when the TSB level is gt15
mg/dL (260 µmol/L). If intensive phototherapy
fails to lower a TSB level of gt20 mg/dL (340
µmol/L), exchange transfusion is recommended. If
the TSB level is gt25 mg/dL (430 µmol/L) when the
infant is first seen, intensive phototherapy is
recommended while preparations are made for an
exchange transfusion. If intensive phototherapy
fails to lower the TSB level, exchange
transfusion is recommended. The higher TSB levels
in a 25- to 48-hour-old infant suggest that the
infant may not be healthy and indicate the need
for investigation into the cause of
hyperbilirubinemia, such as hemolytic disease.

Phototherapy may be considered for the 49- to
72-hour-old jaundiced infant when the TSB level
is gt15 mg/dL (260 µmol/L). Phototherapy is
recommended when the TSB level reaches 18 mg/dL
(310 µmol/L). If intensive phototherapy fails to
lower the TSB level when it reaches or is
predicted to reach 25 mg/dL (430 µmol/L), an
exchange transfusion is recommended. If the TSB
level is gt30 mg/dL (510 µmol/L) when the infant
is first seen, intensive phototherapy is
recommended while preparations are made for
exchange transfusion. If intensive phototherapy
fails to lower the TSB level, an exchange
transfusion is recommended.
For the infant gt72 hours old, phototherapy may be
considered if the TSB level reaches 17 mg/dL (290
µmol/L). Phototherapy needs to be implemented at
a TSB level of gt20 mg/dL (340 µmol/L). If
intensive phototherapy fails to lower a TSB level
of gt25 mg/dL (430 µmol/L), exchange transfusion
is recommended. If the TSB level is gt30 mg/dL
(510 µmol/L) when the infant is first seen,
intensive phototherapy is recommended while
preparations are made for an exchange
transfusion. If intensive phototherapy fails to
lower the TSB level, an exchange transfusion is
recommended.

Treatment of Jaundice Associated with
Breast-feeding in the Health Term Newborn
The AAP discourages the interruption of
breast-feeding in healthy term newborns and
encourages continued and frequent breast-feeding
(at least eight to tem times every 24 hours).
Supplementing nursing with water or dextrose
water does not lower the bilirubin level in
jaundiced, health, breast-feeding infants.
Depending on the mother's preference and the
physician's judgment, however, a variety of
options are available for possible implementation
beyond observation, including supplementation of
breast-feeding with formula or the temporary
interruption of breast-feeding with formula,
either of which can be accompanied by
phototherapy.

DEVELOPER(S)
American Academy of Pediatrics
GUIDELINE COMMITTEE
Provisional Committee on Quality Improvement
Subcommittee on Hyperbilirubinemia

10
Cochrane Collaboration was used including
searches of the Cochrane Controlled Trials
Register, MEDLINE, EMBASE and discussion with
experts in the field.

In the first week of life approximately 50 of
newborn infants have clinically detectable
jaundice (Maisels 1982). The majority of these
infants have no underlying disease and their
jaundice results from the increased bilirubin
production and decreased excretion which are
normally seen in the newborn period
(physiological jaundice). In a minority, jaundice
indicates a more serious underlying pathology
such as haemolysis, septicaemia or metabolic
disease (non-physiological jaundice). Elevated
serum bilirubin (SBR) can damage neurones, and
for this reason it is measured in a newborn
infant with obvious jaundice or signs of
underlying disease.

Since the early 1970's neonatal jaundice has been
treated with phototherapy. Phototherapy causes
photoisomerisation of bilirubin into a
water-soluble form which can be excreted by the
kidney. It effectively decreases the SBR in
jaundiced newborn infants and decreases the need
for exchange blood transfusion (Maisels 1992). To
deliver phototherapy the infant is nursed under
halogen or fluorescent lamps and the eyes are
covered with a mask to prevent retinal damage.
The disadvantages of delivering phototherapy in
this way are that it can interfere with
parent-child bonding (Fetus Newborn 1986), and
that a displaced eye mask can cause nasal
obstruction (Al-Salihi 1975). However, this
method of delivering phototherapy (conventional
phototherapy) remains widely used.

Root causes identified Examination of the recent
cases has identified a pattern of root causes
related to four patient care processes
Patient assessment
The unreliability of the visual assessment of
jaundice in newborns with dark skin.
Failure to recognize jaundice in an infant--or
its severity--based on visual assessment, and
measure a bilirubin level before the infant's
discharge from the hospital or during a follow-up
visit.
Failure to measure the bilirubin level in an
infant who is jaundiced in the first 24 hours.
Continuum of care
Early discharge (before 48 hours) with no
follow-up within one to two days of discharge.
This is particularly important for infants less
than 38 weeks of gestation.
Failure to provide early follow-up with physical
assessment for infants who are jaundiced before
discharge.
Failure to provide ongoing lactation support to
ensure adequacy of intake for breast-fed
newborns.

13
Inadecuado MAL HECHO BIEN HECHO

Manejo de Hiperbilirrubinemia inadecuado en las
primeras 24 h.
No esta estudiada la hiperbilirrubinemia s/ guias
Manejo inadecuado de Hiperbilirrubinemia al 7 dia
con niveles de 29 mg
No tiene valoración neurologica en la HC
No hay firma de docente responsable

FOTOTERAPIA TARDIA
BILIRRUBINAS MAL INTERPRETADAS

14
Adecuado bien hecho mal hecho

Bilirrubinas tomadas en las primeras 24 horas

Fototerapia tardia
Examen neurologico

Patient and family education
Failure to provide appropriate information to
parents about jaundice and failure to respond
appropriately to parental concerns about a
jaundiced newborn, poor feeding, lactation
difficulties and change in newborn behavior and
activity.
Treatment
Failure to recognize, address or treat rapidly
rising bilirubin.
Failure to aggressively treat severe
hyperbilirubinemia in a timely manner with
intensive phototherapy or exchange transfusion