Medical Care of neonatal jaundice

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Medical Care of neonatal jaundice

• Dr.SAMER JENIDI

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Medical Care

• Phototherapy
• Exchange transfusion
• Drugs
• Diet

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• Phototherapy

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Phototherapy

• Is the primary treatment .
• Was discovered serendipitously in England in
  the 1950s .

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Why Phototherapy is effective?

• Three reactions can occur when bilirubin is
  exposed to light
• 1- photooxidation
• 2- Configurational isomerization
• 3- Structural isomerization

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Phototherapy effect photooxidation

• Was believed to be responsible for the beneficial
  effect of phototherapy.
• Although bilirubin is bleached through the
  action of light,
• the process is slow and is now believed to
  contribute only minimally to the therapeutic
  effect of phototherapy.

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Phototherapy effect Configurational
isomerization

• Is a very rapid process that changes some of the
  predominant bilirubin isomer to water-soluble
  isomers .
• The isomer constitutes 20 of circulating
  bilirubin after a few hours of phototherapy.
• This proportion is not influenced significantly
  by the intensity of light.

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Phototherapy effect Structural
isomerization

• Consists of intramolecular cyclization,
  resulting in the formation of lumirubin.
• This process is enhanced by increasing the
  intensity of light.
• During phototherapy, lumirubin may constitute
  2-6 of the total serum bilirubin concentration

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Phototherapy effect Bear in mind

• when initiating phototherapy
• lowering of the total serum bilirubin
  concentration is only part of the therapeutic
  benefit.
• 75-80 of the total bilirubin is present in
  a form that can enter the brain.
• So

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So

• Phototherapy reduces the risk of
  bilirubin-induced neurotoxicity as soon as the
  lights are turned on.

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Factors That Affect the Dose and Efficacy of
Phototherapy

• Wavelength
• Irradiation level
• Distance
• Bilirubin concentration
• Nature and character of the light source

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Factors That Affect the Dose and Efficacy of
Phototherapy

• Wavelength
• Irradiation level
• Distance
• Bilirubin concentration
• Nature and character of the light source

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Wavelength

• - Bilirubin absorbs light primarily around
  450 nm. typically 425 to 475 nm
• - In practice, light used in wavelengths
• white, blue, and green

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Factors That Affect the Dose and Efficacy of
Phototherapy

• Wavelength
• Irradiation level
• Distance
• Bilirubin concentration
• Nature and character of the light source

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Irradiation level

• A dose-response relationship exists
• 30-40 mW/cm2/nm.
• 6 mW/cm2/nm

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Factors That Affect the Dose and Efficacy of
Phototherapy

• Wavelength
• Irradiation level
• Distance
• Bilirubin concentration
• Nature and character of the light source

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Distance

• Distance should not be greater than
• 50 cm (20 in)
• and can be less if the infant's
  temperature is monitored.
• Energy delivered decreases with increasing
  distance .

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Factors That Affect the Dose and Efficacy of
Phototherapy

• Wavelength
• Irradiation level
• Distance
• Bilirubin concentration
• Nature and character of the light source

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Bilirubin concentration

• The efficiency of phototherapy increases with
• - serum bilirubin concentration.
• - skin surface

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Factors That Affect the Dose and Efficacy of
Phototherapy

• Wavelength
• Irradiation level
• Distance
• Bilirubin
• Nature and character of the light source

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Nature and character of the light source

• - Quartz halide spotlights
• - Green light
• - Blue fluorescent tubes
• Narrow-spectrum
• Ordinary
• - White (daylight) fluorescent tubes
• - White quartz lamps
• - Fiberoptic light

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The purpose of phototherapy

• is
• to avoid neurotoxicity.

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Historical data

• derived from infants with hemolytic jaundice
  suggest that
• total serum bilirubin levels greater than
  (20 mg/dL) were associated with increased risk of
  neurotoxicity, at least in full-term infants.

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Autopsy findings

• suggested that
• Immature infants were at risk of bilirubin
  encephalopathy at lower total serum bilirubin
  levels than mature infants.

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But .

• Unfortunately, because the endpoint of
  bilirubin neurotoxicity is permanent brain
  damage,
• a randomized study to reassess the
  guidelines is
• ethically unthinkable.

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Indications for phototherapy

• In most neonatal wards, total serum bilirubin
  levels are used as the primary measure of risk
  for bilirubin encephalopathy.
• Test for serum albumin have failed to gain
  widespread acceptance.

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Indications for phototherapy

• A number of guidelines for the management of
  neonatal jaundice have been published with
  significant disparity .
• This disparity illustrates how difficult to
  translate clinical data into sensible treatment
  guidelines.

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Indications for phototherapy

• The 2004 AAP guidelines represent a significant
  change from the 1994 guidelines.
• The emphasis on
• preventive action and
• risk evaluation
• is much stronger.

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Indications for phototherapy

• Physicians in different ethnic or geographic
  regions must consider factors that are unique to
  their medical practice settings.
• Such factors may include
• - racial characteristics
• - prevalence of congenital hemolytic disorders
• - environmental concerns

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Key points in the practice

• - Maximizing energy delivery
• - Maximizing the available surface area.

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Key points in the practice

• 1 - Maximizing energy delivery
• - Distance should be no greater than 50
  cm and may be reduced down to 10-20 cm if
  temperature homeostasis is monitored to reduce
  the risk of overheating.
• - Cover the inside of the bassinet with
  reflecting material white linen works well.
• - Hang a white curtain around the
  phototherapy unit and bassinet.
• These simple expedients can multiply
  energy delivery by several fold.

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Key points in the practice
2- Maximizing the available surface area.
The infant should be naked except for diapers and
the eyes should be covered to reduce risk of
retinal damage.
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Intermittent Versus Continuous Phototherapy ?

• Clinical studies have produced conflicting
  results.
• Individual judgment should be exercised.
• If the infants bilirubin level is approaching
  the exchange transfusion zone , phototherapy
  should be administered continuously until a
  satisfactory decline in the serum bilirubin level
  occurs or exchange transfusion is initiated.

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What about insensible water loss?

• New data suggest that if temperature homeostasis
  is maintained, fluid loss is not increased
  significantly by phototherapy.
• In infants who are fed orally, the preferred
  fluid is milk, since milk serves as a vehicle to
  transport bilirubin out of the gut.

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Timing of follow-up serum bilirubin ?

• - In infants admitted with extreme serum
  bilirubin values ( 30 mg/dL) monitoring should
  occur every hour or every other hour.---------?
  Reductions in serum bilirubin values (5
  mg/dL/h).
• - In infants with more moderate elevations
  of serum bilirubin
• monitoring every 6-12 hours .

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Expectations regarding efficacy of phototherapy ?

• - Bilirubin concentrations are still
  rising-----?
• a significant reduction of the rate of
  increase .
• - Bilirubin concentrations are close to their
  peak-----? phototherapy should result in
  measurable reductions in serum bilirubin levels
  within a few hours.
• In general, the higher the starting serum
  bilirubin concentration, the more dramatic the
  initial rate of decline.

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When discontinuation of phototherapy?

• When serum bilirubin levels fall
• (1.5-3 mg/dL)
• below the level that triggered the initiation
  of phototherapy.
• Serum bilirubin levels often rebound , and
  follow-up tests should be obtained within 6-12
  hours after discontinuation.

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What about prophylactic Phototherapy ?

• No purpose
• In general, the lower the serum bilirubin level,
• the less efficient the phototherapy.

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Phototherapy complications

• Phototherapy is very safe,
• and
• it may have no serious long-term effects
  in neonates .

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Phototherapy complications

• Insensible water loss is not as important as
  previously believed.
• Loose stools.
• Retinal damage
• Effects on cellular genetic material
• in vitro and animal data have not been shown
  any implication for treatment of human neonates.
• However, most hospitals use cut-down diapers
  during phototherapy .

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Phototherapy complications

• Skin blood flow is increased--?
• redistribution of blood flow may occur in
  small premature infants--?
• Increased incidence of patent ductus
  arteriosus (PDA) has been reported
• But this effect is less pronounced in modern
  servocontrolled incubators.

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Phototherapy complications

• Hypocalcemia in premature infants . It has been
  suggested that this is mediated by altered
  melatonin metabolism.
• Deteriorationof certain amino acids in total
  parenteral nutrition (TPN) solutions
• Shield TPN solutions from light as much as
  possible.
• Accidents have been reported, including burns
  resulting from failure to replace UV filters.

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• Exchange
• transfusion

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What are indications of Exchange transfusion?

• Avoiding bilirubin neurotoxicity when other
  therapeutic modalities have failed.
• In addition, even in the absence of high serum
  bilirubin levels, the procedure may be indicated
  in infants with erythroblastosis .

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Exchange transfusion has been
performed because of

• - Cord hemoglobin
  lt11 g/dL
• - Cord bilirubin
  gt 4.5 mg/dL
• - Rapid rate of increase in bilirubin
  gt1 mg/dL/h
• - More moderate rate of increase in bilirubin
  gt 0.5
• in the presence of moderate anemia
  Hb11-13
• - Hemolytic jaundice with bilirubin
  gt 20
• or a rate of increase that predicted this
  level
• (fear of 20) .
• .

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Why Exchange transfusion become a rare procedure
??

• Immunotherapy in Rh-negative women So ,ABO
  incompatibility has become the most frequent
  cause of hemolytic disease in industrialized
  countries.
• Effective phototherapy
• Recently, immunotherapy has been introduced as
  treatment in the few remaining sensitized
  infants. Results are promising

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So.. When exchange transfusion should be
performed ?

• When phototherapy does not significantly lower
  serum bilirubin levels
• Intensive phototherapy is strongly recommended
  in preparation for an exchange transfusion. do
  not await laboratory test results in these cases .

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Does nonhemolytic jaundice cause Neurotoxicity ?

• Many physicians believe that hemolytic jaundice
  represents a greater risk for neurotoxicity than
  nonhemolytic jaundice, although the reasons for
  this belief are not obvious .
• In animal studies, bilirubin entry into the
  brain was not affected by the presence of
  hemolytic anemia..

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• DRUGS

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What about Phenobarbital ?an inducer of hepatic
bilirubin metabolism

• Several studies have shown that
  phenobarbital is effective .
• Phenobarbital may be administered
• - pre-natally in the mother or
• - post-natally in the infant.
• However, concerns exist regarding the
  long-term effects of phenobarbital on these
  children.

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What about IV immunoglobulin (500 mg/kg) ?

• Significantly reduce the need for exchange
  transfusions in infants with isoimmune hemolytic
  disease.
• The mechanism is unknown .
• Experience is somewhat limited, but it does not
  appear risky .

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New therapy Mesoporphyrins and Protoporphyrins

• Currently under development
• Inhibition of bilirubin production through
  blockage of heme oxygenase.
• Apparently, heme can be excreted directly
  through the bile .
• This approach may virtually eliminate neonatal
  jaundice as a clinical problem.
• But

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Important questions before the treatment can be
applied

• - Long-term safety ?.
• - Complete understanding of putative role
  for bilirubin in light of data suggesting that
  bilirubin may play an important role as a free
  radical quencher ( anti-oxidant ) ?.

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• DIETE

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Temporary interruption of breastfeedingis it
recommended ?

• It is not recommended
• unless serum bilirubin levels reach 20 mg/dL

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Supplementation with dextrose solution is it
recommended ?

• It is not recommended
• because
• - it may decrease caloric intake
• - it may decrease milk production
• - it may accelerate entero_hepatic
• circulation
• and consequently delay the drop in serum
  bilirubin concentration

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So .. What is the recommendation ?

• Increase breastfeeding to 8-12 times per day
  
• Breastfeeding can also be supported with
  manual or electric pumps and the pumped milk
  given as a supplement to the baby.

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• Some questions ???

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When infants can be discharged ?

• When they are
• - feeding adequately and
• - demonstrating a trend towards
• lower values.
• Auditory function tests prior is advisable in
  infants who have had severe jaundice.

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How to manage infants released within the first
48 hours of life ?

• In the era of early discharge in recent years, a
  number of infants have developed kernicterus ---?
• Infants need to be reassessed for jaundice
  within 1-2 days.
• Use of hour-specific bilirubin nomogram may
  assist in selecting infants .

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Are infants need follow-up obsevation after
Bilirubin falls?

• Infants with hemolytic jaundice require follow-up
  observation for several weeks because hemoglobin
  levels may fall lower than seen in physiologic
  anemia.
• Erythrocyte transfusions may be required if
  infants develop symptomatic anemia.

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FinallyWhat about Prognosis ?

• Prognosis is excellent if the patient receives
  treatment according to accepted guidelines.
• The increased incidence of kernicterus in recent
  years may be due to the misconception that
  jaundice in the healthy full-term infant is not
  dangerous and can be disregarded.

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thanks