Neonatal Hyperbilirubinemia

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Neonatal Hyperbilirubinemia
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Jaundice

• Yellowish discoloration of skin /- sclera of
  newborns due to bilirubin
• Affects nearly all newborns
• Peak 48-120 hours, typically 5-6 mg/dL, usually
  does not exceed 17-18 mg/dL
• Pathologic TSB exceeds age (in hours) specific
  95th percentile according to Bhutani nomogram

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Effects of hyperbilirubinemia

• Bilirubin toxicity
• Toxicity due to unbound (free) form
• Focal necrosis of neurons and glia
• Acute bilirubin encephalopathy
• Chronic kernicterus
• Most often affects basal ganglia and brainstem
  nuclei
• Movement disorders
• Impaired upward gaze
• Auditory abnormalities

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Effects

• Bilirubin toxicity
• At risk when TSB gt 25-30 mg/dL
• Premature and sick infants
• Albumin level
• Drugs- silfisoxazole, moxalactam, ceftriaxone
• Acidosis
• Near term (35-37) weeks
• Breast fed
• Hemolytic disease
• Discharge before 48 hours

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Manifestations

• Phase one- 1st few days
• Lethargy, hypotonia, poor suck, high pitched cry
• Phase two- end of 1st week
• Irritable, hypertonia, retrocollis, opisthotonus
• Phase three- after 1st week
• Stupor, coma, shrill cry

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Evaluation

• Transcutaneous bilirubin
• Total serum bilirubin
• End-tidal carbon monoxide
• Blood type, direct Coombs test
• CBC, peripheral blood smear
• Reticulocytes, G6PD screen
• Serum albumin

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Special circumstances

• Jaundice in 1st 24 hours
• Frequently due to hemolysis
• Require immediate evaluation and close
  surveillance
• Other reasons for increased bilirubin production
• Cephalohematoma, extensive bruising, conjugation
  disorders

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Management

• Phototherapy
• Mechanisms
• Structural isomerization
• Photoisomerization
• Photo-oxidation
• Irradiance
• Initiation if bilirubin exceeds the 95th
  percentile for hour-specific TSB concentration
  and risk category

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Risk categories-phototherapy

• Lower risk at least 38 weeks gestation, no risk
  factors
• gt12 mg/dL at 24 hours, gt15 mg/dL at 48 hours, gt18
  mg/dL at 72 hours
• Medium risk at least 38 weeks with risk factors
  or 35-38 weeks without risk factors
• gt10 mg/dL at 24 hours, gt13 mg/dL at 48 hours, gt15
  mg/dL at 72 hours
• Higher risk 35-38 weeks with risk factors
• gt8 at 24 hours, gt11 at 48 hours, gt13.5 at 72
  hours

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Management

• Rate of decline of TSB
• Irradiance
• Surface area
• Initial TSB
• Discontinuation
• TSB level below 95th percentile for age
• Is less than 13 mg/dL

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Management

• Exchange transfusion
• Hyperbilirubinemia unresponsive to phototherapy
• Especially useful with immune-mediated hemolysis
• Removal of circulating antibodies and sensitized
  RBCs
• For TSB gt 25 mg/dL
• Presence of bilirubin neurotoxicity

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Risk categories- exchange transfusion

• Lower risk at least 38 weeks gestation, no risk
  factors
• gt19 mg/dL at 24 hours, gt22 mg/dL at 48 hours, gt24
  mg/dL at 72 hours
• TSB/Albumingt8.0
• Medium risk at least 38 weeks with risk factors
  or 35-38 weeks without risk factors
• gt16.5 mg/dL at 24 hours, gt19 mg/dL at 48 hours,
  gt21 mg/dL at 72 hours
• TSB/Albumingt7.2
• Higher risk 35-38 weeks with risk factors
• gt15 at 24 hours, gt17 at 48 hours, gt18.5 at 72
  hours
• TSB/Albumingt6.8

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Summary

• Assess for jaundice every 8-12 hours
• Assess risk factors
• If discharging, appropriate follow-up is
  necessary
• Treatment should be initiated immediately upon
  identifying significant hyperbilirubinemia