Clinical Aspect of Hyperbilirubinemia on LBW Infant

7/30/2019 Clinical Aspect of Hyperbilirubinemia on LBW Infant

1/39

Clinical Aspect of Hyperbilirubinemia


2/39

CLINICAL JAUNDICE

80% of premature baby

Visible jaundice: serum bilirubin > 5 mg/dL


3/39

Neonatal Jaundice:

WHY WE WORRY ?

Acute Bilirubin EncephalopathyEarly phase

lethargic, hypotonia, suck poorlyIntermediate phase

stupor, irritability, hypertonia(retrocollis and opistotonus)

Fever, high-pitched cry

Kernicterus

Chronic form of bilirubin encephalopathyAthetoid CP, auditory dysfunction, paralysis upward gaze


4/39

Kernicterus - Neuropathology

Yellow staining and neuronal necrosis Basal ganglia:

globus pallidus

subthalamic nucleus

Cranial nerve nuclei:

vestibulocochlear

oculomotor

facial

Cerebellar nuclei


5/39

1990 -..125 CASES OF KERNICTERUSin the United States

Cases of Kernicterusin Indonesia ?

A preventable tragedy


6/39

BILIRUBIN SYNTHESIS, TRANSPORT, AND

METABOLISM


7/39

BASIS FOR INCREASED BILIRUBIN LEVELS

IN THE NEWBORN


8/39

Serum Bilirubin levels

in term and preterm infants

0

2

4

6

8

1012

14

16

day 1 day 2 day 3 day 4 day 5 day 6 day 7

Normal term

Preterm


9/39

Jaundice in preterm neonates

Onset earlier

Peaks later

Higher peak

Takes longer to resolve up to 3 weeks

What level is physiologic?


10/39

Physiologic vs Non-physiologic

hyperbilirubinemia

0

24

6

8

10

12

1416

18

20

day 1 day 2 day 3 day 4 day 5 day 6 day 7

physiologic

non- physiologic


11/39

Criteria that Rule Out the Diagnosis

of Physiologic Jaundice

Clinical jaundice in the first 24 hours of live

Jaundice lasting longer than 21 days in preterm infants

STB concentration increasing by more 0.2 mg/dLper hour or 5 mg/dL per day

Direct serum bilirubin concentration exceeding1.5-2 mg/dL

Jaundice who need phototherapy

Sign ofunderlying disease


12/39

CAUSES OF NEONATAL

INDIRECT HYPERBILIRUBINEMIA

BASIS CAUSES


13/39

Indirect HYPERBILIRUBINEMIA

OVERPRODUCTION ( HEMOLYSIS) Extravascular blood-hematomas, bruises

Feto-maternal blood group incompatibilityRh - mom / baby Rh +

O group mom / baby A or B

Intrinsic red cell defects

G-6-PD deficiencyhereditary spherocytosis

Polycythemia


14/39

X- Linked disorder (2-6% carrier rate in Indonesia)

enzyme protects red cell from oxidative damage

>150 mutations

Onset of jaundice usually day 2 - 3, peaks day 4 - 5

Hyperbilirubinemia may be out of proportion to anemia

Diagnosis- enzyme assay baby and mother DNA analysis


G6PD DEFICIENCY


15/39

Prematurity

Hypothyroidism

Inherited deficiency of conjugating enzymeuridine diphosphate glucuronyl transferase

Other metabolic disorders


UNDERSECRETION


16/39

ENTEROHEPATIC CIRCULATION

Decreased enteral intake Pyloric stenosis Intestinal atresia/ stenosis Meconium ileus Meconium plug Hirschsprungs disease


SECRETED but REABSORBED from gut


17/39

Cholestasis

Biliary atresia Choledochal cyst

# Direct bilirubin > 2 mg/dL

# Time of appearance# Color of stools# Color of urine

Direct HYPERBILIRUBINEMIA

OBSTRUCTIVE DISORDERS


18/39

Bacterial sepsis Intrauterine infections: TORCH

HYPERBILIRUBINEMIA

MIXED


19/39

History

Physical exam: gestational age activity/ feeding level of icterus pallor hepatosplenomegaly bruising, cephalhematoma

HYPERBILIRUBINEMIA

DIAGNOSIS


20/39

Laboratory tests

Bilirubin levels: total and direct Mothers blood group and Rh type

Babys blood group and Rh type

Direct Coombs test on baby

Hemoglobin Blood smear

Reticulocyte count

HYPERBILIRUBINEMIA

DIAGNOSIS


21/39

Likely

Rhesus, ABO, or other hemolytic disease Spherocytosis

Less likely

Congenital infection G-6-P-D deficiency

Rapidly developing jaundice

on Day 1


22/39

Rapidly onset jaundice

after 48 hours of ageLikely

Infection G-6-P-D deficiency

Less likely

Congenital Rh, ABO, spherocytosis


23/39

HYDRATION - FEEDING

PHOTOTHERAPY

EXCHANGE TRANSFUSION

Phenobarbital Tin protoporphyrin

HYPERBILIRUBINEMIA

MANAGEMENT


24/39

Management of Hyperbilirubinemia

in the Newborn Infant35 or more weeks of gestation

Promote and support successful breast-feeding

Perform a systematic assessment before dischargefor the risk of severe hyperbilirubinemia

Provide early and focussed follow-up based on riskassessment

When indicated, treat newborns with phototherapyor exchange transfusion to prevent the developmentof severe jaundice and possibly, kernicterus.


25/39

Feeding to Prevent and Treat

Neonatal Jaundice

Mothers should breast feed their babies

caloric intake / dehydrationJaundice

Supplementation with water or dextrosewater will not prevent or treathyperbilirubinemia


26/39

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/ DAT

Monitor infant for jaundice at least every 8-12 hours

If level of jaundice appears excessive for age,perform transcutaneous bilirubin or total serumbilirubin measurement


27/39

Clinical

assessmentof severity of

jaundice

Cephalocaudal progression

face 5 mg/dL (approximately)

upper chest 10 mg/dL (approximately)

abdomen and upper thighs 15 mg/dL (approximately) soles of feet 20 mg/dL (approximately)

Visual inspection may be misleading


28/39

Transcutaneous Bilirubinometers

Useful as screening device TcB measurement fairly accuratein most infants with TSB < 15 mg/dL Independent of age, race and weight Not accurate after phototherapy


29/39


30/39

Complications of phototherapy

Significant complications very rare

separation of mother and baby increased insensible water loss and

dehydration in premature baby

PDA

ROP


31/39

What decline in serum bilirubin can

you expect with phototherapy?

Rate of decline depends on effectiveness ofphototherapy and underlying cause of jaundice

Intensive phototherapy should produce a decline inSTB of 1-2 mg/dL within 4-6 hours, and the STB levelshould continue to decline and remain below thethreshold level for exchange transfusion

With standard phototherapy, expect decrease of 6%to 20% of the initial bilirubin level in the first 24 hours


32/39

Exchange Transfusion


33/39

Exchange Transfusion

waste

Red Blood Cells

Double volumeExchange Transfusion2 X 85 mL/kg


34/39

EXCHANGE TRANSFUSION

COMPLICATIONS cardiac failure

metabolic- hypoglycemia, hyperkalemia, hypocalcemia

air embolism

bacterial sepsis

transfusion transmitted viral disease

necrotizing enterocolitis portal vein thrombosis

Mortality / permanent sequelae 1-12%


35/39

Total Bilirubin Level (mg/dL)*Birth Weight (g)

Phototherapy Exchange Transfusion

< 1.500 5-8 13-16

1.500-1.999 8-12 16-18

2.000-2.499 11-14 18-20

Guidelines for the use of phototherapy andexchange transfusion in low birth weight infants

based on birth weight


36/39

Total bilirubin level (mg/dL)

Exchange transfusionGestational age

(weeks) Phototherapy

Sick* Well36 14.6 17.5 20.5

32 8.8 14.6 17.5

28 5.8 11.7 14.6

24 4.7 8.8 11.7

Guidelines for use of phototherapy and exchange

transfusion in preterm infants based on gestational age


37/39

< 1.250 g 1.250-1.499 g 1.500-1.999 g 2.000-2.499 g

Standard risk

Total bilirubin 13 15 17 18

B/A ratio 5.2 6.0 6.8 7.2

High risk*

Total bilirubin 10 13 15 17

B/A ratio 4.0 5.2 6.0 6.8

Guidelines according to birth weight forexchange transfusion in low birth weight infants

based on total serum bilirubin (mg/dL) andbilirubin/albumin ratio (mg/g) (whichever comes first)

Guidelines for the Management of Hyperbilirubinemia Based on


38/39

g yp

Birth Weight and Relative Health of the Newborn

Serum Total Bilirubin Level (mg/dL)

Healthy SickBirth Weight

Phototherapy ExchangeTransfusion

Phototherapy ExchangeTransfusion

Premature

< 1000 g

1001 1500 g

1501 2000 g

2001 2500 g

Term> 2500 g

5 7

7 10

10 12

12 15

15 18

Variable

Variable

Variable

Variable

20 25

4 6

6 8

8 10

10 12

12 15

Variable

Variable

Variable

Variable

18 20

Averys Diseases of the Newborn. 2005


39/39

Tatalaksana IkterusBilirubin Serum Total (mg/dL)

Terapi sinar Transfusi tukarUSIA

Tanpa

Faktor Risiko

Prematur atau

Dengan Faktor Risiko

Tanpa

Faktor Risiko

Prematur atau

Dengan Faktor Risiko

Hari 1 Setiap ikterus yang terlihat 15 13

Hari 2 15 13 25 15

Hari 3 18 16 30 20

Hari 4 dst 20 17 30 20

Pocket Book WHO, 2005

Clinical Aspect of Hyperbilirubinemia on LBW Infant

Documents

Transcript of Clinical Aspect of Hyperbilirubinemia on LBW Infant