Hiperbilrubin Aap
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Transcript of Hiperbilrubin Aap
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AMERICAN ACADEMY OFPEDIATRICS
Subcommittee on Hyperbilirubinemia
Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant >35 Weeks of Gestation
Pediatrics 2004 (July);114:297
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AAP Jaundice Guideline
The 10 Key Elements
1. Promote and support successfulbreastfeeding.
2. Establish nursery protocols–includecircumstances in which nurses can order abilirubin.
3. Measure TSB or TcB if jaundiced in the first24 hours.
4. Visual estimation of jaundice can lead toerrors, particularly in darkly pigmentedinfants.
5. Interpret bilirubin levels according to theinfant’s age in hours.
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AAP Jaundice Guideline
The 10 Key Elements (cont)
6. Infants <38 weeks, particularly if breastfed,
are high risk7. Perform risk assessment prior to discharge.
8. Give parents written and oral information .
9. Provide appropriate follow-up based on timeof discharge and risk assessment.
10. Treat newborns, when indicated, withphototherapy or exchange transfusion.
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Risk assessment and
follow up will preventdisasters
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We need to assess
jaundice risks the waywe assess other risks
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Risk Assessment
Do this on every baby
Risk factors and/or measure TcB or TSB
Best to use both
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Risk Factors for Developing
Hyperbilrubinemia
TSB or TCB >75%
Jaundice <24hr or before discharge ABO with +ve DAT or other hemolytic disease(G6PD)
Gestation <39wk
Previous sibling jaundiced
Cephalhematoma or bruising (vacuum)
Exclusive breastfeeding
East Asian
Male
Discharge <72hr
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Predictive Ability of a
Predischarge Hour-specific SerumBilirubin for Subsequent
Significant Hyperbilirubinemia inHealthy Term and Near-Term
Newborns
Bhutani VK, Johnson L, Sivieri EM.
Pediatrics 1999;103:6-14
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Newman Arch Ped Adolesc Med 2005;159:113
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Predischarge Bilirubin Levels and
Risk of Subsequent Hyperbilirubinemia
TSB after dischargeTSB before discharge
126 (4.4%)2840TOTAL
68/172 (39.5%)
46/356 (12.9%)
12/556 (2.15%)
0/1756
172 (6.1%)
356 (12.5%)
556 (19.6%)
1756 (61.8%)*
95th
76th – 95th
40th – 75th
< 40th
> 95th percentileNPercentile
* Newborn TSB were obtained between 18 and 72 hours and 61.8%
of all values obtained were below the 40th percentile.
Bhutani, et al. Pediatrics 1999;103:6-14.
Gi Ph i i th T l t
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Give Physicians the Tools to
Implement the Guidelines
Risk assessment tool at bedside
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Predischarge Assessment for the Risk of Hyperbilirubinemia in
Infants >35 wk Gestation (Pediatrics 2004;114:257-313)
Postnatal Age (hours)
0 12 24 36 48 60 72 84 96 108 120 132 144
S e r u m B
i l i r u b i n ( m g / d l )
0
5
10
15
20
25
H i g h I n
t e r m e d i a
t e R i s k
Z o n e
L o w I n t
e r m e d i a
t e R i s k
Z o n e
95 th%ile
75th
%ile
40th
%ile
High Risk Zone
Low Risk Zone
*The more risk factors present, the greater the risk of developing severe hyperbilirubinemia
Follow-up should be provided as follows
Any infant discharged before age 72 hours should be seen
within 2 days of discharge.
* If an infant is discharged before age 72 hours AND if you plan to follow up in more than 2 days, please document your reasons in the chart .
**If considering phototherapy or exchange transfusion please refer to the back of this page for guidelines and information.
Date Time Age
(hrs)
TcB TS
B
Initials
TcB – Transcutaneous Bilirubin
TSB – Total Serum Biilirubin/Direct
Risk Factors for Development of Severe Hyperbilirubinemia
Risk Factors Major Risk 3 Minor Risk3
Decreased Risk3
Predischarge TSB or
TcB
(see nomogram above)
In high zone (>95%) In high intermediate zone
(>75%)
Low risk zone (<40%)
Visible Jaundice First 24 hrs. Before dischargeGestational age 35-36 wks 37-38 wks. >41 wk
Previous sibling Received phototherapy Jaundiced, no phototherapy
Blood Groups
Hemolytic disease
Blood grp. incompatibility with
+DAT. Other known hemolytic
disease (eg. G^PD deficiency)
Feeding Exclusive breast (↑risk if poor
feeder or ↑
wt. loss )
Breast fed, nursing well Exclusive formula
feeding.
Race East Asian Hispanic (Mexican)? African American*unless G^PD def.~12% are
G6PD deficient
Other factors Cephalhematoma or significant
bruising
Macrosomic infant of
IDM,male gender, maternal
age >25 yr.
Discharged from
hospital after 72 hrs.
Bhutani, Pediatrics1999;103:6
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Implementation tools (low tech)
Wallet-sized nomogram and guidelines
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Tony Burgos, MD, MPH Chris Longhurst , MD, MS Stuart Turner, DVM
Stanford University and Stanford University and University of California Davis
Packard Children’s Hospital Packard Children’s Hospital