Hyperbilirubinemia€¦ · Benign neonatal hyperbilirubinemia: transient, occurs in almost every...

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Transcript of Hyperbilirubinemia€¦ · Benign neonatal hyperbilirubinemia: transient, occurs in almost every...

  • HyperbilirubinemiaASHLEY HELMBRECHT, DNP, APRN-CNP

  • Objectives1) History of hyperbilirubinemia screening

    2) Physiology of Bilirubin clearance

    3) Physiologic vs Pathologic Hyperbilirubinemia.

    4) Treatment for Hyperbilirubinemia

    5) AAP recommended guidelines

  • History of Screening

    Icterus Neonatorum

    1885

    Icterus gravis showed high recurrence

    within families early

    1900’s

    Discovery of Rh group of

    red cell antigens

    1940

    Research on hemolytic

    disease of the newborn

    1940-1950’s

    Rhogam1968

    Rh erythroblastosisfetalis becomes

    rare1970’s

    Phototherapy intervention of

    choice1980’s

    Official AAP guidelines

    2004

  • Jaundice:

    Yellow/orange discoloration of the skin and sclera caused by an

    elevated bilirubin level

    **Not reliable

    Bilirubin: Metabolic end product of RBC

    breakdown

    https://www.medlife.com/web/jaundice-newborns-infant-jaundice-causes-symptoms/

  • Evaluate Jaundice in Good Lighting

  • https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.shutterstock.com%2Fsearch%2Fjaundice&psig=AOvVaw0utf5c29zsY2i8Y6gmWcie&ust=1593572494580000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCKD8v9DHqOoCFQAAAAAdAAAAABAL

  • Bilirubin Synthesis and Transport

  • Bilirubin Metabolism, Clearance and ExcretionSome bilirubin binds to albumin and transported directly to the liver

    Enterohepatic circulation

  • Copyrights apply

  • Hyperbilirubinemia__________ __________ ____________________Too much Bilirubin In the bloodstream

  • HyperbilirubinemiaPHYSIOLOGIC unconjugated PATHOLOGIC unconjugated

    Jaundice after 24-48hr of life Jaundice within the first 24hrRequires no treatment Evaluation & treatmentPeak: Day of life 3 in term, Day of life 5-6 in preterm

    Bili increases >5mg/dL each day

    Resolved by 14 days of life Jaundice lasting longer than 14 daysNormal infant appearance Anemic, discolored stools or urine

    Normal physiology: Increased RBCdestruction, Reduced hepatic uptake, Enterohepatic reabsorption & Decreased clearance

    Cause varies, any process that is exaggerated

  • How do we test ?Gold standard is (TSB) Total Serum Bilirubin

    Heelstick is sufficient: 0.3mL **check what your facility requires

    Plot on age-specific nomogram

    Rate of rise

    Mom and Baby blood type. If coombs is positive that means there is an antibody-mediated hemolysis

  • Copyrights apply

  • Bhutani Nomogram

    HTTPS://WWW.NEJM.ORG/DOI/FULL/10.1056/NEJMCT0708376

    High Risk

    Low Risk

  • Rate of Rise = Current Bili – Previous BiliNumber of hours between labs

  • How else do we test?Transcutaneous Bilirubin (TcB)

    Use the forehead or sternum

    Do not use on bruises, birthmarks or excessively hairy skin

    Do not use if baby is undergoing phototherapy

    May be affected by skin pigmentation

    HTTP://STATIC.PROGRESSIVEMEDIAGROUP.COM/UPLOADS/IMAGELIBRARY/NRI/MEDICALDEVICE/JAUNDICE.JPG

  • Classification of Hyperbilirubinemia

    Benign neonatal hyperbilirubinemia: transient, occurs in almost every newborn “physiologic jaundice”

    Significant hyperbilirubinemia: infants ≥ 35weeks with TSB >95thpercentile on nomogram

    Severe neonatal hyperbilirubinemia: a TSB >25mg/dL and increased risk for BIND

    Extreme hyperbilirubinemia: TSB >30mg/dL associated with increased risk for BIND

  • Bilirubin-induced Neurologic Dysfunction

    (BIND)

    Acute BilirubinEncephalopathy (ABE)

    Chronic BilirubinEncephalopathy (CBE)

    Significant lethargy

    Hypotonia

    Poor sucking

    High-pitched Cry

    Arching of the trunk

    Arching of back and neck

    Seizures

    1 in 10,000 1 in 40,000

    Cerebral Palsy

    Hearing loss

    Abnormal gaze

    Dental enamel hypoplasia

  • BreastMILK Jaundice BreastFEEDING JaundiceOnset 4-7 days Onset 2-4 days

    May persist for up to 2 months Self-limiting as maternal milk supply increases

    1 in 200 infants 1 in 10 infants

    Exaggerated physiologic jaundice related to substances in maternal breastmilk

    Related to low or inadequate enteralintake

    No treatment More common in Late Preterm Infant

  • Factors That Increase Risk of Hyperbili

  • Copyrights apply

  • InterventionsGoal is to intervene based on the probability a baby will develop severe hyperbilirubinemiaPhototherapyIVIGExchange Transfusion

    HTTPS://THECONVERSATION.COM/JAUNDICE-IN-NEWBORNS-COULD-BE-AN-EVOLUTIONARY-SAFEGUARD-AGAINST-DEATH-FROM-SEPSIS-97049

  • Interventions: Phototherapy

    HTTPS://THECONVERSATION.COM/JAUNDICE-IN-NEWBORNS-COULD-BE-AN-EVOLUTIONARY-SAFEGUARD-AGAINST-DEATH-FROM-SEPSIS-97049

    Most common & safe

    It is a treatment with adverse effects

    LED lights, fiberoptic lights, swaddles

    Decreases bilirubin regardless of ethnicity

    Know the number of banks

    Monitor: Temperature, hydration

  • Interventions: PhototherapyPhotons are emitted by blue to blue-green light

    Isomerization -> Lumirubin

    Photoisomerization -> quick fix

    Cover eyes and genitals

    When do you stop?

    Bronze baby syndrome

    https://www.nejm.org/doi/full/10.1056/nejmct0708376

  • Phototherapy

    http://www.warm-patch.com/sale-11796666-different-oem-size-neonatal-phototherapy-eye-mask-infant-eye-mask-ce-fda.htmlhttp://www.parentspowwow.net/jaundice-in-the-newborn-neonatal-jaundice/

  • HTTP://GYANPRO.COM/BLOG/HOW-IS-PHOTO-THERAPY-A-CURE-FOR-NEONATAL-JAUNDICE/

    https://www.google.com/url?sa=i&url=http%3A%2F%2Fgyanpro.com%2Fblog%2Fhow-is-photo-therapy-a-cure-for-neonatal-jaundice%2F&psig=AOvVaw2e1Mm1srIi_OeXkVHKKlfM&ust=1593577659053000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCPiKw9XZqOoCFQAAAAAdAAAAABAD

  • Copyrights apply

    1215

    18

    How do youknow whento treat??

  • Interventions: IVIGInconclusive

    Rh and ABO hemolytic disease

    Reduces need for exchange transfusion

    0.5-1g/kg over 2hr

    Repeat every 12hr PRN

    HTTP://AMERICANINFUSIONCENTERS.COM/WP-CONTENT/UPLOADS/2017/03/IVIG.PNG

  • Interventions: Exchange TransfusionRare, expensive & time consuming

    Trained personnel

    Quickest way to decrease bilirubin

    Consider whenSymptomatic for BINDPhototherapy has failed

    Full, partial, double volume

    HTTP://MIMANIHOSPITAL.COM/WP-CONTENT/UPLOADS/2017/02/EXCHANGE-TRANSFUSION.JPG

  • Copyrights apply

    How do youknow whento treat??

  • https://medicalxpress.com/news/2020-03-app-jaundice-deaths-newborns.html

    https://intermountainhealthcare.org/blogs/topics/transforming-healthcare/2017/11/researchers-use-app-to-detect-newborn-jaundice/

    https://www.washington.edu/news/2014/08/27/new-smartphone-app-can-detect-newborn-jaundice-in-minutes/

  • Put the baby next to the window?Sunlight does include the effective blue-green light wavelength and can lower levels of TSB

    UV radiation

    Risk of sunburn and hyperthermia, hypovolemia and long term skin malignancies

    Filtered light using special window tinting films may be a reasonable and cost-effective alternative

  • AAP Guidelines

  • AAP Guideline 1

    Early and frequent breastfeeding 8-12 times per day

    Goal of 4-6 wet diapers per day

    Recommends against routine formula supplementation

  • AAP Guideline 2

    Receive ongoing assessments

    Blood typing on all womenBaby blood typing on all O mothers and Rh negative

    Jaundice assessment every time VS are taken at least every 8-12hr

  • AAP Guideline 3

    Jaundice in the first 24hr is abnormal

    Recommended lab guideline

  • AAP Guideline 3 Continued

  • AAP Guideline 4

    You can’t guess a TSB level with your eyes

  • AAP Guideline 5

  • AAP Guideline 6 & 7

    Every newborn should be assessed for risks especially if discharge before 72hr

  • AAP Guideline 8

  • AAP Guideline 9

    All infants should be examined by a qualified healthcare professional in the first few days after discharge

    Delay discharge until appropriate follow up is ensured

  • AAP Guideline 10

    Indirect versus direct hyperbilirubinemia

    Admit to nursery, NICU or pediatric unit

  • Questions?

    HTTPS://WWW.THEGENIUSWORKS.COM/2020/01/QUESTION-BURST-QUESTIONS-ARE-MUCH-MORE-POWERFUL-THAN-ANSWERS-SAYS-HAL-GREGERSEN-THE-CHALLENGE-FOR-LEADERS-IS-TO-ASK-BETTER-

    QUESTIONS/

  • ReferencesAmerican Academy of Pediatrics (2004). Management of hyperbilirubinemia of the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316.

    Bhutani, V. K., & Johnson, L. (2009). Kernicterus in the 21st century: Frequently asked questions. Journal of Perinatology, 29, S20-S24. doi: 10.1038/jp.2008.212

    Cashore, W. (2010). A brief history of neonatal jaundice. Medicine & Health Rhode Island, 93(5), 154-155.

    Gomella, T. L. (2009). Neonatology Management, Procedures, On-Call Problems, Diseases and Drugs 6th ed. McGraw Hill.

    Muchowski, K. E. (2014). Evaluation and treatment of neonatal hyperbilirubinemia. American Family Physician, 89(11), 873-898.

    Pace, E. J., Brown, C. M., & DeGeorge, K. C. (2019). Neonatal hyperbilirubinemia: An evidence-based approach. The Journal of Family Practice, 68(1), E4-E11.

    Varvarigou, A., Fouzas, S., Skylogianni, E., Mantagou, L., Bougioukou, D., & Mantagos, S. (2009). Transcutaneous bilirubin nomogram for prediction of significant neonatal hyperbilirubinemia. Pediatrics, 124(4), 1052-1059. doi: 10.1542/peds.2008-2322

    UpToDate (2020). Hyperbilirubinemia newborn. Retrieved fromhttps://www-uptodate-com.webproxy2.ouhsc.edu/contents/search?search=hyperbilirubinemia%20newborn&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&searchOffset=1&autoComplete=true&language=&max=0&index=1~10&autoCompleteTerm=hyperbii

    https://www-uptodate-com.webproxy2.ouhsc.edu/contents/search?search=hyperbilirubinemia%20newborn&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&searchOffset=1&autoComplete=true&language=&max=0&index=1%7E10&autoCompleteTerm=hyperbii

    HyperbilirubinemiaSlide Number 2ObjectivesHistory of ScreeningSlide Number 5Evaluate Jaundice in Good LightingSlide Number 7Bilirubin Synthesis and TransportBilirubin Metabolism, Clearance and ExcretionSlide Number 10Slide Number 11HyperbilirubinemiaHyperbilirubinemiaSlide Number 14How do we test ?Slide Number 16Slide Number 17Bhutani NomogramSlide Number 19Slide Number 20Slide Number 21How else do we test?Slide Number 23Slide Number 24Slide Number 25Classification of HyperbilirubinemiaSlide Number 27Slide Number 28Slide Number 29Factors That Increase Risk of HyperbiliSlide Number 31Slide Number 32InterventionsInterventions: PhototherapyInterventions: PhototherapyPhototherapySlide Number 37Slide Number 38Interventions: IVIGInterventions: Exchange TransfusionSlide Number 41Slide Number 42Slide Number 43Put the baby next to the window?Slide Number 45AAP GuidelinesAAP Guideline 1AAP Guideline 2AAP Guideline 3AAP Guideline 3 ContinuedAAP Guideline 4AAP Guideline 5AAP Guideline 6 & 7Slide Number 54AAP Guideline 8AAP Guideline 9AAP Guideline 10Slide Number 58Questions?References