JAUNDICE AND THE NEWBORN

Abbey Rupe, MD

Objectives

Definitions Prevention Risk factors Assessment Treatment

What is jaundice?

Hyperbilirubinemia Indirect/Unconjugated Direct/Conjugated

Considered elevated if direct portion is >20% of total bilirubin level

Scope won’t be discussed in this lecture

Definitions

Unconjugated Physiologic jaundice

Most babies develop some jaundice Mean peak of 5-6 mg/dl between 60-72 hr of life

Breast-feeding jaundice Decreased calories, increased enterohepatic

circulation Breast-milk jaundice

Prolonged after 2-3 weeks of age ?? Protein in breast milk that increases

enterohepatic circulation

Definitions

Pathologic Jaundice appearing in first 24 h of life TSB > 95th percentile for age TSB increasing at rate >0.2 mg/dl/h or > 5

mg/dl/d Elevated direct component Jaundice persisting > 2 weeks in full-term

infants Exception: breast-milk jaundice

“Severe” hyperbilirubinemia Generally considered to be TB >25-30

Complications of untreated jaundice Bilirubin-induced neurologic dysfunction

(BIND) Bilirubin crosses BBB and binds to brain tissue Risk increased when TB >25-30

Acute bilirubin encephalopathy (ABE) Initial phase: lethargy, hypotonia, decreased

movement, poor suck Intermediate phase: stupor, irritability, increased

tone (retrocolis and opisthotonos), fever Advanced phase: deep stupor or coma, inability

to feed, shrill cry, apnea, seizures **potentially reversible!

Complications

Chronic bilirubin encephalopathy (kernicterus) Choreoathethoid cerebral palsy Sensorineural hearing loss Palsy of vertical gaze Dental enamel hypoplasia Up to 10% mortality

Most (but no all) infants with kernicterus previously manifested symptoms of ABE

Why do neonates become jaundiced? Increased bilirubin production

More RBCs + shorter RBC life span = increased turnover and increased bilirubin

Decreased bilirubin clearance Deficiency of UGT

UGT activity at 7 days of age is approx 1% of adult

Reaches adult levels around 14 days of age Increased enterohepatic circulation

Pathologic jaundice--causes

Rh or ABO incompatibility Enzyme deficiencies: G6PD, pyruvate

kinase Hemoglobinopathies Infection Increased RBC load

Cephalohematomas, etc Polycythemia Infants of diabetic mothers

Pathologic jaundice--causes

Disorders of bilirubin clearance Crigler-Najjar, Gilbert

Metabolic and endocrine Galactosemia, hypothyroidism

Increased enterohepatic circulation Breast-feeding jaundice Conditions causing GI obstruction or

decreased motility

Risk factors for severe jaundice

Major: Predischarge bili in high-risk zone Observed jaundice in 1st 24 hours of life Blood group incompatibility w/ positive DAT Previous sibling required ptx Cephalotematoma or other significant

bruising Exclusive breastfeeding (esp if not going

well and weight loss is excessive) East Asian race

Risk factors for severe jaundice Minor risk factors

Predischarge bili in high-intermediate risk zone

GA 37-38 weeks Jaundice observed before discharge Previous sibling with jaundice Macrosomic IDM Maternal age ≥ 25 years Male gender

Risk factors for severe jaundice DECREASED risk

Pre-discharge bili in low-risk zone GA ≥ 41 weeks Exclusive bottle feeding Black race Discharge from hospital after 72 hours

Hyperbilirubinemia--prevention Pregnant women:

ABO and Rh testing Rhogam as indicated

screen for isoimmune antibodies If mom is Rh- or ABO/Rh status unknown

Check blood type, Rh, and DAT on neonate (cord blood) If DAT positive: needs frequent (q6-12hr)

checking of TSB

Jaundice--prevention

Newborn nursery: Advise mothers to nurse 8-12 times per day

for first several days Evaluate for jaundice every time vitals

taken (q8-12 hr)

Testing for jaundice

Before discharge, ALL newborns should be assessed for jaundice (2004 AAP Practice Guideline) Visual assessment

Need adequate ambient light or daylight fluorescent light

Subjective and not recommended as lone assessment More difficult in darker-complected infants

TSB (total serum bilirubin) Oftentimes drawn with metabolic screen

TcB (transcutaneous bilirubin) Method implemented at SRHC in 2010

Assessment tools

AAP bilirubin nomograms Electronically

UpToDate calculator BiliTool.org

Online calculator App for iPhone or iPod touch Palm OS

Phototherapy

Using the nomograms

Use total bilirubin (don’t subtract direct component)

Risk factors: Isoimmune hemolytic disease G6PD deficiency Asphyxia Significant lethargy Temp instability Sepsis Acidosis Albumin < 3.0 (if measured)

Exchange transfusion

Discharge and follow-up

Infant Discharged Should Be Seen By Age

Before age 24 hours old 72 hours old

Between 24 and 47.9 h 96 h

Between 48 and 72 h 120 h

Follow-up by a “qualified health care professional”typically with PCP or mid-level provider

nurse/lactation specialist home health nurse visitIf follow-up cannot be ensured, may be necessary to delay discharge

Anticipatory Guidance

Jaundice progresses head to toe, then as it resolves, disappears from toe to head

Testing for jaundice: blanch skin with finger

Call if: Jaundiced to belly button Not waking well for feeds or feeding poorly Decreased wet diapers Shrill cry

Follow-up appointment

Weight and % change from BW Adequacy of po intake Pattern of voiding and stooling Presence or absence of jaundice

+/- checking bili level If predischarge bili was high-intermediate risk, I

nearly always recheck a bili If predischarge bili was low-risk, I rarely do If predischarge bili was low-intermediate, I do if

concerns present

So . .. .you’ve reached LL.Now what? History and physical exam Laboratory testing Phototherapy Assess hydration

Laboratory evaluation

Approaching or at light level: Direct and total bilirubin Blood type and DAT CBC Peripheral smear Consider: retic count, G6PD, ETCOc Consider: UA (for reducing substances)

with culture, sepsis eval

Lab evaluation

Approaching exchange levels or not responding to phototherapy Retic, G6PD, albumin, ETCOc UA Sepsis eval

Elevated direct (or conjugated) bilirubin UA and urine culture Evaluate for sepsis if indicated by history

and physical exam

Treatment—Phototherapy

Mechanism of action: Exposes skin to light of specific wavelength

(425-475 nm/blue-green spectrum)

Converts bilirubin to lumirubin Lumirubin is more soluble than bilirubin and is

excreted without conjugation into the bile and urine

Phototherapy options

Bili blanket Home or hospital

Bili bed Home or hospital

“Bank” phototherapy Hospital only

Home vs hospital Home is an option 2-3mg/dl below LL in

infant with no risk factors and caregivers with ready access to medical care

Treatment--phototherapy

Technique—bank phototherapy Infant should wear diaper only, and diaper

should be pulled down as much as possible to increase skin exposure

“baby sunglasses” Ensure that banks of lights are at appropriate

distance from infant Infant needs to remain under lights

continuously, only to be taken out for feedings Can utilize biliblanket to continue some ptx during

feeds

Phototherapy

phototherapy typically results in a decline of TB of 2-3 mg/dl within 4-6 hours Obviously, more lights = faster decline

Recheck TB within 2-6 hours of starting ptx Then, recheck every 6-12 hours, if TB is falling If doing home therapy, need to redraw daily

Hospitalize if surpasses LL, excessive rate of rise, or other concerns develop

Phototherapy—side effects

Generally considered safe Transient erythematous rashes Loose stools Hyperthermia Increased insensible water loss Possible retinal degeneration (hence the

sunglasses) Parents/caregivers:

some models can cause HA and nausea Frustrating to not get to hold baby

“bronze baby syndrome” If used on infant with cholestasis

Management—assess hydration Maintaining adequate hydration and UOP

is important Lumirubin excreted in urine > stool

Encourage breast or bottle feeding Lactation consult prn Supplement with EBM or formula in

breastfed infants with excessive weight loss (>12%) or evidence of hypovolemia

IVF if oral intake is inadequate

Phototherapy . .. When to stop? No strict guideline

when TSB <13-14 When TSB back to, or lower-than, level at

which ptx was initiated Sometimes at lower level if started during

NB stay and treatment initiated at lower LL

Phototherapy . . . When to stop? “checking for rebound”

TB will typically re-increase by small amount (typically <1 mg/dl) after discontinuation of ptx DON’T have to keep pt hospitalized to check for

rebound, unless risk-factors present DO check in hospital or clinic the next day if:

ptx discontinued prior to 5-6 days old (may not have reached peak yet)

Other concerns For “nervous Nellie’s” (like myself): night

before anticipated discharge, check TSB. Continue ptx until 2 or 3am, then d/c. Check bili with AM labs, should see if significant rebound present

If not improving

Likely that hemolysis is occurring: Increase # banks Labs:

Retic, G6PD, albumin, ETCOc Sepsis eval UA and urine culture

Add IVF Consult pediatrician +/- neonatologist

Exchange transfusion in NICU

Lab evaluation

Jaundice preset at ≥ 2-3 weeks Total and direct bili

If direct bili elevated, evaluate for causes of cholestasis

Check NB thyroid and galactosemia; evaluate infant for signs/sx of hypothyroidism

If indirect elevated and breast-fed, potentially breast-milk jaundice

Option to give formula in place of breast milk x24 hours (controversial)

?Sunny window?

Technically. . .. NO Risk for sunburn Risk for hypo- or hyper-thermia