Jaundice - mmc.sbmu.ac.ir

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Transcript of Jaundice - mmc.sbmu.ac.ir

late preterm • • ,Rh or ABO (G6PD) deficiency • hereditary spherocytosis
: •
The best method for predicting hyperbilirubinemia is a timed total serum bilirubin (TSB) measurement, analyzed in the context of an infant’s gestational age and direct antibody test (DAT)
• Transcutaneous bilirubin (TcB) can be used as an initial screening tool
Alerting Signs:
• All infants at 24-48h of age
• Before discharge from hospital when they are less than 24 h old
For these at-risk infants, entry into the Jaundice Sequence occurs when the screening bilirubin value is known
Infants with risk factors for hemolysis or who present with visible jaundice before 24 h of age require a
bilirubin measurement sooner
Infants at increased risk for severe hyperbilirubinemia include:
• Late-preterm infants (34 to 36 w) who are discharged within 48 h of birth
• Infants born to mothers with known RBC antibodies
• Infants with significant bruising or cephalohematoma
• Infants of Asian, Middle Eastern, and Mediterranean backgrounds
• Infants with a sibling who had severe hyperbilirubinemia
Visible jaundice
• Jaundice may be noticeable with bilirubin at 85 μmol/L, but it can also remain undetected at levels as high as 204 μmol/L, even by experienced clinicians
• False negative assessments: In late preterm newborns and early discharge and in infants with darker skin tones
• Bilirubin levels should be measured by TcB or TSB in all infants with visible jaundice
Bilirubin at treatment level • Phototherapy thresholds
• Exchange transfusion thresholds
• Predictive nomogram for hyperbilirubinemia
For infants born at less than 35 weeks gestation, GA-specific phototherapy graphs are required to direct management
Phototherapy thresholds (term and late preterm infants)
Exchange transfusion thresholds(term and late preterm infants)
Predictive nomogram for hyperbilirubinemia
Bilirubin is below the phototherapy threshold
Bilirubin is at or above the phototherapy threshold and below the exchange transfusion threshold
Phototherapy treatment
• Breastfeeding should be continued as infants receive phototherapy
• Supplemental fluids: should only be administered to infants who are at exchange transfusion threshold
• The goal of treatment is to maximize the rate of bilirubin clearance to prevent or minimize the neurotoxic effects of severe hyperbilirubinemia
Bilirubin is at or above the exchange transfusion threshold
Volume expansion
• Supplemental fluids can markedly reduce the frequency of exchange transfusions in infants whose bilirubin levels are near or at exchange levels, even when they are not obviously dehydrated
• An IV bolus of 10 mL/ kg 0.9% NaCl (normal saline) is administered initially, followed by a continuous dextrose infusion to supplement feeding
BIND Score
Intensive phototherapy
Irradiance greater than 30 μW/cm2/nm should be administered to infants at higher risk: • DAT-positive • Suspected to hemolysis • TSB at or above the exchange transfusion
• Infants with a positive DAT who are at or progressing to exchange transfusion levels despite intensive phototherapy may benefit from IVIG at a dose of 1 g/kg
• Level 3 consultation and direction before initiating this treatment is essential
Intravenous immunoglobulin
Next Steps
History: Antepartum
• Blood group incompatibility or maternal RBC antibodies
• Evidence of hemolysis, fetal anemia studies, or intrauterine transfusions
• Intrauterine maternal infection
•Family history of inherited disorders causing jaundice
• Splenectomy
• Preterm or late preterm gestation
• Instrumented delivery, cephalohematoma, excessive bruising
• Poor feeding, decreased urine or stool output, or other signs of dehydration
Focused physical examination
Extent of jaundice
• Hydration status, intake and output, and fluid requirements:
Current weight compared with birth weight and percentage of weight loss
Feeding frequency, eagerness to feed, latch and suck, duration of feeds
Frequency of wet diapers, absence of (or excessive) stool output
• Presence of hepatosplenomegaly, ecchymosis, or petechiae
• Presence of cephalohematoma, excessive bruising
• Neurologic signs
Blood work
• Blood group-type: mother and infant
• Reticulocytes: may indicate ongoing hemolysis
• An elevated white cell count or left shift may be seen in jaundice associated with infection
• A low serum albumin: increase risk for neurotoxicity by increasing free unconjugated bilirubin
• Serum albumin level: when bilirubin at or above exchange level, and in cases of hyperbilirubinemia in extremely premature infants
Specific Diagnosis and Management