Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is...

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Michelle B. Kravitz, MD Michelle B. Kravitz, MD June 29, 2006 June 29, 2006

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Page 1: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Michelle B. Kravitz, MDMichelle B. Kravitz, MD

June 29, 2006June 29, 2006

Page 2: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Case 1Case 1

You are called by the nurse that a You are called by the nurse that a newborn’s TcB is 11.1.newborn’s TcB is 11.1.

Is this concerning?Is this concerning? What information do you need to answer What information do you need to answer

that question?that question?

Page 3: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Case 2Case 2

You are called by the ER to see an infant You are called by the ER to see an infant whose bili is 22.whose bili is 22.

Must you admit?Must you admit? What information do you need to answer What information do you need to answer

this question?this question?

Page 4: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

OutlineOutline

Review of physiologyReview of physiology KernicterusKernicterus Risk factorsRisk factors Assessing the riskAssessing the risk TherapiesTherapies

Page 5: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

BILIRUBINBILIRUBIN

Non-polar, water insoluble compound Non-polar, water insoluble compound requiring conjugation with glucuronic acid requiring conjugation with glucuronic acid to form a water soluble product that can be to form a water soluble product that can be excreted.excreted.

It circulates to the liver reversibly bound It circulates to the liver reversibly bound to albuminto albumin

Page 6: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

BILIRUBIN PHYSIOLOGYBILIRUBIN PHYSIOLOGY

Increased production in neonate due to larger red Increased production in neonate due to larger red cell volume, which produces bilirubin as cells cell volume, which produces bilirubin as cells are broken down and shorter RBC life span, so are broken down and shorter RBC life span, so broken down faster.broken down faster.

Heme is catabolized within the Heme is catabolized within the reticuloendothelial system by heme oxygenase to reticuloendothelial system by heme oxygenase to form biliverdin.form biliverdin.

Biliverdin is metabolized to bilirubin in the Biliverdin is metabolized to bilirubin in the presence of biliverdin reductasepresence of biliverdin reductase

Page 7: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

BILIRUBIN BILIRUBIN PHYSIOLOGYPHYSIOLOGY

Heme BiliverdinHeme oxygenase

Bilirubin

Biliverdin reductase

Page 8: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Bilirubin PhysiologyBilirubin Physiology

Ligandins responsible for transport from Ligandins responsible for transport from plasma membrane to endoplasmic plasma membrane to endoplasmic reticulum.reticulum.

Bilirubin conjugated in presence of Bilirubin conjugated in presence of UDPGT (uridine diphosphate glucuronyl UDPGT (uridine diphosphate glucuronyl transferase) to mono and diglucoronides, transferase) to mono and diglucoronides, which are then excreted into bile which are then excreted into bile canaliculi.canaliculi.

Page 9: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Enterohepatic CirculationEnterohepatic Circulation

Meconium contains 100-200mg of conjugated Meconium contains 100-200mg of conjugated bilirubin at birth.bilirubin at birth.

Conjugated bilirubin is unstable and easily Conjugated bilirubin is unstable and easily hydrolyzed to unconjugated bilirubin.hydrolyzed to unconjugated bilirubin.

This process occurs non-enzymatically in the This process occurs non-enzymatically in the duodenum and jejunum and also occurs in the duodenum and jejunum and also occurs in the presence of beta-glucuronidase, an enteric presence of beta-glucuronidase, an enteric mucosal enzyme, which is found in high mucosal enzyme, which is found in high concentration in newborn infants and in human concentration in newborn infants and in human milk.milk.

Page 10: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

ConjugationConjugation

Since conjugated bilirubin crosses the placenta Since conjugated bilirubin crosses the placenta very little, conjugation is not active in the fetus very little, conjugation is not active in the fetus with levels of UDPGT about 1% of adult levels with levels of UDPGT about 1% of adult levels at 30 - 40 weeks gestationat 30 - 40 weeks gestation

After birth, the levels of UDPGT rise rapidly but After birth, the levels of UDPGT rise rapidly but do not reach adult levels until 4-6 weeks of age.do not reach adult levels until 4-6 weeks of age.

Ligandins, which are necessary for intracellular Ligandins, which are necessary for intracellular transport of bilirubin, are also low at birth and transport of bilirubin, are also low at birth and reach adult levels by 3-5 days.reach adult levels by 3-5 days.

Page 11: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

CONJUGATED VS CONJUGATED VS UNCONJUNCATED UNCONJUNCATED

HYPERBILIHYPERBILI Conjugated hyperbilirubinemia is always Conjugated hyperbilirubinemia is always

pathologicpathologic When the total bili is quite high, the conjugated When the total bili is quite high, the conjugated

fraction can rise to as high as 20% of the total, fraction can rise to as high as 20% of the total, although it usually stays under 1.0.although it usually stays under 1.0.

Always check a total and direct, so that you can Always check a total and direct, so that you can be sure you are excluding conjugated be sure you are excluding conjugated hyperbilirubinemia, which has totally different hyperbilirubinemia, which has totally different etiologies and treatments.etiologies and treatments.

Page 12: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

KERNICTERUSKERNICTERUS

Why we care about indirect hyperbilirubinemiaWhy we care about indirect hyperbilirubinemia Staining of the brain by bilirubinStaining of the brain by bilirubin Early symptoms-acute bilirubin encephalopathy-Early symptoms-acute bilirubin encephalopathy-

poor feeding, abnormal cry, hypotonia, poor feeding, abnormal cry, hypotonia, Intermediate phase-stupor, irritability, Intermediate phase-stupor, irritability,

hypertoniahypertonia Late – shrill cry, no feeding, opisthotonus, Late – shrill cry, no feeding, opisthotonus,

apnea, seizures, coma, deathapnea, seizures, coma, death

Page 13: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

KERNICTERUSKERNICTERUS

Late sequelae can includeLate sequelae can includegaze abnormalitiesgaze abnormalitiesfeeding difficultiesfeeding difficultiesdystoniadystoniaincoordinationincoordinationchoreoathetosischoreoathetosissensorineural hearing losssensorineural hearing losspainful muscle spasmspainful muscle spasms

Page 14: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

KERNICTERUSKERNICTERUS

Incidence of bilirubin levels>30 1/10,000Incidence of bilirubin levels>30 1/10,000 Over 120 cases kernicterus documented since Over 120 cases kernicterus documented since

19901990 Overwhelming majority term, breastfedOverwhelming majority term, breastfed Majority of those had levels in high 30s to 40s.Majority of those had levels in high 30s to 40s. Lowest level recorded in case series of 111 from Lowest level recorded in case series of 111 from

1991-2002 was 20.7, but the mean was 38.1991-2002 was 20.7, but the mean was 38. Many cases had no planned follow up and had Many cases had no planned follow up and had

been discharged early (<48 hours).been discharged early (<48 hours).

Page 15: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.
Page 16: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

KERNICTERUS AND FREE KERNICTERUS AND FREE BILIRUBINBILIRUBIN

An article published this year in An article published this year in PediatricsPediatrics makes the case for establishing free bilirubin makes the case for establishing free bilirubin levels rather than total serum bilirubin levels to levels rather than total serum bilirubin levels to monitor jaundice and assess risk for kernicterus.monitor jaundice and assess risk for kernicterus.

Since bilirubin travels bound to albumin Since bilirubin travels bound to albumin predominantly, the free bilirubin is inversely predominantly, the free bilirubin is inversely proportional to the albumin concentration.proportional to the albumin concentration.

Page 17: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

ALBUMINALBUMIN

A low albumin level could possibly be the A low albumin level could possibly be the reason behind kernicterus occurring in some reason behind kernicterus occurring in some infants at relatively low bilirubin levels.infants at relatively low bilirubin levels.

There was a report of a 29 week infant whose There was a report of a 29 week infant whose peak bilirubin level was only 15.7 and yet peak bilirubin level was only 15.7 and yet developed classic kernicterus with spasticity, developed classic kernicterus with spasticity, dystonia, ballismus, and gaze abnormalities.dystonia, ballismus, and gaze abnormalities.

Her bilirubin/albumin molar ratio was 0.67. It Her bilirubin/albumin molar ratio was 0.67. It has been suggested that a ratio of >0.5 might be has been suggested that a ratio of >0.5 might be a threshold in sick preterm infants.a threshold in sick preterm infants.

Page 18: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

ALBUMINALBUMIN

Wenneberg et. al. suggest that an infant with an Wenneberg et. al. suggest that an infant with an albumin level of 2 would be at the same risk for albumin level of 2 would be at the same risk for kernicterus with a bilirubin of 15 as an infant kernicterus with a bilirubin of 15 as an infant with a bilirubin of 30 and an albumin level of 4.with a bilirubin of 30 and an albumin level of 4.

We do not have data on albumin levels in We do not have data on albumin levels in healthy term infants, but most likely, healthy term infants, but most likely, hypoalbuminemia is a concern in extremely hypoalbuminemia is a concern in extremely preterm or otherwise sick infants.preterm or otherwise sick infants.

Page 19: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

RISK FACTORS FOR RISK FACTORS FOR SIGNIFICANT JAUNDICESIGNIFICANT JAUNDICE

Gestational AgeGestational Age RaceRace Family history of jaundice requiring Family history of jaundice requiring

phototherapyphototherapy Hemolysis (ABO or other)Hemolysis (ABO or other) Severe bruisingSevere bruising BreastfeedingBreastfeeding

Page 20: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

TIME COURSE OF TIME COURSE OF JAUNDICEJAUNDICE

Pathologic by definition if significant Pathologic by definition if significant in first 24 hoursin first 24 hours

Usually begins to peak by 48 hours Usually begins to peak by 48 hours and continues until 96 hoursand continues until 96 hours

In Asian infants and preterm infants, In Asian infants and preterm infants, peak can continue out to 5-7 days.peak can continue out to 5-7 days.

Page 21: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

RISK FACTORS-RACERISK FACTORS-RACE

Asians-highest riskAsians-highest risk Levels peak at 16-18 as opposed to average Levels peak at 16-18 as opposed to average

Caucasian levels of 6-8. There is also a later Caucasian levels of 6-8. There is also a later peak which can occur at 5-7 days.peak which can occur at 5-7 days.

Black infants have a lower peak, rarely Black infants have a lower peak, rarely exceeding 12. (but they have a much higher exceeding 12. (but they have a much higher incidence of G6PD deficiency)incidence of G6PD deficiency)

Caucasians are in the middle.Caucasians are in the middle.

Page 22: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.
Page 23: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

RISK FACTORS-RISK FACTORS-GESTATIONAL AGEGESTATIONAL AGE

The younger the gestation, the higher the The younger the gestation, the higher the risk of jaundice.risk of jaundice.

37 weeks more prone to jaundice than 40 37 weeks more prone to jaundice than 40 weeker who is more prone than a 42 weeker.weeker who is more prone than a 42 weeker.

35 and below is much more prone35 and below is much more prone Extreme preemies also more prone to Extreme preemies also more prone to

kernicterus and are treated at much lower kernicterus and are treated at much lower levels.levels.

Page 24: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

RISK FACTORS-FAMILY RISK FACTORS-FAMILY HXHX

A child whose sibling needed A child whose sibling needed phototherapy is 12 times more likely to phototherapy is 12 times more likely to also have significant jaundice.also have significant jaundice.

Frequently peak bilirubin levels correlate Frequently peak bilirubin levels correlate between siblings.between siblings.

Page 25: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

RISK FACTORS-RISK FACTORS-HEMOLYSISHEMOLYSIS

ABO Incompatibility is the most common cause of ABO Incompatibility is the most common cause of hemolysis causing jaundice.hemolysis causing jaundice.

Only 10-20% of infants with ABO mismatch develop Only 10-20% of infants with ABO mismatch develop significant jaundice.significant jaundice.

Some of these infants, however, develop very Some of these infants, however, develop very significant jaundice quickly.significant jaundice quickly.

Coombs positive ABO is more likely to cause Coombs positive ABO is more likely to cause hemolysis, but many babies will be asymptomatic. hemolysis, but many babies will be asymptomatic. Conversely, Coombs negative ABO mismatch does Conversely, Coombs negative ABO mismatch does occasionally cause significant hemolysis, but this is occasionally cause significant hemolysis, but this is rather rare.rather rare.

Page 26: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

RISK FACTORS-RISK FACTORS-PATHOLOGICPATHOLOGIC

G6PD DeficiencyG6PD Deficiency Hereditary SpherocytosisHereditary Spherocytosis Glucuronyl Transferase Deficiency Type 1 Glucuronyl Transferase Deficiency Type 1

(Crigler Najar Syndrome)(Crigler Najar Syndrome) GT deficiency Type 2 (Arias Syndrome)GT deficiency Type 2 (Arias Syndrome) PolycythemiaPolycythemia

Page 27: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

BREASTMILK/BREASTFEEDINGBREASTMILK/BREASTFEEDING JAUNDICEJAUNDICE

Breastfeeding jaundice occurs earlyBreastfeeding jaundice occurs early It is due to the lack of breast milkIt is due to the lack of breast milk It is often associated with poor passage of It is often associated with poor passage of

meconium.meconium. Treatment should be aimed at supporting Treatment should be aimed at supporting

breastfeeding while supplementing as breastfeeding while supplementing as needed to avoid extreme weight loss, needed to avoid extreme weight loss, dehydration, and worsening jaundice.dehydration, and worsening jaundice.

Page 28: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

BREASTMILK/BREASTFEEDING BREASTMILK/BREASTFEEDING

JAUNDICEJAUNDICE Breast milk jaundice is a different, more benign entity, Breast milk jaundice is a different, more benign entity,

which tends to occur late in the first week or afterwards.which tends to occur late in the first week or afterwards. It is actually due to something in the breast milk which It is actually due to something in the breast milk which

tends to prolong jaundice.tends to prolong jaundice. Usually weight gain is good, and the baby is otherwise Usually weight gain is good, and the baby is otherwise

well.well. Jaundice might persist as late as 3-4 weeks, but usually Jaundice might persist as late as 3-4 weeks, but usually

will peak by 2 weeks.will peak by 2 weeks. Textbook treatment is to interrupt breastfeeding (I Textbook treatment is to interrupt breastfeeding (I

usually do not do this).usually do not do this).

Page 29: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

ASSESSING THE RISK OF ASSESSING THE RISK OF JAUNDICE BY THE NUMBERSJAUNDICE BY THE NUMBERSBhutani curveBhutani curve

Page 30: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.
Page 31: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

ASSESSING THE RISK OF ASSESSING THE RISK OF JAUNDICE BY THE NUMBERSJAUNDICE BY THE NUMBERS

Maisels’ and Kring’s study showed that Maisels’ and Kring’s study showed that not all early higher TcB will continue not all early higher TcB will continue going up.going up.

They divided the rate of rise to be They divided the rate of rise to be concerned with into concerned with into

6-24hr6-24hr >0.22/hr>0.22/hr 24-4824-48 >0.15/hr>0.15/hr 48+48+ >0.06/hr>0.06/hr

Page 32: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Copyright ©2004 American Academy of Pediatrics

Subcommittee on Hyperbilirubinemia, Pediatrics 2004;114:297-316

Guidelines for phototherapy in hospitalized infants of 35 or more weeks' gestation

Page 33: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

ASSESSING THE RISK OF ASSESSING THE RISK OF JAUNDICE BY THE NUMBERSJAUNDICE BY THE NUMBERS

www.bilitool.orgwww.bilitool.org

Palm downloadable! Palm downloadable!

Page 34: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

THERAPIES-THERAPIES-PHOTOTHERAPYPHOTOTHERAPY

Phototherapy has been the mainstay of treating Phototherapy has been the mainstay of treating hyperbilirubinemia since the 1960s.hyperbilirubinemia since the 1960s.

Phototherapy causes structural isomerization, Phototherapy causes structural isomerization, forming lumirubin, which is then excreted in the forming lumirubin, which is then excreted in the bile and urine.bile and urine.

Since photoisomers are water soluble, they Since photoisomers are water soluble, they should not be able to cross the blood-brain should not be able to cross the blood-brain barrier, so starting phototherapy should decrease barrier, so starting phototherapy should decrease the risk of kernicterus by turning 20-25% of the risk of kernicterus by turning 20-25% of bilirubin into a form unable to cross, even before bilirubin into a form unable to cross, even before the level has lowered significantly.the level has lowered significantly.

Page 35: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

THERAPIES-THERAPIES-PHOTOTHERAPYPHOTOTHERAPY

Bilirubin absorbs light best at 450 nm, but Bilirubin absorbs light best at 450 nm, but longer wavelenths penetrate skin better.longer wavelenths penetrate skin better.

Make sure skin is as exposed as possible Make sure skin is as exposed as possible and that light is not too far from baby.and that light is not too far from baby.

Fiberoptic light (bili blanket) is much less Fiberoptic light (bili blanket) is much less efficacious on its own. efficacious on its own.

Page 36: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

THERAPIES-EXCHANGE THERAPIES-EXCHANGE TRANSFUSIONTRANSFUSION

Double volume exchange transfusion was Double volume exchange transfusion was a common procedure prior to advent of a common procedure prior to advent of Rhogam and phototherapy.Rhogam and phototherapy.

Now fortunately a rare occurrenceNow fortunately a rare occurrence Used for bilirubin >25 in a term infant and Used for bilirubin >25 in a term infant and

not decreasing despite phototherapynot decreasing despite phototherapy

Page 37: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

THERAPIES-Sn THERAPIES-Sn MesoporphyrinMesoporphyrin

SnMP is a structural analog of hemeSnMP is a structural analog of heme It blocks the site on heme oxygenase where It blocks the site on heme oxygenase where

conversion of heme to bilirubin occurs.conversion of heme to bilirubin occurs. Still under investigation (why?)Still under investigation (why?) Administered parenterally in a small dose (6 Administered parenterally in a small dose (6

micromoles/kg)micromoles/kg) In term infants, obviated need for phototherapyIn term infants, obviated need for phototherapy Some preterm infants still needed phototherapy Some preterm infants still needed phototherapy

but none needed exchange transfusionbut none needed exchange transfusion Virtually 100% efficacyVirtually 100% efficacy

Page 38: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

THERAPIES-Sn THERAPIES-Sn MesoporphyrinMesoporphyrin

Can also be used repeatedly for patients with Can also be used repeatedly for patients with Crigler-Najar (effects last several days).Crigler-Najar (effects last several days).

StanateStanate®®-currently being patented-currently being patented Ongoing study at Children’s Hospital of Ongoing study at Children’s Hospital of

Columbus in newborns at risk of exchange Columbus in newborns at risk of exchange transfusiontransfusion

Accepting patients until September, 2006Accepting patients until September, 2006 Richard McCleod, MD, Principal InvestigatorRichard McCleod, MD, Principal Investigator 614-722-2718614-722-2718

Page 39: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Review of Case 1Review of Case 1

How old is the patient?How old is the patient? What is the gestational age?What is the gestational age? What other risk factors are present?What other risk factors are present?

– 12 hours old12 hours old– Full termFull term– ABO incompatibleABO incompatible

Page 40: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Review of Case 2Review of Case 2

How old is the patient?How old is the patient? What is the fractionation?What is the fractionation? Breast or bottle fed?Breast or bottle fed? Other risk factors?Other risk factors?

– 10 days10 days– 22 total / 0.8 direct22 total / 0.8 direct– Breast fedBreast fed– NoneNone

Page 41: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

MANAGING JAUNDICE-MANAGING JAUNDICE-TAKE HOME POINTSTAKE HOME POINTS

Consider the risk factors, particularly Consider the risk factors, particularly prematurity and hemolysisprematurity and hemolysis

Follow up is key!Follow up is key! Consider how well baby is feeding, parents’ Consider how well baby is feeding, parents’

ability to return, reliability, etcability to return, reliability, etc The higher the number of risk factors, the lower The higher the number of risk factors, the lower

the level at which to intervenethe level at which to intervene Sometimes, you will be surprised. We can’t Sometimes, you will be surprised. We can’t

always prevent hyperbilirubinemia, but we always prevent hyperbilirubinemia, but we should always prevent kernicterus.should always prevent kernicterus.

Page 42: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.
Page 43: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

REFERENCESREFERENCES

Tate, M, Neonatal Hyperbilirubinemia, Revised, Tate, M, Neonatal Hyperbilirubinemia, Revised, June 2001 in MICC Curriculum. June 2001 in MICC Curriculum.

Maisels MJ and E Kring, Transcutaneous Maisels MJ and E Kring, Transcutaneous bilirubin levels in the first 96 hours in a normal bilirubin levels in the first 96 hours in a normal newborn population of >/= 35 weeks’ gestation. newborn population of >/= 35 weeks’ gestation. Pediatrics. 2006, 117(4):1169-73.Pediatrics. 2006, 117(4):1169-73.

Wennberg et. al., Toward understanding Wennberg et. al., Toward understanding kernicterus: a challenge to improve the kernicterus: a challenge to improve the management of jaundiced newborns. Pediatrics. management of jaundiced newborns. Pediatrics. 2006, 117(2):474-485.2006, 117(2):474-485.

Page 44: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

Watchko JF, Vigintophobia revisited. Watchko JF, Vigintophobia revisited. PediatricsPediatrics, 2005, , 2005, 115(6):1747-53.115(6):1747-53.

Gourley GR et. al., A controlled, randomized, double Gourley GR et. al., A controlled, randomized, double blind trial of prophylaxis against jaundice among blind trial of prophylaxis against jaundice among breastfed newborns. breastfed newborns. PediatricsPediatrics, 2005, 116(2):385-91., 2005, 116(2):385-91.

Merhar SL and DL Gilbert, Clinical Findings and Merhar SL and DL Gilbert, Clinical Findings and Cerebrospinal fluid neurotransmitters in 2 children with Cerebrospinal fluid neurotransmitters in 2 children with severe chronic bilirubin encephalopathy, including a severe chronic bilirubin encephalopathy, including a former preterm infant without marked former preterm infant without marked hyperbilirubinemia. hyperbilirubinemia. Pediatrics, 2005, 116(5):1226-30.Pediatrics, 2005, 116(5):1226-30.

Page 45: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

M Herschel et. al., Isoimmunization is unlikely M Herschel et. al., Isoimmunization is unlikely to be the cause of hemolysis in ABO-to be the cause of hemolysis in ABO-incompatible but direct antiglobulin test-negative incompatible but direct antiglobulin test-negative neonates. neonates. Pediatrics.Pediatrics. 2002, 110(1):127-30. 2002, 110(1):127-30.

LD Eggert et. al., The effect of instituting a LD Eggert et. al., The effect of instituting a prehospital-discharge newborn bilirubin prehospital-discharge newborn bilirubin screening program in an 18-hospital health screening program in an 18-hospital health system. system. Pediatrics. Pediatrics. 2006, 117(5):e855-62.2006, 117(5):e855-62.

Page 46: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

A Kappas, A method for interdicting the A Kappas, A method for interdicting the development of severe jaundice in newborns by development of severe jaundice in newborns by inhibiting the production of bilirubin. inhibiting the production of bilirubin. PediatricsPediatrics. . 2004, 113(1)119-23.2004, 113(1)119-23.

D Alexander, Commentary on “A method for D Alexander, Commentary on “A method for interdicting the development of severe jaundice interdicting the development of severe jaundice in newborns by inhibiting the production of in newborns by inhibiting the production of bilirubin. bilirubin. Pediatrics.Pediatrics. 113(1):135. 113(1):135.

Page 47: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

J Grupp-Phelan et. Al., Early newborn hospital J Grupp-Phelan et. Al., Early newborn hospital discharge and readmission for mild and severe discharge and readmission for mild and severe jaundice. jaundice. Arch Pediatr Adolesc Arch Pediatr Adolesc Med.Med. 1999;153:1283-1288.  1999;153:1283-1288.

P Goevaert et. al. Changes in globus pallidus P Goevaert et. al. Changes in globus pallidus with pre(term) kernicterus. with pre(term) kernicterus. Pediatrics. 2003, Pediatrics. 2003, 112 112 (6): 1256-1263.(6): 1256-1263.

S Ip et. al. An evidence-based review of S Ip et. al. An evidence-based review of important issues concerning neonatal important issues concerning neonatal hyperbilirubinemia. hyperbilirubinemia. Pediatrics.Pediatrics. 2004, 2004, 114(1):e130-153.114(1):e130-153.

Page 48: Michelle B. Kravitz, MD June 29, 2006 Case 1 You are called by the nurse that a newborn’s TcB is 11.1. You are called by the nurse that a newborn’s TcB.

T WR Hansen, Neonatal Jaundice. T WR Hansen, Neonatal Jaundice. eMedicine.com/ped/topic1061.htm, eMedicine.com/ped/topic1061.htm, updated June 8, 2006.updated June 8, 2006.


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