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Hyperbilirubinemia

Hyperbilirubinemia. By Nikette Neal, MD. Definition. Hyperbilirubinemia, also known as jaundice, is a yellowing of the skin and eyes secondary to the build up of bilirubin. Epidemiology. 60% of term newborns develop jaundice 1% of which were hospitalized for phototherapy

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Hyperbilirubinemia

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  1. Hyperbilirubinemia By Nikette Neal, MD

  2. Definition • Hyperbilirubinemia, also known as jaundice, is a yellowing of the skin and eyes secondary to the build up of bilirubin.

  3. Epidemiology • 60% of term newborns develop jaundice • 1% of which were hospitalized for phototherapy • There is a higher incidence of jaundice in infants of East Asian, American Indian, and Greek descent • There is a lower incidence in Black Americans • There is a higher incidence in males. • Risk of jaundice is inversely proportional with gestational age.

  4. Etiology • Jaundice is caused by a combination of 2 factors: • Increased bilirubin production secondary to the breakdown of erythrocytes. Fetal RBCs occur in larger quantities and have a shorter half life. • Immature production of proteins by the liver. This causes decreased levels of ligandin, a binding protein, and glucoronyltransferase, a conjugating enzyme. • Pathological jaundice may be due to hemolysis, infections, or hereditary disease

  5. Risks

  6. Signs and Symptoms • Neonatal jaundice may present as a yellowing of the skin and eyes that may become more apparent upon blanching. There is usually a cephalocaudal progression • In more severe cases, the newborn may also have drowsiness, decreased urine and stool output, changes in muscle tone, or seizures. • Note: It is important to also check for signs of hemolysis including hepatosplenomegaly, bruising, petechiae, etc.

  7. Differentials • Breastfeeding jaundice • Breast milk jaundice • Biliary Atresia • Hemolytic disease of the newborn • Hypothyroidism • Duodenal atresia • G6PD • CMV infection • Cholestasis • Dubin-Johnson Syndrome • Polycythemia • Hepatitis B

  8. Tests and Diagnosis • Bilirubin may be measured using • Transcutaneous bilirubinometry • Total serum bilirubin level • Additional studies may include • Blood type and Rh • Direct Coombs test • Hemoglobin and hematocrit • Direct bilirubin • LFTs and TFTs

  9. Bilirubin Nomogram All bilirubin levels should be plotted to determine the patient’s risk for further investigation.

  10. Treatment • Often, improving oral intake can lead to a decrease in bilirubin levels • This is especially true in breastfed infants • For patients who meet requirements for treatment there are two main therapies: • Phototherapy • Exchange transfusion • Bilitool is a resource endorsed by the AAP to help determine the need for further treatment. • www.BiliTool.org

  11. Phototherapy Nomogram For patients with elevated bilirubin levels or risk factors, this nomogram may be used to determine the need for phototherapy.

  12. Exchange Transfusion Nomogram For patients who exceed the requirements for phototherapy this nomogram may be used to determine the need for exchange transfusion.

  13. AAP Jaundice Guidelines • Promote and support successful breastfeeding • Establish nursery protocols- include circumstances in which nurses can order a bilirubin • Measure TSB or TcB if jaundiced in the first 24 hours • Visual estimation of jaundice can lead to errors, particularly in darkly pigmented infants • Interpret bilirubin levels according to the infants age in hours

  14. AAP Jaundice Guidelines • Infants <38 weeks are high risk, particularly if breastfed • Perform risk assessment prior to discharge • Give parents written and oral information • Provide appropriate follow up based on time of discharge and risk assessment • Treat newborns with phototherapy or exchange transfusion when indicated

  15. References • AAP. Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant >35 weeks of Gestation. Pediatrics. 2004;114:297 • Keren R. Diagnosis and Management of Neonatal Hyperbilirubinemia in Term and Late Preterm Infants. Center for Pediatric Clinical Effectiveness • Huang MJ, Kua KE, Teng HC, Tang KS, Weng HW, Huang CS. Risk factors for severe hyperbilirubinemia in neonates. Pediatr Res. Nov 2004;56(5):682-9.

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