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Neonatal Hyperbilirubinemia

Neonatal Hyperbilirubinemia. Jaundice. Yellowish discoloration of skin +/- sclera of newborns due to bilirubin Affects nearly all newborns Peak: 48-120 hours, typically 5-6 mg/dL, usually does not exceed 17-18 mg/dL

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Neonatal Hyperbilirubinemia

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  1. Neonatal Hyperbilirubinemia

  2. Jaundice • Yellowish discoloration of skin +/- sclera of newborns due to bilirubin • Affects nearly all newborns • Peak: 48-120 hours, typically 5-6 mg/dL, usually does not exceed 17-18 mg/dL • Pathologic: TSB exceeds age (in hours) specific 95th percentile according to Bhutani nomogram

  3. Effects of hyperbilirubinemia • Bilirubin toxicity • Toxicity due to unbound (free) form • Focal necrosis of neurons and glia • Acute bilirubin encephalopathy • Chronic= kernicterus • Most often affects basal ganglia and brainstem nuclei • Movement disorders • Impaired upward gaze • Auditory abnormalities

  4. Effects • Bilirubin toxicity • At risk when TSB > 25-30 mg/dL • Premature and sick infants • Albumin level • Drugs- silfisoxazole, moxalactam, ceftriaxone • Acidosis • Near term (35-37) weeks • Breast fed • Hemolytic disease • Discharge before 48 hours

  5. Manifestations • Phase one- 1st few days • Lethargy, hypotonia, poor suck, high pitched cry • Phase two- end of 1st week • Irritable, hypertonia, retrocollis, opisthotonus • Phase three- after 1st week • Stupor, coma, shrill cry

  6. Evaluation • Transcutaneous bilirubin • Total serum bilirubin • End-tidal carbon monoxide • Blood type, direct Coombs test • CBC, peripheral blood smear • Reticulocytes, G6PD screen • Serum albumin

  7. Special circumstances • Jaundice in 1st 24 hours • Frequently due to hemolysis • Require immediate evaluation and close surveillance • Other reasons for increased bilirubin production • Cephalohematoma, extensive bruising, conjugation disorders

  8. Management • Phototherapy • Mechanisms • Structural isomerization • Photoisomerization • Photo-oxidation • Irradiance • Initiation if bilirubin exceeds the 95th percentile for hour-specific TSB concentration and risk category

  9. Risk categories-phototherapy • Lower risk: at least 38 weeks gestation, no risk factors • >12 mg/dL at 24 hours, >15 mg/dL at 48 hours, >18 mg/dL at 72 hours • Medium risk: at least 38 weeks with risk factors or 35-38 weeks without risk factors • >10 mg/dL at 24 hours, >13 mg/dL at 48 hours, >15 mg/dL at 72 hours • Higher risk: 35-38 weeks with risk factors • >8 at 24 hours, >11 at 48 hours, >13.5 at 72 hours

  10. Management • Rate of decline of TSB • Irradiance • Surface area • Initial TSB • Discontinuation • TSB level below 95th percentile for age • Is less than 13 mg/dL

  11. Management • Exchange transfusion • Hyperbilirubinemia unresponsive to phototherapy • Especially useful with immune-mediated hemolysis • Removal of circulating antibodies and sensitized RBCs • For TSB > 25 mg/dL • Presence of bilirubin neurotoxicity

  12. Risk categories- exchange transfusion • Lower risk: at least 38 weeks gestation, no risk factors • >19 mg/dL at 24 hours, >22 mg/dL at 48 hours, >24 mg/dL at 72 hours • TSB/Albumin>8.0 • Medium risk: at least 38 weeks with risk factors or 35-38 weeks without risk factors • >16.5 mg/dL at 24 hours, >19 mg/dL at 48 hours, >21 mg/dL at 72 hours • TSB/Albumin>7.2 • Higher risk: 35-38 weeks with risk factors • >15 at 24 hours, >17 at 48 hours, >18.5 at 72 hours • TSB/Albumin>6.8

  13. Summary • Assess for jaundice every 8-12 hours • Assess risk factors • If discharging, appropriate follow-up is necessary • Treatment should be initiated immediately upon identifying significant hyperbilirubinemia

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