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Management of neonatal jaundice

Management of neonatal jaundice. Mary Waiyego KPA 2019 10 th April 2019. Outline. Introduction Challenges increasing the risk of EHB Management – phototherapy Diagnostics Complications – chronic bilirubin encephalopathy Concept of BIND Aspects of phototherapy and ELBW.

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Management of neonatal jaundice

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  1. Management of neonatal jaundice Mary Waiyego KPA 2019 10th April 2019

  2. Outline • Introduction • Challenges increasing the risk of EHB • Management – phototherapy • Diagnostics • Complications – chronic bilirubin encephalopathy • Concept of BIND • Aspects of phototherapy and ELBW

  3. Greco et al. Neonatology 2016;110:172–180

  4. Challenges leading to incidences of EHB • Ante natal screening gaps ABO and Rhesus • Screening for G6PD • Cost of anti D • Absence of rapid results testing POC and non invasive methodologies • Early discharges • Unassured follow up • Lack of effective therapy capable of giving upto 30uw/cm2

  5. In other settings • Delayed Cord Clamping • Exclusive Breast-Feeding – do we ensure adequacy before discharge, stretched systems • Late Preterm Births • Early Discharges

  6. Phototherapy –Mechanism of Actions 1. Geometric Isomerization: • (Z to E) IXα 4z15z to • 4E15z or 4E15E, etc 2. Structural Isomerization: Lumirubin 3. Photo-oxidation: • Biliverdin, dipyrroles, • monopyrroles

  7. Phototherapy – Dose related Effects • Spectral qualities of the Light source (wave length • range [400-520 nm] & Peak 460 + 10 nm] • Intensity of light (number of photons delivered per square centimetre of exposed body surface; spectral irradiance [μW/cm2/nm]) • Distance between the light and infant’s skin • Body surface area exposed • Standard phototherapy 8-10 • Intense phototherapy >30

  8. Phototherapy • Fluorescent tubes • Halogen bulbs • LED • LED • The emission spectrum is narrower. • The irradiance decreases more slowly over time. • Generate less heat

  9. Jaundice and follow up

  10. Risk factors • Sepsis • Asphyxia • Serum albumin < 3 % • G6PD deficiency • Acidosis • Iso-immune haemolysis • Temperature instability

  11. Transcutaneous Bilirubinometry • Reduce the cost of managing jaundice • Experts support TCB in light of newer, improved technology • Newer multi-wavelength • spectral reflectance correlate 0.88 with the serum value

  12. Transcutaneous Bilirubinometry

  13. Long term effects of EHB

  14. Are there more sensitive tests? – no consensus guidelines

  15. Phototherapy and ELBW • In the collaborative phototherapy trial, phototherapy reduced serum bilirubin but not NDI. • In recent Neonatal Network Trial, aggressive phototherapy compared to conservative phototherapy reduced both peak bilirubin and profound NDI at 18-22 months. • However, both trials suggested that intense phototherapy associated trends to mortality among the ELBW. • High priority should be given to developing and rigorously testing better treatment methods to reduce the serum bilirubin. Moris B H et al NEJNM 2008

  16. Is phototherapy safe for ELBW infants? • Photochemical reactions create other photoisomers analogous to lumirubins that are not easily appreciated. • Animal studies have shown phototherapy effects on VEGF levels and angiogenesis. • ELBW infants have translucent skin. • Less antioxidant properties Moris B H et al NEJNM 2008

  17. Best practices in ELBW Stevenson et al Clin Perinatol - (2016)

  18. Potentially safer treatment strategies that need evaluation in ELBW • Reduce irradiance • Narrow- spectrum LED devices • Cycled phototherapy

  19. Summary • Ability to test for bilirubin levels is essential for optimal management • Proper phototherapy equipment capable of delivering both conventional and intensive irradiance are essential • Proper follow up and linkage to care mechanism are important for early detection and institution of treatment • Wide spread use of innovative diagnostic modalities with reduced turn around time is needed • The reported burden of jaundice is still high more efforts should be directed towards reducing the trends

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