Neonatal Hyperbilirubinemia
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Transcript Neonatal Hyperbilirubinemia
Neonatal
Hyperbilirubinemia
Topic Sections
General
Information
Screening Techniques
Treatment
Follow-up Care
Systematic Prevention of Kernicterus
Presentation Objectives
Following the presentation, discussion and reading, the participant will be able to:
Describe the most common causes of neonatal hyperbilirubinemia;
Differentiate between physiologic and pathologic jaundice;
List 5 factors which increase an infants risk of excessive hyperbilirubinemia;
Discuss the differences between breast milk jaundice and breastfeeding
jaundice;
Demonstrate accurate lactation assistance to mothers exclusively
breastfeeding;
Identify signs of worsening Acute Bilirubin Encephalopathy;
Describe the components of a systematic evaluation, universal screening and
assessment;
Implement hyperbilirubinemia decision making nomogram with infants 35 weeks
gestation or more;
Describe nursing responsibilities when caring for an infant receiving
phototherapy;
Provide discharge teaching regarding the risk of excessive hyperbilirubinemia;
Describe appropriate follow-up for infants discharged at less than 72 hours of
age; and
List 5 root causes of excessive hyperbilirubinemia and 2 interventions to
prevent each.
General Information
Overview
Most newborn infants experience some degree of
jaundice
Most jaundice is benign, but because of the
potential for bilirubin toxicity, newborn infants
must be monitored to identify those at risk for
excessive hyperbilirubinemia, treated
appropriately and followed-up by experienced
perinatal health care professionals.
125 case reports have been filed since 1982. This
represents an under-reporting since Acute
Bilirubin Encephalopathy and Kernicterus are not
mandatory reporting diagnosis and many
providers do not diagnose these problems.
Neonatal Intensive Care Vol3,June 2000
Definitions
Hyperbilirubinemia is an increase in the serum bilirubin
characterized by jaundice
Bilirubin
Unconjugated (indirect acting)
Conjugated (direct acting)
Jaundice is an yellowish
discoloration of the skin,
sclera and mucous membranes which is rarely
perceptible until the serum
bilirubin level exceeds 7.0 mg/dl
Acute Bilirubin Encephalopathy: clinical nervous
system findings caused by bilirubin toxicity
Kernicterus: chronic, permanent clinical sequelae of
bilirubin toxicity
Hyperbilirubinemia
Types of Hyperbilirubinemia
Physiologic
Pathologic
Hemolytic Disease
– Rhesus Incompatibilities
– ABO Incompatibilities
Neonatal Sepsis
“Breast Milk” Jaundice
Hyperbilirubinemia
Physiologic Jaundice
increase
in bilirubin by the second day of
life
declines by the fifth day of life
onset and resolution maybe delayed in
premature infants (5 and 14 days,
respectively)
Hyperbilirubinemia
Pathologic Jaundice
Apparent jaundice in the first 24 hours of life
Total serum bilirubin levels increasing by more than
5 mg/dl per day
Total bilirubin levels > 12.5 to 15 mg/dl
Direct (conjugated) levels >1.5 - 2.0 mg/dl
Persistent jaundice (beyond the first week of life in
the full term infant or second week in the preterm
infant)
Hepatitis, biliary atresia, Down syndrome,
hypothuroidism, breast milk inhibitors, etc.
Neonatal Jaundice
Predominant Factors
Gestation, Feeding, Weight loss, Race
Increase Unconjugated (Indirect) Bilirubin
Increased formation / synthesis
Decreased uptake
Decreased conjugation
Decreased elimination
Increase Conjugated (Direct) Bilirubin
Decreased excretion of bilirubin Mono/Diglucuronide
Unconjugated Hyperbilirubinemia
Synthesis
Overload
– Polycythemia
– Organ hemorrhage
– Swallowed maternal blood
Hemolysis
–
–
–
–
Rh, ABO, others
Abnormal RBC morphology
RBC enzyme deficiencies
Sepsis
Abnormal hepatic conjugation and secretion
Conjugation: Type I, II Crigler-Najar
Secretion
- Hypothyroidism
- Galactosemia
- Rare metabolic causes
Unconjugated Hyperbilirubinemia
Increased Enterohepatic Circulation
Pyloric stenosis
Small/Large Bowel Obstruction
Prematurity
Decreased glucoronyl transferase in liver
Decreased serum albumin
Hemolysis
Sepsis
Hypoxemia
Hypothermia
Drug therapy
Hyperbilirubinemia
Bilirubin - Albumin Binding: Conjugation
conjugated bilirubin can not pass the
blood-brain barrier
factors preventing conjugation
prematurity
hypoproteinemia
acidosis (respiratory or metabolic)
neonatal depression
medications: oxytocin, sulfa, diazepam
exchange transfusion
Bone marrow
RBCs
Hgb
RETICULOENDOTHELIAL
SYSTEM (RES)
Hgb
heme
oxygenase
Globin
+
Heme
Globin
Biliverdin
Heme precursors
Myoglobulin
Non-hgb heme proteins
Biliverdin
reductase
Kidney
Bilirubin
Fe
+
Por phogens
Liver
Fe
SHUNT PATHWAY
Bilirubin-Albumin Complex
uptake
ENTEROHEPATIC CIRC
Cytoplasmic
protein
binding
Smooth
endoplasmic
retic ulum
Conj ugated
bilirubin
Urine
urobilinogen
excretion
Hydrolysis
Bilirubin
Intestine
Urobilinogen
Stercobilin
Breast Feeding and Jaundice
Breastfeeding is considered one of the most important risk
factors for hyperbilirubinemia. Exclusive breastfeeding is
most strongly associated with increased risk of jaundice
Breast fed infants are 3 times more likely to have
TSB >12mg/dL than formula fed infants
Bilirubin levels peak later in breastfed infants
1/3 of all breastfed infants are clinically jaundiced beyond
2 weeks of age
Despite the increased risk, exclusive breastfeeding is still the
recommended feeding choice of the AAP
Goal is to optimize breastfeeding, hydration and nutrition
while observing for signs of excessive hyperbilirubinemia
Breast Feeding and Jaundice
Breast Feeding Jaundice (physiologic)
Early onset
Significant institutional variation
Frequency and effectiveness of nursing
“Starvation/Dehydration”
Breast Milk Jaundice (dysfunctional)
Later onset (10-14 days)
Universal
Familial
Gaining weight, thriving
Prolonged (~ 2-3 months)
Gradual Decline
Differences in Total Serum Bilirubin Levels by Feeding Method
Number of Infants
140
Breast
Bottle
120
100
80
60
40
20
0
0
2
4
6
8 10 12 14 16 18
Maximum Total Bilirubin Concentration mg/dl
Is Breastfeeding Really Favoring Early Neonatal Jaundice?
n= 2174, 37wks
TSB in jaundiced infants during first days of life
Type of feeding, method of delivery,Wt loss,
maternal and neonatal risk factors assessed
5.1% of infants exceeded bilirubin levels of
12.9mg/dL
Average Bilirubin Peak Levels
Breastfed exclusively: 10.3 mg/dL +/- 2.5
Mixed feedings: 10.8 mg/dL +/- 2.2
Bottle-fed exclusively: 11.0 mg/dL +/- 4.5
G. Bertini,MD; C.Dani,MD; M. Tronchin,PhD;F. Rubalteli,MD
PEDIATRICS Vol.107 March 2001
Is Breastfeeding
Really Favoring
Early Neonatal
Jaundice?
G. Bertini,MD; C.Dani,MD; M. Tronchin,PhD;F. Rubalteli,MD
PEDIATRICS Vol.107 March 2001
Support for Breastfed Infants
Support optimal breastfeeding
Infant to breast immediately after birth
Infant and mothers remain physically together 24 hours a day
Breastfeeding 8-12 times per day
Avoid supplementation unless medically indicated, ordered by physician and
consented to by mother
Educate mother on signs of effective breastfeeding: good latch, audible
swallows, changes in breast after feeding, appropriate voiding and stooling
for age in days, appropriate weight changes (total weight loss < 7%, regain
birthweight by 5-7 days of life, gaining 20-30 grams/day after return to
birthweight)
Provide lactation consultation, referrals and support
Observe for signs of hyperbilirubinemia and screen appropriately
If clinical course requires supplementation or interruption of
breastfeeding ensure maintenance of mothers milk by regular emptying
of the breast. Do not supplement with water or dextrose water. Consider
supplementation with expressed breast milk or formula.
Conjugated Hyperbilirubinemia
Cause
Hepatocellular disturbance
Primary Hepatitis
Toxic Hepatitis
Hematologic Disorders
Metabolic disorders
Ductal disturbance
Extra/Intra Hepatic Biliary Atresia
Alagille Syndrome
Cystic Disease
Bile plug syndrome
Tumors of the liver and biliary tract
Conjugated Hyperbilirubinemia
Evaluation
Consider transfer to NICU and consultation with
Neonatologist, Gastrenterologist, Hematologist
Liver function tests
Hematologic tests
Tests for infectious Disease
Urine tests
Liver Biopsy
Ultrasound
Acute Bilirubin Encephalopathy (ABE)
Acute clinical nervous system manifestations of bilirubin toxicity
Early
Intermediate (anecdotal evidence suggests emergent exchange
transfusion at this stage may reverse the CNS changes)
Severe jaundice
Lethargy
Hypotonia
Poor suck
Moderate stupor
Irritability
Hypertonia: backward arching the neck (retrocollis) or the truck (opisthotonus)
Fever
High-pitched cry
Hypertonia alternating with drowsiness and hypotonia
Advanced (CNS damage is most likely irreversible at this point)
Pronounced retrocollis-opisthotonus
Shrill cry
No feeding
Apnea, deep stupor to coma
Fever
Seizures, Death
Kernicterus
Chronic, permanent clinical sequelae of bilirubin toxicity
Resulting from deposits of unconjugated bilirubin within the
brain.
Visualized as yellow staining of basal ganglia,
hippocampus, geniculate bodies, brain stem nuclei and
cerebellum
Causing neuronal necrosis
Bilirubin levels at which kernicterus occurs vary depending
on the presence of hemolytic disease and gestational age
No “safe” levels of bilirubin have been identified
Thought to be highly preventable in most cases
Kernicterus
Full-Term: associated with severe hyperbilirubinemia
Preterm: may occur at low bili levels
Risk Factors
Peak bilirubin level
Duration of hyperbilirubinemia
Bilirubin: Albumin ratio
Signs and symptoms
Early signs as seen in Advanced ABE are possible
Late Signs
–
–
–
–
–
Athetoid cerebral palsy
Auditory dysfunction
Dental enamel dysplasia
Paralysis of the upward gaze
Less frequently: Intellectual and other handicaps
Screening & Evaluation
Risk Factors for Severe Hyperbilirubinemia
Jaundice in first 24 hrs of life
Previous jaundiced sibling with phototherapy
Visible jaundice before discharge
35-38 weeks gestation
Exclusive breastfeeding
East Asian race
Cephalhematoma, Bruising
Maternal age 25y
Male sex
Assessment
Suggest
hemolytic disease
Family history
Jaundice < 24hrs
Bilirubin > 0.5mg/dL/hr
Pallor, hepatosplenomegaly
Rapid after 24-48hrs (G6PD)
Ethnicity (G6PD)
Phototherapy failure
Differential Diagnosis
Clinical signs suggesting the possibility of other
diseases such as Sepsis, Galactosemia
Vomiting
Lethargy
Poor feeding
Hepatosplenomegaly
Excessive wt. loss
Apnea
Tachypnea
Temperature instability
Signs of cholestatic jaundice, biliary atresia, others
Dark urine, or positive for Bilirubin
Light-colored stools
Persistent jaundice for > 3wks
Hyperbilirubinemia
Laboratory Evaluation
Prenatal maternal blood
type
Rh negative or Type
unknown: Neonatal blood
type, Direct Coombs
Save cord blood (Type O
mothers or Rh negative)
Serum bilirubin levels
(direct and indirect)
CBC
differential
platelets
reticulocyte count
Further Evaluation
Cord blood serology
Smear morphology
Sepsis work-up
blood cultures
CSF evaluation
G6PD
Hemoglobin
electrophoresis
Hematology
consultation
The Value of First-Day Bilirubin Measurement in Predicting the Development
of Significant Hyperbilirubinemia in Healthy Term Newborns
SBL in the First 24hrs
of life
Cases with Peak SBL
<20mg/dLafter72hrs of
age(n)
< 6mg/dL(n=292)
292
6mg/dL(n=206)
192
Cases Requiring
Phototherapy
Treatment with a
Peak SBL
20mg/dL after
72hrs of age(n)
0
Sensitivity
(%)
Specificity
(%)
Positive
Predictive
Value (%)
Negative
Predictive
Value
100
60
6.7
100
14
F. Alpay,MD;U. Sarici,MD; H. Tosuncuk,MD, N. Inanc,phD,E. Gokcay,MD
PEDIATRICS Vol.106, August 2000
Predictive Ability of Predischarge Hour-specific Serum Bilirubin for Subsequent
Significant Hyperbilirubinemia in Healthy Term and Near Term Newborns
n=13,003, Coombs negative, 60% breastfeeding
TSB with newborn screening
Percentile-based bilirubin nomogram
6.1% High-Risk Zone
32.1% Intermediate-Risk Zones
61.8% Low-Risk Zone
V. Bhutani,MD; L.Johnson,MD; E.Sivieri,MS
PEDIATRICS Vol.103 January 1999
Predictive Ability of Predischarge Hour-specific Serum Bilirubin for Subsequent
Significant Hyperbilirubinemia in Healthy Term and Near Term Newborns
PEDIATRICS Vol.103 January 1999
Noninvasive Measurement of Total Serum Bilirubin in a Multiracial Predischarge
Newborn Population to Assess the Risk of Severe Hyperbilirubinemia
n
= 490 (59%W, 29%B, 3.5%H, 4.5A, 3.5% others)
12-98 hrs, BW 2000-5665gms, 35-42wks
TSB range = 0.2 - 18.2mg/dL
TcB in 2 institutions, 11 devices
BiliCheck device (spectRx Inc, Norcross,GA)
V. Bhutani,MD; G.Gourley,MD; S. Adler,MD; B. Kreamer,BS, L. Johnson,MD
PEDIATRICS Vol.106 No.2 August 2000
Transcutaneous Bilirubin Measurement:
A Multicenter Evaluation of a New Device
n = 210 infants (140W, 31A, 14H, 9 B, 16 other)
6 European hospitals
Less than 28 days old , greater than 30 weeks
gestation
Co. Coefficient 0.89 (95% C.I.)
Analysis covariance: transcutaneous bilirubin
measurement accurate independent of race,
birthweight, gestational age, chronological age
TCB reliable substitute of TSB (better in higher level)
BiliCheck (BC SpectRx Inc, Norcross,GA)
F. Rubaltella,MD;G. Gourley,MD;N. Loskamp,MD,N. Modi,MD;P. Vert,MD
PEDIATRICS Vol..107, June2001
1
Indirect Serum Bilirubin Concentration
and Its Relation To The Progression
of Dermal Icterus in Full-Term Infants*
2
Bilirubin (mg/100 mL)
Dermal
Zone
5
3
5
1
2
3
4
5
Mean ± SD
5.9 ± 0.3
8.9 ± 1.7
11.8 ± 1.8
15 ± 1.7
Range
4.3 ± 7.9
5.4 ± 12.2
8.1 ± 16.5
11.1 ± 18.37
>15
Observations
13
49
52
45
29
4
*Includes all infants whose rate of serum bilirubin rise was 0.7
mg/dL /h or less.
5
Dermal Zones of J aundice
Evaluation
Assess risk factors first
Assess for jaundice every
8-12 hours
Standing orders for RN to
perform TCB or order
TSB if jaundice noted on
first day, is more severe
than expected for age in hours or increasing rapidly
Plot TCB of TSB findings on nomogram
Assess risk zone, or change in risk zones
BIND Score
Treatment
Treatment
Goals
Prevention of kernicterus
Treatment of underlying conditions
Maintenance of hydration and nutrition
Interventions
Intensive Phototherapy
Adjuct therapies
– Albumin
– Hydration
– Other Medications
Exchange transfusion
Phototherapy
Indication for early phototherapy
Bilirubin rising faster than 0.5mg/dL/hr or 5mg/dL/d
Persistent, severe metabolic or respiratory acidosis
Sepsis
Sick VLBW infants
Indication for photherapy in infants >35 weeks gestation
AAP: Clinical Practice
Guideline: Management
of Hyperbilirubinemia in
the Newborn Infant 35 or
More Weeks Gestation,
July 2004
Phototherapy
Mechanism of action
Skin exposure to lights causing geometric photoisomerization and
bilirubin photooxidation allowing diffusion and albumin binding
Not useful in neonates with elevated conjugated bilirubin
Technique
Light source
–
–
–
–
banks, spotlights, fiber optic blankets, LED
white, blue, green
wave length: 420-500nm
irradiance > 5 uW/sq cm/nm or change bulbs every 2000 hours
Positioned 15-20cm above infant
Largest surface area possible exposed
Intermittent vs. Continuous: current evidence does not allow
recommendations
Special Blue
Vita Lite
550
600
350
400
450
500
400
450
500
550
600
350
350
400
450
500
550
600
Blue
350
400
450
500
550
600
400
450
500
550
600
350
350
400
450
500
550
600
Daylight
Tungsten-halogen
Wavelength (nm)
Gr een
Phototherapy Precautions
Ensure patent airway
Maintain constant body temperature by using incubator and Neutral Thermal
Environment. Assess temperature every 4-8 hours
Maintain fluid balance by increasing intake and minimizing loss (insensible,
respiratory, GI)
Cover eyes and genitalia
Assure skin integrity
frequent diaper changes
water baths
no lotions or oils on skin
position to avoid skin irritation
Careful technique when repeatedly drawing labs
Consider use of automatic lancet
Warm foot before procedure
Avoid areas of previous puncture
Provide comfort measures before and during procedure (swaddling, sucrose)
Complications of Phototherapy
Dehydration
increased insensible water loss
loose stools
Irritability or lethargy
Skin rashes
Overheating
Retinal injury
Adverse effect on cell growth
Oxidize essential fatty acids, decreases vitamins
and calcium in premature infants
Tanning/Bronze Baby Syndrome
Home Phototherapy
AAP Guidelines
Healthy full term infant
Greater than 48 hrs. old
TSB between 14 and 20mg/dL
No direct hyperbilirubinemia.
No history or signs of hemolysis
Rate of bili increase <1mg/dL in 3-4hrs
Pharmacologic Treatments
Phenobarbital
Accelerates metabolic pathways for bilirubin
clearance
Tin-mesoporphyrin
inhibits heme oxygenase
IV
gamma globulin
inhibits hemolysis
Act.
Charcoal
binds bili in the intestine
Exchange Transfusion
Procedure
Transfer care to Neonatologist and NICU
Complications
Thrombocytopenia
Portal vein thrombosis/perforation
Necrotizing Enterocolitis
Cardiac arrythmias
Hypo- Calcemia, magnesemia, glycemia
Respiratory & metabolic accidosis
HIV, Hepatitis B & C infection
Exchange Transfusion
Indication in infants 35 weeks gestation or more
AAP: Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn
Infant 35 or More Weeks Gestation, July 2004
Future Issues and Therapies
Predicting
Hyperbilirubinemia using
transcutaneous bilimeters, ETCO (exhales
carbon monoxide)
Registry to report cases of excessive
hyperbilirubinemia ( 20mg/dL) and poor
neurologic outcome
Metalloporphyrin for high producers
Gene therapy for conjugation defect
Follow-up Care
Follow-up Care
Plan based on
Age in hours at discharge
Risk of excessive hyperbilirubinemia
Availability and reliability of follow-up
Components
Written discharge instructions regarding
hyperbilirubinemia, breastfeeding, dehydration
Time specific appointment based on age in hours at
discharge and risk factors
–
–
–
–
Infant < 24 hours old: should be seen by 72 hours of age
Infant between 24-47.9 hours old: seen at 96 hours of age
Infant between 48-72 hours old: seen at 120 hours of age
Infant >72 hours old at discharge: physician’s discretion
Follow-up resources for lactation support
Systematic Prevention
Overview
System
failures associated with identifying
and treating severe hyperbilirubinemia
Root causes related to four patient care
processes:
Patient Assessment
Continuum of Care
Patient & Family Education
Treatment
Root Causes Identified
Patient Care Related
The unreliability of the visual assessment of jaundice in newborns with dark
skin.
Failure to recognize jaundice in the infant –or its severity– based on visual
assessment, and measure a bilirubin level before the infant’s discharge from
the hospital or during a follow-up visit.
Failure to measure the bilirubin level in an infant who is jaundiced in the first
24 hours.
Continuum of Care
Early discharge (<48 hours) with no follow-up within one to two days of
discharge.
Failure to provide early follow-up with physical assessment for infants who
are jaundiced before discharge.
Failure to provide ongoing lactation support to ensure adequacy of intake for
breast-fed newborns.
Patient Education
Failure to provide appropriate information to parents about jaundice and
failure to respond appropriately to parental concerns about a jaundiced
newborn, poor feeding, lactation difficulties and change in newborn behavior
and activity.
Sentinel Alerts 18/31, JCAHO, 2001
Risk Reduction Strategies
Predischarge TCB/TSB with use of a percentile based on nomogram to
predict the risk and guide follow-up
Policies and procedures or standing orders allowing nurses to order
TCB/TSB for jaundiced newborns, proper documentation of bilirubin
values and a report
Policies for assessing the risk of severe hyperbilirubinemia in all infants by
history, clinical evaluation and, if necessary, by laboratory measurement.
Procedures for follow-up of all newborns within 24-48 hours by a physician
or pediatric nurse. If this cannot be achieved, decisions regarding timing of
discharge or other follow-up must be based on risk assessment.
Policies and procedures on jaundice management that specifically cover the
nurse’s role, documentation, charting requirements, and monitoring of jaundice
predischarge. Policies should also cover the ER and Newborn NICU.
Provide parents with adequate educational materials about newborn infants that
includes information about jaundice.
Provide adequate equipment – bilirubin lights and blankets, and non-invasive
TcB measurement device or lab services for timely TSB test.