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    Hyper Bilirubin Emi A

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    Mateen Shukri
    This document discusses hyperbilirubinemia in neonates. It begins by outlining the objectives which are to understand the bilirubin pathway, differentiate between physiologic and pathologic hyperbilirubinemia, understand the risk of kernicterus, and why hyperbilirubinemia is important. It then provides details on the physiology and etiologies of hyperbilirubinemia. It also discusses guidelines for screening and treatment thresholds using AAP charts. The document uses a case example to demonstrate clinical signs that indicate sepsis rather than simple jaundice and outlines key learning objectives.

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    Hyper Bilirubin Emi A

    Uploaded by

    Mateen Shukri
    81 views33 pages
    This document discusses hyperbilirubinemia in neonates. It begins by outlining the objectives which are to understand the bilirubin pathway, differentiate between physiologic and pathologic hyperbilirubinemia, understand the risk of kernicterus, and why hyperbilirubinemia is important. It then provides details on the physiology and etiologies of hyperbilirubinemia. It also discusses guidelines for screening and treatment thresholds using AAP charts. The document uses a case example to demonstrate clinical signs that indicate sepsis rather than simple jaundice and outlines key learning objectives.

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    This document discusses hyperbilirubinemia in neonates. It begins by outlining the objectives which are to understand the bilirubin pathway, differentiate between physiologic and pathologic hyperbilirubinemia, understand the risk of kernicterus, and why hyperbilirubinemia is important. It then provides details on the physiology and etiologies of hyperbilirubinemia. It also discusses guidelines for screening and treatment thresholds using AAP charts. The document uses a case example to demonstrate clinical signs that indicate sepsis rather than simple jaundice and outlines key learning objectives.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    81 views33 pages

    Hyper Bilirubin Emi A

    Uploaded by

    Mateen Shukri
    This document discusses hyperbilirubinemia in neonates. It begins by outlining the objectives which are to understand the bilirubin pathway, differentiate between physiologic and pathologic hyperbilirubinemia, understand the risk of kernicterus, and why hyperbilirubinemia is important. It then provides details on the physiology and etiologies of hyperbilirubinemia. It also discusses guidelines for screening and treatment thresholds using AAP charts. The document uses a case example to demonstrate clinical signs that indicate sepsis rather than simple jaundice and outlines key learning objectives.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 33

    Hyperbilirubinemia

    Monica Stemmle

    Objectives
    Understand pathway where bilirubin
    comes from
    Physiologic vs Pathologic
    Hyperbilirubinemia
    Understand the risk for Kernicterus
    Understand why we care about
    hyperbilirubinemia

    Physiology

    Physiologic
    hyperbilirubinemia
    1. Increased production: Increased
    RBC volume and decreased lifespan
    of RBC in neonates
    2. Decreased Excretion: UGT
    activity is decreased in neonates for
    first few days. Also increased
    enterohepatic circulation

    Pathologic
    Hyperbilirubinemia
    Can you name some of the risk
    factors :
    1. Increased bilirubin load?
    2. Decreased bilirubin clearance?

    Increased bilirubin load


    Hemolysis
    Immune mediated (ABO, rH, minor antigens)
    Heritable defects (RBC membrane defect,
    RBC enzyme defects, hemoglobinopathies)

    Sepsis/DIC
    Hematomas
    Polycthemia
    Macrosomia
    Increased enterohepatic ciculation

    Decreased bilirubin
    clearance
    G6PD deficiency
    Meconium plug
    Imperforate anus

    Risk of Hyperbilirubinemia

    KERNICTERUS

    Kernicterus
    Physiology not well understood
    Believed that exposure to bilirubin at
    a sensitive window of neuronal
    development may lead to apoptosis
    Requires PROLONGED HIGH bilirubin

    Kerniticus studies
    1. Outcomes among Newborns with Total Serum Bilirubin Levels
    of 25 mg per Deciliter or More Thomas B. Newman N Engl J Med
    354;18 may 4, 2006
    Kaiser data. Infants with bili >24. No cases of kernicterus and no
    neurologic difference

    2. Outcomes in a Population of Healthy Term and Near-Term


    Infants With Serum Bilirubin Levels of >19 mg/dL Who Were
    Born in Nova Scotia, Canada, Between 1994 and 2000.
    Pediatrics. Jangaard et al. 122 (1): 119. (2008).
    Babies in Nova Scotia bw 1994-2000. No dif in neuro problems or
    deafness between severe hyperbili (>19) and no hyperbili (<13).

    3. Synopsis report from the Pilot USA Kernicterus Registry VK


    Bhutani and L Johnson Journal of Perinatology (2009) 29, S4S7.
    No cases of kernicterus at bili <20, very usual at 20-25 and 25-35 could
    be reversible if acted on quickly

    So who do you screen


    AAP recommends universal screening
    either with TcB or TSB
    USPSTF recommends against universal
    screening.
    Risks: treating unneccesarily, interrupting
    breastfeeding, increased treatment and cost
    of hospitalization.

    Summary: Screen with TcB or TSB


    with clinical judgment and weighing
    baby risk factors!

    Risk Factors to Consider


    Can you name a few for
    hyperbilirubinemia needing
    photo AND nuerotoxicity?

    Risk Factors for Hyperbili


    Predischarge TSB or TcB in the HR or HIR
    zone
    Lower Gestational age
    Exclusive breasfeeding (esp if not going
    well or weight loss excessive)
    Jaundice in first 24 hours
    Isoimmune or other hemolytic disease
    Cephalohematoma or significant bruising
    East Asian Race

    Risk factors for


    neurotoxicity

    Isoimmune hemolytic disease


    G6PD
    Asphyxia
    Sepsis
    Acidosis
    Albumin <3

    Charts To help
    Do you know what the 3 charts and
    what they look at are that we use?

    AAP Charts
    Risk Zones
    Phototherapy
    Exchange Transfusion

    Risk Zones

    Phototherapy

    So what does all this mean?


    Approach each baby individually
    Importance is WHY the baby is
    jaundiced not that the baby is
    jaundiced
    Use clinical judgment and think
    about risks when deciding when to
    recheck and when to treat.

    Questions
    You are the junior on at Valley and
    have a baby that is being admitted
    for hyperbili. Meanwhile 3 other kids
    hit the floor at the same time. In
    order to triage you send the intern to
    see the hyperbili first while you see
    the sicker patients. When you
    reunite with the intern what are your
    4 top questions you want to ask the
    intern?

    Gestational age and chronologic age


    Bili level (and hours that it was
    taken)
    Baby vital signs and general
    appearance
    Baby blood type and mom blood type

    Intern Response
    6 day old ex 36 0/7 with a bili of
    15.8. Vitals not done yet. Mom is A
    +, Ab neg. Which places the baby at
    risk for severe hyperbili?
    Late preterm
    Moms blood type
    Male
    6 days old

    Late preterm
    And

    Male

    A little more history


    Baby is 3% down from BW currently
    drinking breast and bottle. Baby
    looks fine. Why do you think the
    baby has hyperbili?

    Breastfeeding jaundice
    Breastmilk Jaundice
    Exaggerated physiologic jaundice
    Other

    Exaggerated physiologic jaundice or other


    reason

    What labs do you want?


    CBCd
    Retic
    Direct bili
    Type and cooms

    You get all because you dont have a


    good explanation for the high bili
    level. While you are waiting for the
    results the nurse mentions the baby
    has low tone. You go to examine the
    baby and notice the baby does not
    suck much. You look back at the
    vitals and note the temp was low.
    You also notice his perfusion is poor.
    What next?

    Rule out Sepsis


    Evaluation!

    What would you order?


    LP
    CBCd
    Blood culture
    Urine culture
    CRP

    You correctly order the full workup.


    During the tap the baby has
    respiratory arrest. You then transfer
    to the NICU. In transport you get a
    call that the CBC shows a white
    count of 3.7 but the smear says
    many bacteria. What were your
    warning signs that this was not a
    simple case of neonatal jaundice?

    Abnormal vital signs (low temp).


    No clear cause for jaundice (older
    baby, not that far from BW, not a risk
    with mom blood type)
    Poor perfusion.

    Objectives reviewed
    Understand pathway where bilirubin
    comes from
    Physiologic vs Pathologic
    Hyperbilirubinemia
    Understand the risk for Kernicterus
    Understand why we care about
    hyperbilirubinemia

    Questions?

    References
    Hyperbilirubinemia in the Newborn Infant >35 Weeks Gestation: An Update With
    Clarifications
    M. Jeffrey Maisels Vinod K. Bhutani, Debra Bogen, Thomas B. Newman, MD, Ann R. Stark, and
    Jon F. Watchko
    PEDIATRICS Volume 124, Number 4, October 2009

    Screening of Infants for Hyperbilirubinemia to Prevent Chronic Bilirubin


    Encephalopathy: US Preventive Services Task Force Recommendation Statement
    US Preventive Services Task Force Pediatrics 2009; 124;1172-1177

    Neonatal Jaundice
    M. Jeffrey Maisels
    Pediatr. Rev. 2006;27;443-454
    Trends in Hospitalizations for Neonatal Jaundice and Kernicterus in the United
    States, 1988_2005
    Bryan L. Burke, James M. Robbins, T. Mac Bird, Charlotte A. Hobbs, Clare Nesmith and John
    Mick Tilford
    Pediatrics 2009;123;524-532

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