Hyperbiribunemia: Tjakrapawira, Agnes Yarte, Dana

HYPERBIRIBUNEMIA
Tjakrapawira, Agnes
Yarte, Dana
JAUNDICE
Jaundice is a yellow discoloration of the skin and eyes caused by
hyperbilirubinemia
Jaundice usually becomes visible on the sclera at a level of 2 to 3

mg/dL (34 to 51 mol/L)
On the face at about 4 to 5 mg/dL (68 to 86 mol/L)
At the feet at about 20 mg/dL (340 mol/L)
With increasing bilirubin
levels, jaundice seems to
advance in a head-to-foot
direction, appearing at
the umbilicus at about
15mg/dL (258 mol/L)
MECHANISM OF
HYPERBILIRUBINEMI
A
Increased production
Decreased hepatic uptake
Decreased conjugation
Impaired excretion
Impaired bile flow (cholestasis)
Increased enterohepatic circulation
ETIOLOGY Classification CAUSES
1. Transient jaundice on Physiologic hyperbilirubinemia
healthy neonates Breastfeeding jaundice
Breast milk jaundice
2. Physiologic or pathologic Pathologic hyperbilirubinemia due
3. Unconjugated, conjugated, to haemolytic disease
or both (based on levels)
Physiologic VS Pathologic
Hyperbilirubinemia
Physiologic Hyperbilirubinemia
1. Occurs in almost all neonates
2. Shorter neonatal RBC life span increases bilirubin production
3. Deficient conjugation due to the deficiency of UGT decreases
clearance
4. Low bacterial levels in the intestine combined with increased
hydrolysis of conjugated bilirubin
5. Increase enterohepatic circulation
6. Bilirubin levels can rise up to 18 mg/dL by 3 to 4 days of life (7days in
Asian infants) and fall thereafter
Pathologic Hyperbilirubinemia
1. In term infants is diagnosed if jaundice appears in the first 24 hours
2. After the first week of life
3. Or lasts > 2 week total serum bilirubin (TSB) rises by > 5mg/dL/day
4. TSB is >18 mg/dL infant shows symptoms or signs of a serious illness

5. Some of the most common pathologic causes are:
Immune and nonimmune haemolytic anemia
G6PD deficiency
Hematoma resorption
Sepsis
Hypothyroidism
Breastfeeding VS Breast milk
Jaundice
Breastfeeding Jaundice
Develops in 1/6 of breastfed infants during the first week of life
Breastfeeding increases enterohepatic circulation of bilirubin in some

infants who have decreased milk intake (dehydration or low caloric
intake)
Breast milk Jaundice
Different from breastfeeding jaundice
Develops after the first 5-7 days of life and peaks at about 2 weeks
caused by an increased concentration of -glucuronidase in breast

milk -> increase in the deconjugation and reabsorption of bilirubin ->
increased enterohepatic circulation = reduced intestinal bacteria ->
convert bilirubin to nonresorbed metabolites
EVALUATION
History of present illness
1. Note age of onset and duration of jaundice
2. Associated symptoms: lethargy and poor feeding (suggesting possible

kernicterus) -> progress to stupor, hypotonia or seizures ->hypertonia
3. Patterns of feeding
4. History should include: What is being fed, how much and how frequent ->
urine and stool production
Past Medical History
1. Should focus on maternal infections (toxoplasmosis, other pathogens, rubella,
cytomegalovirus, and herpes simplex [TORCH] infections)
2. Disorders that can cause early hyperbilirubinemia (maternal diabetes)
3. Maternal Rh factor and blood group (maternofetal blood group incompatibility)
4. History of a prolonged or difficult birth (hematoma or forceps trauma)
5. Family history should note known inherited disorders that can cause jaundice,
including G6PD deficiency, thalassemias and spherocytosis
6. History of siblings who have had jaundice
7. Drug history should specifically note drugs that may promote jaundice
Review of Systems
Should seek symptoms of causes:
1. Respiratory distress
2. Fever, and irritability
3. Lethargy (Sepsis)
4. Hypotonia and poor feeding (hypothyroidism, metabolic disorder)
5. Repeated episodes of vomiting (intestinal obstruction)
RED FLAGS
1. Jaundice in the first day of life
2. TSB > 18 mg/dL
3. Rate of rise of TSB > 0.2 mg/dL/hr (>3.4 mol/ L/hr) or > 5
mg/dL/day
4. Conjugated bilirubin concentration >1 mg/dL (>17 mol/L) if TSB is
20% of TSB (suggests neonatal cholestasis)
5. Jaundice persisting after 2 weeks of age
6. Lethargy, irritability, respiratory distress
TREATMENT
Physiologic Jaundice
1. Usually is not clinically significant and resolves within 1 week
2. Frequent feedings -> increasing GI motility and frequency of stools _-
> minimizing the enterohepatic circulation
TX: Breastfeeding Jaundice
1. May be prevented or reduced by increasing the frequency of
feedings
2. If the bilirubin level continues to increase > 18 mg/dL in a term infant

with early breastfeeding jaundice, a temporary change from breast milk
to formula may be appropriate
3. Phototherapy also may be indicated at higher levels

4. Stopping breastfeeding is necessary for only 1 or 2 days, and the
mother should be encouraged to continue expressing breast milk
5. Safely resume breastfeeding (not advisable to supplement with water

or dextrose because that may disrupt the mothers production of milk)
when jaundice has decreased and give the expressed breast milk.
INTERVENTION
A. Phototherapy
Mechanism:
Photoisomerize unconjugated bilirubin
into forms that are more water-soluble
and can be excreted rapidly by the liver
and kidney without glucuronidation.
B. Exchange Transfusion
Rapidly remove bilirubin from

circulation and is indicated for severe
hyperbilirubinemia (immunemediated
hemolysis)
Small amounts of blood are withdrawn
and replaced through an umbilical vein
catheter to remove partially hemolyzed
+ antibody coated RBCs + circulating Igs
Blood is replaced with uncoated donor
RBCs

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HYPERBIRIBUNEMIA

Jaundice usually becomes visible on the sclera at a level of 2 to 3

2. After the first week of life

4. TSB is >18 mg/dL infant shows symptoms or signs of a serious illness

Breastfeeding increases enterohepatic circulation of bilirubin in some

caused by an increased concentration of -glucuronidase in breast

2. Associated symptoms: lethargy and poor feeding (suggesting possible

2. If the bilirubin level continues to increase > 18 mg/dL in a term infant

3. Phototherapy also may be indicated at higher levels

5. Safely resume breastfeeding (not advisable to supplement with water

Rapidly remove bilirubin from

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