Approach To Neonatal Hyperbilirubinemia

approach to neonatal
hyperbilirubinemia
 Jaundice = visible manifestation in skin and
sclera of elevated serum bilirubin
 Visible in adults at STB > 2mg/dl
 In neonates if STB> 5 mg/dl
METABOLISM OF HAEMOGLOBIN
BILIRUBIN PHYSIOLOGY
Bilirubin Ligandin (Y‐acceptor)
Bilirubin MG, Bilirubin DG

EH circulation
Bile Small
Bowel
Stercobilin (gut bacteria) β‐glucuronidase
Excreted Deconjugated
PHYSIOLOGICAL MECHANISMS OF NEONATAL JAUNDICE
 Increased bilirubin synthesis

 Less efficient binding and transport of
bilirubin
 Less efficient hepatic conjugation and
excretion
 Enhanced absorption of bilirubin via
enterohepatic circulation
CHARACTERISTICS OF PHYSIOLOGICAL
JAUNDICE
 Appears between 24‐72 hrs.. of life
 Peak STB levels are seen between 3rd – 5th days

of life in term and 3rd ‐ 7th day in preterm
 Usually does not exceed 15 mg/dl
 Does not persist for more than 2 weeks in a
full term infant
 No treatment usually required
CLINICAL CRITERIA TO ASSESS JAUNDICE
(KRAMER’S RULE)
 Head & Neck : 4‐8 mg/dl

 Upper trunk : 5‐12 mg/dl
 Lower trunk and thighs : 8‐16 mg/dl
 Arms and lower legs : 11‐18 mg/dl
 Palms and soles : >15 mg/dl
PATHOLOGICAL JAUNDICE: CLINICAL CRITERIA
 Clinical jaundice in the first 24 hours of life.

 STB > 17 mg/dl.
 Rate of STB increase > 0.2 mg/dl/h or 5mg/dl/d.
 Direct serum bilirubin > 2 mg/dl.
 Clinical jaundice persisting for > 2 weeks in a full

term infant.
CAUSES OF PATHOLOGICAL JAUNDICE IN NEWBORN
 Appearing within 24 hours of birth

 Rh and ABO incompatibility
 G6PD and PK enzyme deficiency
 Infections: TORCH, Bacterial, Malaria
 Appearing within 24‐72 hours after birth
I. Physiological jaundice
II. Neonatal jaundice
III. Polycythemia
IV. Extra vascular blood
• Cephalohematoma
• Sub‐galeal hematoma
• Intraventricular bleed
• Subarachnoid bleed
V. Increased enterohepatic circulation
• Intestinal obstruction
 Appearing after 72 hours after birth:
• Neonatal Sepsis
• Cephalhematoma
• Neonatal hepatitis
• EHBA
• Breast milk jaundice
• Metabolic causes:
• Hypothyroidism
• Hypopituitarism
• Crigler‐Najjar syndrome
• Gilbert disease
BREAST MILK JAUNDICE
 May persist as a prolonged physiological jaundice or appear de‐
novo after 1st week
 Common in exclusively breast fed babies
 Maximum intensity is between 10‐14 days
 If STB > 15 mg/dl, temporary cessation of breast feeding for 48

hours leads to dramatic fall and does not rise thereafter, but such
a practice can defeat breast feeding and must be avoided
 For higher levels, phototherapy may be needed
 The exact cause is still not understood
APPROACH TO A JAUNDICED BABY
 Ascertain birth weight, gestation and post‐natal age in
hours.
 Assess clinical condition (well or ill).
 Decide whether jaundice is physiological or pathological .
 If physiological and baby well, only observation is required.
 If deeply jaundiced, look for Kernicterus (lethargy, poor

feeding, poor/absent Moro, hypertonia, opisthotonus or
convulsions).
KERNICTERUS
 Acute
• Stage 1(1st few days): Lethargy, poor sucking, hypotonia,
• Stage 2(Mid‐1st week): Rigid extension of extremities, seizures, high

pitched cry, opisthotonus, retrocollis
• Stage 3(after 1st week): Stupor/coma, marked opisthotonus
 Chronic
• Movement disorders
• Gaze anomalies
• Auditory abnormalities
WORK UP OF JAUNDICED NEWBORN
 Maternal and perinatal history
 Physical examination
 Lab Studies:
• Total , direct and indirect serum bilirubin
• Blood grouping and Rh typing
• Hematocrit, Reticulocyte count, PBS
• Direct Coomb’s test of baby
• Sepsis screen
• Liver function and Thyroid tests
• Torch assay
MANAGEMENT
•Aims:
1.To prevent STB from rising

2.To reduce STB level
3.To prevent neurotoxicity
PREVENTION OF HYPERBILIRUBINEMIA
• Early and frequent breast feeding

• Adequate hydration
• Administration of Anti‐D injection to Rh

negative mother (when the baby is Rh
positive)
REDUCTION OF STB LEVELS AND PREVENTION OF
NEUROTOXICITY
• Phototherapy
• Exchange blood transfusion
PHOTOTHERAPY
• Phototherapy results in production of photoproducts which are
excreted in the bile and subsequently removed in stool.
• It uses blue light in spectrum of 450‐460nm wavelength and
irradiance of 6‐12µW/cm2/nm.
• The maximal surface area of naked baby is exposed to this light
at a distance of 45 cm.
• The eyes and genitalia of baby should be covered during
phototherapy.
• Feeding every 2 hours and frequent change of posture are
PHOTOTHERAPY ‐ CONT..
• The first type of reaction is formation of configurational
isomers of bilirubin 4Z15E.
• Native bilirubin is 4Z15Z.
• The photo isomer 4Z15E becomes more polar and therefore

more water soluble and can be excreted through bile.
• However, this reaction is potentially reversible, after which
they can be reabsorbed by enterohepatic circulation.
• The second type of photoreaction leads to formation of structural
isomer Lumirubin.
• This is an irreversible reaction and hence cannot be
reconverted to native bilirubin and reabsorbed.
• Hence formation of this isomer produces more rapid and efficient
decline in STB levels.
• However, formation of lumirubin efficiently requires high intensity
phototherapy (irradiance of 25‐40 µW/cm2/nm) at
15‐20 cm
• Temp is monitored every 2‐4 hrs..
• Weight is taken daily.
• More frequent breast feeds or 10‐20% extra IV

fluids are provided.
• STB is measured every 12 hrs..
• Phototherapy is discontinued if 2 STB values are <

10 mg/dl.
PHOTOTHERAPY: ADVERSE EFFECTS
• Increased insensible water loss.

• Loose green stools.
• Hyperthermia / Hypothermia.
• Rashes (erythema).
• Oxidative injury.
• UV light irradiation.
• Bronze baby syndrome.
EXCHANGE TRANSFUSION
• The most effective and reliable method to reduce STB.
• It decreases the risk of bilirubin encephalopathy by:
 Reducing total bilirubin load.
 Increasing the binding sites of plasma albumin.
 Shifting bilirubin out of plasma.
 Providing erythrocytes less apt to haemolyse.
 Removes sensitized RBC.

• Umbilical venous catheterization is done
• 5‐10 ml aliquots are removed and replaced sequentially

until about twice the blood volume of neonate has been
replaced
• Choice of blood:
• ABO Incompatibility: use O+ve blood. Ideal is O+ve cells

suspended in AB plasma
• Rh Isoimmunization: in emergency use O‐ve blood.

CONJUGATED HYPERBILIRUBINEMIA
• Defined as direct serum bilirubin > 2mg/dl
• Clues to suspect conjugated hyperbilirubinemia:

• High colored urine
• White / clay colored stool
• Persistence of jaundice beyond 2 weeks
• Hepato‐splenomegaly
CAUSES OF UNCONJUGATED
HYPERBILIRUBINEMIA
• Idiopathic neonatal hepatitis
• Inspissated bile syndrome
• Infections: Hepatitis B, TORCH, Sepsis
• Biliary tract malformations : EHBA, annular pancreas,

choledochal cyst, bile duct stenosis
• Metabolic disorders: Galactosemia, hereditary fructose
intolerance, alpha‐1AT deficiency, tyrosinemia, glycogen storage
disease IV, hypothyroidism
• TPN

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approach to neonatal

Bilirubin Ligandin (Y‐acceptor)

Bilirubin MG, Bilirubin DG

Stercobilin (gut bacteria) β‐glucuronidase

 Increased bilirubin synthesis

 Peak STB levels are seen between 3rd – 5th days

 Head & Neck : 4‐8 mg/dl

 Clinical jaundice in the first 24 hours of life.

 Clinical jaundice persisting for > 2 weeks in a full

 Appearing within 24 hours of birth

 If STB > 15 mg/dl, temporary cessation of breast feeding for 48

 If deeply jaundiced, look for Kernicterus (lethargy, poor

• Stage 1(1st few days): Lethargy, poor sucking, hypotonia,

• Stage 2(Mid‐1st week): Rigid extension of extremities, seizures, high

• Stage 3(after 1st week): Stupor/coma, marked opisthotonus

• Blood grouping and Rh typing

• Hematocrit, Reticulocyte count, PBS

• Direct Coomb’s test of baby

• Liver function and Thyroid tests

1.To prevent STB from rising

• Early and frequent breast feeding

• Administration of Anti‐D injection to Rh

• The photo isomer 4Z15E becomes more polar and therefore

• More frequent breast feeds or 10‐20% extra IV

• Phototherapy is discontinued if 2 STB values are <

• Increased insensible water loss.

• The most effective and reliable method to reduce STB.

• It decreases the risk of bilirubin encephalopathy by:

 Reducing total bilirubin load.

 Increasing the binding sites of plasma albumin.

 Shifting bilirubin out of plasma.

 Providing erythrocytes less apt to haemolyse.

 Removes sensitized RBC.

• 5‐10 ml aliquots are removed and replaced sequentially

• ABO Incompatibility: use O+ve blood. Ideal is O+ve cells

• Rh Isoimmunization: in emergency use O‐ve blood.

• Clues to suspect conjugated hyperbilirubinemia:

• White / clay colored stool

• Persistence of jaundice beyond 2 weeks

• Biliary tract malformations : EHBA, annular pancreas,

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