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