Cases Discussion R1 吳宗祐 CR 潘妤玟 2017/03/09

Case1 7-day-old male, GA 37+3 weeks TCB 17.8mg/dL at our OPD  admission

Case1 7-day-old male, GA 37+3 weeks TCB 17.8mg/dL at our OPD  admission Normal newborn at our hospital TCB 16.7 before discharge Newborn screen: suspect G6PD deficiency No decreased appetite with breast milk and formular No abnormal color/shape of defecation No tea color urine No decreased alertness, no hypotonia, no poor feeding condition, nor hypertonia Father’s blood type: O Mother’s blood type: O

Case1

Case1 Tentative Diagnosis Plan Neonatal indirect hyperbilirubinemia Glucose-6-phosphate dehydrogenase deficiency Plan Intensive phototherapy Monitor bilirubin level frequently Fluid supplements Consider blood exchange therapy if poor response to phototherapy

Case2 10-day-old male, GA 37+4 weeks, BBW 2870g Yellowish skin for days

Case2 10-day-old male, GA 37+4 weeks, BBW 2870g Yellowish skin for days G1P1, C/S due to breech, Apgar score 6  9 Feeding: Regular formula mixed with some breast milk Yellowish skin on 2-day-old, TCB 7.6  Phototherapy TCB 3.4 on 2/21  D/C Pho; TCB 12 on 2/22  Pho Clay color stool(-), Decreased urine output(-) Newborn screen: normal No hematoma or ecchymosis Father’s blood type: B Mother’s blood type: O

Case2

Case2 Tentative Diagnosis Plan Neonatal indirect hyperbilirubinemia, suspect ABO incompatibility associated hemolysis related Plan Intensive phototherapy Monitor bilirubin level frequently Consider blood exchange therapy if poor response to phototherapy

Case3 5-day-old male, GA36+3 weeks, BBW: 3090g, born at LMD TCB 18mg/dL was noted at LMD  NCKUH ER

Case3 5-day-old male, GA36+3 weeks, BBW: 3090g, born at LMD TCB 18mg/dL was noted at LMD  NCKUH ER 1-day-old, TCB 9  photo  Recheck: decreased  D/C pho 2-day-old, TCB 13  pho 3-day-old, TCB 9  discharge with mother 5-day-old TCB 18 No family history of G6PD No hematoma or ecchymosis after birth Mother’s blood type: O Father’s blood type: A

Case3

Case3 Tentative Diagnosis Plan Neonatal indirect hyperbilirubinemia, suspect due to ABO incompatibility Plan Intensive phototherapy Monitor bilirubin level frequently Fluid supplements Consider blood exchange therapy if poor response to phototherapy

Case4 2-day-old male GA 34+1 weeks, BBW 1944gm(AGA) Born at 麻豆新樓H, transferred to NCKUH due to respiratory distress Hyperbilirubinema was noted after admission

Case4 G1P1, GA34+1, Vaginal delivery with vacuum extraction, PPROM(+) Mother’s Blood type: AB, Rh(+); Thalassemia (+) Aspar score 4 (poor activity, bradycardia)  7 Respiratory distress after birth  Nasal CPAP  Intubation.

Case4

Case4 Tentative diagnosis Plan Neonatal indirect hyperbilirubinemia, suspect due to prematurity 34+1weeks Plan Intensive phototherapy + monitor bilirubin level frequently Prepare for blood exchange therapy if poor response to phototherapy

Case5 6-day-old male GA 37+2 weeks, BBW 2480gm TCB showed 22mg/dL at LMD  NCKUHER No18078451

Case5 6-day-old male GA 37+2 weeks, BBW 2480gm TCB showed 22mg/dL at LMD  NCKUHER TCB normal at 3-day-old Feeding: breast milk + S26 for 3 days, and then pure BM No abnormal color/shape of defecation, no tea color urine, no decreased alertness, hypotonia, or hypertonia. The blood type of the parents is unknown. The father: G6PD deficiency(+) Newborn screen: no abnormal findings, G6PD(-)

Case5

Case5 Tentative diagnosis Plan Neonatal indirect hyperbilirubinemia Intensive phototherapy + monitor serum bilirubin level frequently Consider blood exchange therapy if poor response to phototherapy

Jaundice & Hyperbilirubinemia in the Newborns

Introduction During the 1st week of life Metabolism of bilirubin 60% of term infants 80% of preterm infants. Metabolism of bilirubin During fetal stage: elimination of the lipid- soluble, unconjugated bilirubin via placenta Adult stage: excretion of the water-soluble, conjugated form via hepatic cells into the biliary system and G-I tract

Etiology Indirect hyperbilirubinemia Increases the load of bilirubin Hemolytic anemias, polycythemia, bruising or internal hemorrhage, shortened red blood cell life as a result of immaturity or transfusion of cells, increased enterohepatic circulation, infection Damages or reduces activity of the transferase enzyme or other related enzymes Genetic deficiency, hypoxia, infection, thyroid deficiency Competes for or blocks the transferase enzyme Drugs and other substances requiring glucuronic acid conjugation Absence or decreased amounts of the enzyme or to reduction of bilirubin uptake by liver cells Genetic defect, and prematurity

Treatments for Indirect Hyperbilirubinemia Regardless of the cause To prevent neurotoxicity related to indirect bilirubin Phototherapy Exchange transfusion Others IVIg: especially in ABO/Rh hemolytic diseases Metalloporphyrins: especially in G6PD or ABO incompatibility

Treatment Criteria For Prematurity GA <35 weeks NICE criteria For Near-term or term, GA >=35 weeks AAP criteria ( based on the Bhutani’s curve)

The Bhutani Curve

The Bhutani Curve Nomogram in 2840 well newborns GA >=36 weeks with birth weight >= 2000 GA >=35 weeks with birth weight >= 2500 Based on the hour-specific serum bilirubin values. The zone predicted the likelihood of a subsequent bilirubin level > 95th percentile = high risk zone 75~95th percentile = high intermediate risk zone 40~75th percentile = low intermediate risk zone < 40th percentile = low risk zone Only 4% of the study cases are Asian newborns

The 東華-NCKUH Curve 95th percentile 75th percentile Mean

The 東華-NCKUH Curve 2013~2014, 470 Healthy newborns, with GA 35-42 wks Transcutaneous bilirubinometry TCB was performed on newborns every 12 hrs since birth and followed up to discharged. The bilirubin levels were plotted against hs and by 40th, 75th, and 95th percentile of TCB values. Exclusion: Chromosome anomaly, G6PD deficiency, received phototherapy within 60 hrs of life.

The 東華-NCKUH Curve Slightly higher than the Bhutani curve Race? Admission durations? SB/TCB? The AAP/NICE criteria may not be 100% suitable for Taiwanese newborn More research is necessary

Thank you for your attention