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

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

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

4. Case1

5. 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

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

7. 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

8. Case2

9. 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

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

11. 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

12. Case3

13. 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

14. 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

15. 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.

16. Case4

17. 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

18. Case5 6-day-old male GA 37+2 weeks, BBW 2480gm
TCB showed 22mg/dL at LMD  NCKUHER No

19. 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(-)

20. Case5

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

22. Jaundice & Hyperbilirubinemia in the Newborns

23. 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

24. 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

26. 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

27. 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)

30. The Bhutani Curve

31. 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

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

33. 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.

35. 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

36. Thank you for your attention