1. JAUNDICE AND THE NEWBORN
Abbey Rupe, MD

2. Objectives
Definitions
Prevention
Risk factors
Assessment
Treatment

3. What is jaundice? Hyperbilirubinemia Indirect/Unconjugated
Direct/Conjugated
Considered elevated if direct portion is >20% of total bilirubin level
Scope won’t be discussed in this lecture

4. Definitions Unconjugated Physiologic jaundice Breast-feeding jaundice
Most babies develop some jaundice
Mean peak of 5-6 mg/dl between hr of life
Breast-feeding jaundice
Decreased calories, increased enterohepatic circulation
Breast-milk jaundice
Prolonged after 2-3 weeks of age
?? Protein in breast milk that increases enterohepatic circulation
Peak and age range differs between races

5. Definitions Pathologic Jaundice appearing in first 24 h of life
TSB > 95th percentile for age
TSB increasing at rate >0.2 mg/dl/h or > 5 mg/dl/d
Elevated direct component
Jaundice persisting > 2 weeks in full-term infants
Exception: breast-milk jaundice
“Severe” hyperbilirubinemia
Generally considered to be TB >25-30

6. Complications of untreated jaundice
Bilirubin-induced neurologic dysfunction (BIND)
Bilirubin crosses BBB and binds to brain tissue
Risk increased when TB >25-30
Acute bilirubin encephalopathy (ABE)
Initial phase: lethargy, hypotonia, decreased movement, poor suck
Intermediate phase: stupor, irritability, increased tone (retrocolis and opisthotonos), fever
Advanced phase: deep stupor or coma, inability to feed, shrill cry, apnea, seizures
**potentially reversible!
Unconjugated bili can cross BBB and penetrate brain cells, may lead to neuronal dysfunction and death

7. Complications Chronic bilirubin encephalopathy (kernicterus)
Choreoathethoid cerebral palsy
Sensorineural hearing loss
Palsy of vertical gaze
Dental enamel hypoplasia
Up to 10% mortality
Most (but no all) infants with kernicterus previously manifested symptoms of ABE

8. Why do neonates become jaundiced?
Increased bilirubin production
More RBCs + shorter RBC life span = increased turnover and increased bilirubin
Decreased bilirubin clearance
Deficiency of UGT
UGT activity at 7 days of age is approx 1% of adult
Reaches adult levels around 14 days of age
Increased enterohepatic circulation
UGT: uridine diphosphogluconurate glucuronosyltranferase

9. Pathologic jaundice--causes
Rh or ABO incompatibility
Enzyme deficiencies: G6PD, pyruvate kinase
Hemoglobinopathies
Infection
Increased RBC load
Cephalohematomas, etc
Polycythemia
Infants of diabetic mothers

10. Pathologic jaundice--causes
Disorders of bilirubin clearance
Crigler-Najjar, Gilbert
Metabolic and endocrine
Galactosemia, hypothyroidism
Increased enterohepatic circulation
Breast-feeding jaundice
Conditions causing GI obstruction or decreased motility

11. Risk factors for severe jaundice
Major:
Predischarge bili in high-risk zone
Observed jaundice in 1st 24 hours of life
Blood group incompatibility w/ positive DAT
Previous sibling required ptx
Cephalotematoma or other significant bruising
Exclusive breastfeeding (esp if not going well and weight loss is excessive)
East Asian race
(again, this is infants 35 weeks and older

12. Risk factors for severe jaundice
Minor risk factors
Predischarge bili in high-intermediate risk zone
GA weeks
Jaundice observed before discharge
Previous sibling with jaundice
Macrosomic IDM
Maternal age ≥ 25 years
Male gender

13. Risk factors for severe jaundice
DECREASED risk
Pre-discharge bili in low-risk zone
GA ≥ 41 weeks
Exclusive bottle feeding
Black race
Discharge from hospital after 72 hours

14. Hyperbilirubinemia--prevention
Pregnant women:
ABO and Rh testing
Rhogam as indicated
screen for isoimmune antibodies
If mom is Rh- or ABO/Rh status unknown
Check blood type, Rh, and DAT on neonate (cord blood)
If DAT positive: needs frequent (q6-12hr) checking of TSB
Most of these are standing orders

15. Jaundice--prevention
Newborn nursery:
Advise mothers to nurse 8-12 times per day for first several days
Evaluate for jaundice every time vitals taken (q8-12 hr)

16. Testing for jaundice
Before discharge, ALL newborns should be assessed for jaundice (2004 AAP Practice Guideline)
Visual assessment
Need adequate ambient light or daylight fluorescent light
Subjective and not recommended as lone assessment
More difficult in darker-complected infants
TSB (total serum bilirubin)
Oftentimes drawn with metabolic screen
TcB (transcutaneous bilirubin)
Method implemented at SRHC in 2010

18. Assessment tools AAP bilirubin nomograms Electronically
UpToDate calculator
BiliTool.org
Online calculator
App for iPhone or iPod touch
Palm OS

19. Phototherapy

20. Using the nomograms
Use total bilirubin (don’t subtract direct component)
Risk factors:
Isoimmune hemolytic disease
G6PD deficiency
Asphyxia
Significant lethargy
Temp instability
Sepsis
Acidosis
Albumin < 3.0 (if measured)

21. Exchange transfusion

22. Discharge and follow-up
Infant Discharged
Should Be Seen By Age
Before age 24 hours old
72 hours old
Between 24 and 47.9 h
96 h
Between 48 and 72 h
120 h
Follow-up by a “qualified health care professional”
typically with PCP or mid-level provider
nurse/lactation specialist
home health nurse visit
If follow-up cannot be ensured, may be necessary to delay discharge
“qualified” implies that, if nurse or HH visit, they have been trained to assess for jaundice and the ability to change to a MD visit if needed (HH nurse when WMC did visits had a biliometer)

23. Anticipatory Guidance
Jaundice progresses head to toe, then as it resolves, disappears from toe to head
Testing for jaundice: blanch skin with finger
Call if:
Jaundiced to belly button
Not waking well for feeds or feeding poorly
Decreased wet diapers
Shrill cry

24. Follow-up appointment
Weight and % change from BW
Adequacy of po intake
Pattern of voiding and stooling
Presence or absence of jaundice
+/- checking bili level
If predischarge bili was high-intermediate risk, I nearly always recheck a bili
If predischarge bili was low-risk, I rarely do
If predischarge bili was low-intermediate, I do if concerns present

25. So . .. .you’ve reached LL. Now what?
History and physical exam
Laboratory testing
Phototherapy
Assess hydration

26. Laboratory evaluation
Approaching or at light level:
Direct and total bilirubin
Blood type and DAT
CBC
Peripheral smear
Consider: retic count, G6PD, ETCOc
Consider: UA (for reducing substances) with culture, sepsis eval

27. Lab evaluation
Approaching exchange levels or not responding to phototherapy
Retic, G6PD, albumin, ETCOc UA
Sepsis eval
Elevated direct (or conjugated) bilirubin
UA and urine culture
Evaluate for sepsis if indicated by history and physical exam

28. Treatment—Phototherapy
Mechanism of action:
Exposes skin to light of specific wavelength ( nm/blue-green spectrum)
Converts bilirubin to lumirubin
Lumirubin is more soluble than bilirubin and is excreted without conjugation into the bile and urine

29. Phototherapy options Bili blanket Bili bed “Bank” phototherapy
Home or hospital
Bili bed
“Bank” phototherapy
Hospital only
Home vs hospital
Home is an option 2-3mg/dl below LL in infant with no risk factors and caregivers with ready access to medical care

30. Treatment--phototherapy
Technique—bank phototherapy
Infant should wear diaper only, and diaper should be pulled down as much as possible to increase skin exposure
“baby sunglasses”
Ensure that banks of lights are at appropriate distance from infant
Infant needs to remain under lights continuously, only to be taken out for feedings
Can utilize biliblanket to continue some ptx during feeds

31. Phototherapy
phototherapy typically results in a decline of TB of 2-3 mg/dl within 4-6 hours
Obviously, more lights = faster decline
Recheck TB within 2-6 hours of starting ptx
Then, recheck every 6-12 hours, if TB is falling
If doing home therapy, need to redraw daily
Hospitalize if surpasses LL, excessive rate of rise, or other concerns develop

32. Phototherapy—side effects
Generally considered safe
Transient erythematous rashes
Loose stools
Hyperthermia
Increased insensible water loss
Possible retinal degeneration (hence the sunglasses)
Parents/caregivers:
some models can cause HA and nausea
Frustrating to not get to hold baby
“bronze baby syndrome”
If used on infant with cholestasis

33. Management—assess hydration
Maintaining adequate hydration and UOP is important
Lumirubin excreted in urine > stool
Encourage breast or bottle feeding
Lactation consult prn
Supplement with EBM or formula in breastfed infants with excessive weight loss (>12%) or evidence of hypovolemia
IVF if oral intake is inadequate
***suppositories

34. Phototherapy . .. When to stop?
No strict guideline
when TSB <13-14
When TSB back to, or lower-than, level at which ptx was initiated
Sometimes at lower level if started during NB stay and treatment initiated at lower LL

35. Phototherapy . . . When to stop?
“checking for rebound”
TB will typically re-increase by small amount (typically <1 mg/dl) after discontinuation of ptx
DON’T have to keep pt hospitalized to check for rebound, unless risk-factors present
DO check in hospital or clinic the next day if:
ptx discontinued prior to 5-6 days old (may not have reached peak yet)
Other concerns
For “nervous Nellie’s” (like myself): night before anticipated discharge, check TSB. Continue ptx until 2 or 3am, then d/c. Check bili with AM labs, should see if significant rebound present

36. If not improving Likely that hemolysis is occurring: Increase # banks
Labs:
Retic, G6PD, albumin, ETCOc
Sepsis eval
UA and urine culture
Add IVF
Consult pediatrician +/- neonatologist
Exchange transfusion in NICU

37. Lab evaluation Jaundice preset at ≥ 2-3 weeks Total and direct bili
If direct bili elevated, evaluate for causes of cholestasis
Check NB thyroid and galactosemia; evaluate infant for signs/sx of hypothyroidism
If indirect elevated and breast-fed, potentially breast-milk jaundice
Option to give formula in place of breast milk x24 hours (controversial)

38. ?Sunny window? Technically. . .. NO Risk for sunburn
Risk for hypo- or hyper-thermia