hyperbilirubinemia

1. Jaundice In Newborn

2. Definition
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

3. Incidence
Chemical hyperbilirubinemia (> 2mg/dl)
universal in newborns during 1st week.
Some degree of Jaundice > 60-70% of
term newborns and 80% of preterm
newborns.
Ref: NNF teaching aids on newborn care

4. Bilirubin physiology
bilirubin Ligandin (Y-acceptor)
UGT
Bilirubin MG, Bilirubin DG
Bile Small Bowel EH
circulation
Stercobilin (gut bacteria) β-glucuronidase
excreted Deconjugated

5. Physiological Mechanisms Of
Neonatal Jaundice
Increased synthesis
Less efficient binding and transport
Less efficient hepatic conjugation and
excretion
Enhanced absorption via enterohepatic
circulation

6. Physiological Jaundice
Appears at 24-72 hrs of life
Peak STB levels at 3rd – 5th days of life in
term and 3rd - 7th day in preterm
Usually not > 15 mg/dl
Usually not > 2 weeks in a full term infant
No Rx usually
Ref: Taeusch & Ballard: Avery’s diseases of the newborn, 8th Edition

7. Pathological Jaundice - Clinical Criteria
Clinical jaundice in 1st 24 hours
STB > 17 mg/dl
Rate of rise > 0.2 mg/dl/h or 5mg/dl/d
Direct serum bilirubin > 2 mg/dl
Clinical jaundice > 2 weeks in a full term
infant
Ref: Taeusch & Ballard, Avery’s disease of the newborn, 8th Edition

8. Clinical Assessment
Extent
Important basic assessments
Clinical clues to causes
Presence of complications of jaundice

9. Clinical Extent Of Jaundice
(Modified from Kramer’s Rule)
Head & Neck : 4-8 mg/dl
Upper trunk : 8-12 mg/dl
Lower trunk and thighs: 12-15 mg/dl
Palms and soles : >15 mg/dl
Ref: Kramer LI: advancement of dermal icterus in the jaundiced newborn. Am J Dis Child
118:454-458, 1969.

10. Important Basic Assessments
Maternal and perinatal history
BW, GA, post-natal age in hours
Clinical condition (well or ill)
Physiological or pathological
If physiological and baby well, observe
If not fitting into physiologic, proceed as
follows

11. Clinical Clues to Causes - 1
Cephalhematoma or subgaleal hematoma
Plethoric look
Evidence of sepsis – purulent skin rash,
infected umbilicus, conjunctivitis,
hypothermia, refusal of feeds, respiratory
distress, seizures, sclerema etc

12. Clinical Clues to Causes - 2
Stigmata of TORCH infections – rashes,
cataracts, hepatosplenomegaly
Hepatomegaly with palpable enlarged GB
Evidence of ICH – seizures, apnea, refusal
of feeds, impaired consciousness
Evidence of GI abnormalities – abdominal
distension, markedly visible peristalsis etc

13. Clinical Clues to Causes - 3
Evidence of hypothyroidism –
hypothermia, LGA, sluggish at feeds,
umbilical hernia
Evidence of Trisomy 21 – Mongolian slant,
Simian crease, thick protruding tongue,
sluggish feeding, etc

14. Clinical Clues - Breast milk jaundice
Presents as prolonged physiological jaundice
or appears de-novo after 1st week
In exclusively BF babies
Maximum between 10-14 days
STB > 15 mg/dl, BF cessation for 48 hours >
dramatic fall > no rise thereafter
For higher levels > phototherapy
Exact cause not understood

15. Complications of Jaundice - 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
Ref: Taeusch & Ballard, Avery’s diseases of the newborn, 8th edition

16. Lab Work Up
Total,direct and indirect serum bilirubin
Blood grouping and Rh typing
Hematocrit, Reticulocyte count, PBS
Direct Coomb’s test on baby
Sepsis screen
Liver function and Thyroid tests
Torch assay

17. Management
Aims:
1. To prevent STB from rising
2. To reduce STB level
3. To prevent neurotoxicity

18. Prevention of hyperbilirubinemia:
1. Early and frequent feeding
2. Adequate hydration
3. Administration of Anti-D injection to Rh
negative mother

19. Reduction of STB levels and
prevention of neurotoxicity
Phototherapy
Exchange transfusion

20. Phototherapy
Phototherapy > unconjugated bilirubin >
conjugated photoproducts > bile > stool, also >
urine
Blue light > 450-460nm wavelength and
irradiance of 6-12µW/cm2/nm .
The maximal surface area of naked baby
exposed
Distance - 45 cm.
The eyes and genitalia covered .
Feeding every 2 hours and frequent change of
posture are necessary.
Ideally double surface

21. Phototherapy Contd.
The baby is turned every 2 hrs or after each
feed
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

22. Phototherapy: adverse effects
Increased insensible water loss
Loose green stools
Hyperthermia / Hypothermia
Rashes (erythema)
Oxidative injury
UV light irradiation
Bronze baby syndrome

23. Exchange transfusion
The most effective and reliable method to reduce
STB
It decreases the risk of bilirubin encephalopathy by:
1. Reducing total bilirubin load
2. Increasing the binding sites of plasma
albumin
3. Shifting bilirubin out of plasma
4. Providing erythrocytes less apt to hemolyze
5. Removes sensitized RBC
Ref: Taeusch & Ballard, Avery’s diseases of the newborn

24. Exchange transfusion Contd.
Umbilical venous catheterization is done
5-10 ml aliquots exchanged
Blood Volume (80 mL/kg) X 2 = Volume of ET
Choice of blood:
a. ABO Incompatibility: use O+ve blood. Ideal
is O+ve cells suspended in AB plasma
b. Rh Isoimmunization: in emergency use
O-ve blood. Ideal is O-ve blood suspended
in AB plasma
Ref: NNF teaching aids on newborn care

25. Maisel’s Chart
STB
(mg/dl)
Birth Wt <24 hrs 24-48 hrs 49-72 hrs >72 hrs
<5` All
5-9 All Photothera
py if
hemolysis
10-14 <2500G
--------------
>2500 G
Exchange
if
hemolysis
Phototherapy
--------------------------------------------------
Investigate if STB > 12 mg/dl
15-19 <2500 g
--------------
>2500 g
Exchange Transfusion
Consider exchange
--------------------------------
Phototherapy
20 and
More
All Exchange Transfusion

26. Maisel’s Chart
For decision making based on Maisel’s
chart, in the presence of following, treat as
in next higher bilirubin category:
a. Perinatal asphyxia
b. Respiratory distress
c. Metabolic acidosis
d. Hypothermia
e. Low serum protein
f. Birth weight < 1500 g
g. Signs of clinical or CNS deterioration
Ref: NNF Teaching aids on newborn care

27. Conjugated Hyperbilirubinemia
Defined as direct serum bilirubin > 2mg/dl
Clues to suspect conjugated
hyperbilirubinemia:
a. High colored urine
b. White / Clay colored stool
c. Persistence of jaundice beyond 2 weeks
d. Hepato-splenomegaly

28. 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
Down’s syndrome
Ref: NNF teaching aids on newborn care