By Adem Lewis / in , , , , , , , , , , , , , /

“Rwandan National
Neonatal Protocol: Hyperbilirubinemia” by Dr.
Bwiza-Muhire Hippolyte. Introduction. Hello. I’m called Dr.
Bwiza-Muhire Hippolyte. I’m a pediatrician and member of
Rwanda Paediatric Association. Today, I’m going to talk
about hyperbilirubinemia. Overview. By the end of this
chapter, participants will you be able
to recognize risk factors for hyperbilirubinemia
in full term and premature infants, to understand how
to assess hyperbilirubinemia on a physical exam and
initiate laboratory testing, to determine,
initiate, and manage appropriate treatment
for hyperbilirubinemia in the neonate. Pathophysiology,
Assessment, and Treatment. Bilirubin is a yellow substance
created as the body replaces old red blood cells. It is broken down by
the liver and removed from the body in the stool. High levels of bilirubin
called hyperbilirubinemia makes the skin and
the sclera of the eyes look yellow, a condition
known as jaundice. Physiologic jaundice occurs
in the first two weeks of life due to a normal
rise in indirect bilirubin while the newborn’s metabolism
and excretion system are still immature. It typically peaks
at the bilirubin of about 12 milligrams
per deciliter in the first weeks of life and
then resolves spontaneously over the first month of life. Physiologic jaundice rarely
occurs in the first day after birth and usually
does not require treatment. Non-physiologic
jaundice is a sign of more extreme
hyperbilirubinemia and involves a peak bilirubin
greater than 12 milligrams per deciliter. That often occurs earlier than
with physiologic jaundice. It can be direct,
indirect, or both. It is typically due to
an underlying condition and requires further
evaluation and treatment. Causes can include
sepsis, hypothyroidism, and congenital syphilis. Neonatal
hyperbilirubinemia can be due to physiologic jaundice,
non-physiologic jaundice, or both. Newborns increased breakdown of
heme-containing red blood cells results in increased
release of bilirubin. Therefore, conditions
in which there is increased red blood cell
breakdown, like hemorrhage or hemolysis, will exacerbate
hyperbilirubinemia. Newborns also have a
decreased metabolism and excretion of bilirubin. This is a complex process
requiring both hepatic function and intestinal excretion. Conditions in which there
is decreased metabolism, such as liver disease or
decreased intestinal excretion of bilirubin, such as
being NPO on IV fluids, will also exacerbate
hyperbilirubinemia. Risk factors for
hyperbilirubinemia include prematurity, low birth
weight, hemolysis, sepsis, and inborn errors of metabolism. Physiologic and
non-physiologic jaundice peaks earlier and higher in preterm,
low birth weight infants due to decreased
metabolism of bilirubin caused by immature
hepatic function and decreased
excretion of bilirubin due to decreased enteral intake. High levels of
bilirubin can cause brain damage making prompt
screening and treatment critical. Ideally, hyperbilirubinemia
is diagnosed with a serum bilirubin
measurement of total, direct, and indirect bilirubin. If it is not possible to
measure serum bilirubin, a rough estimate can be made
by physical examination. Scleral icterus correlates
with a bilirubin of about 5 mg per deciliter. Jaundice of the palms
and soles correlates with a bilirubin of greater
than 20 mg per deciliter. Measure bilirubin if
an infant has jaundice on day of life zero, is
preterm with jaundice on day of life one,
or has jaundice below the chest at any age. Jaundice below the
chest, especially on the palms and the soles,
should cause concern. Consider additional factors
that could worsen jaundice such as sepsis and hemolysis. Laboratory testing to assess
for hemolysis and sepsis would include a full blood
count, blood type of mother, Coombs, CRP, and blood culture. When the hyperbilirubinemia
requires treatment depends on the degree of
production, metabolism, and the excretion of bilirubin. If there is evidence of
moderate to severe jaundice by physical exam,
start phototherapy regardless of serum bilirubin
laboratory measurements. Jaundice of palms and soles
is consistent with a bilirubin level of at least 20
milligram per deciliter, which is equal to 340
micromole per liter. Use these tables to determine
the phototherapy treatment and exchange
transfusion thresholds. Bilirubin conversion is
1 milligram per deciliter equals 17.1 micromole per liter. To start phototherapy, place
the newborn in the bassinet or an incubator if the newborn
is low birth weight less than 2 kg, and an incubator
if available. Ensure that the newborn is
naked except for a diaper and wearing protective
eyewear at all times. Position the phototherapy source
at an appropriate distance above the newborn’s
body, which varies based on the type of light source. Phototherapy should
be continuous without interruptions
except during feedings. While newborns are
receiving phototherapy, closely monitor temperature,
hydration status, and lab test results. Check temperature
every three hours considering that
the normal range is 36.5 to 37.5 degrees Celsius. Phototherapy causes increased
evaporative fluid losses. So fluid intake should be
increased by 20 mL/kg per day. Ensure that the newborn is a
feeding well, seven or eight times per day or on IV fluids,
and urinating at least six times per day. Dehydration, hemoconcentrates
bilirubin and it should be avoided. If initial total bilirubin
is over 20 mg/dL, repeat the measurement
in 6 to 12 hours. If initial total bilirubin
is less than 20 mg/dL, repeat in 24 hours
if the newborn is not on full volume feeds or
24 hours if the newborn is on full volume feeds. There are additional
measures that can be taken if the newborns
bilirubin levels continue to rise despite phototherapy. If this is the case and the
newborn’s bilirubin is still over 20 mg/dL, which is equal
to 340 micromole per liter, feed the newborn
under phototherapy lights rather than removing the
newborn from the phototherapy during feedings. Ensure that the newborn is
naked with no hat, blanket, or clothing covering his skin
ensuring that all skin is exposed to phototherapy. If the newborn is not already
receiving IV fluid, start an IV and provide hydration. Provide an additional
20 to 40 mL/kg per day to total fluid intake and
consider whether IV fluid boluses may be necessary. Continue enteral intake by
mouth or by nasogastric tube to promote excretion of
metabolized bilirubin. Cover the incubator
walls with white sheet to create a reflective
surface if needed. But, be careful not to cover
the ventilation system. If bilirubin exceeds
25 mg per deciliter, which is equal to 425
micromole per liter, and is not improving
with phototherapy, apply the previous measures
and give a 10 to 20 mL/kg normal saline bolus. Strongly consider
nasogastric tube feeding until the newborn’s
bilirubin levels fall below 425
micromole per liter to either supplement or intake. Or if the newborn is
not orally feeding well, give roughly 150 mL/kg per day
of milk via a nasogastric tube. Exchange transfusion
is a treatment for extreme
hyperbilirubinemia and it should be considered
if bilirubin is above 425 micromole per
liter and continues to rise. Phototherapy should
be discontinued once total serum bilirubin
levels falls below treatment thresholds in the table. After discontinuing
phototherapy, recheck total bilirubin
levels after 24 hours. If bilirubin is above
the treatment threshold, restart phototherapy. Remember the following
additional considerations when treating a newborn
with hyperbilirubinemia. Treat other conditions which
may worsen hyperbilirubinemia. If sepsis is suspected, monitor
full blood count and initiate antibiotics. If hemolysis is suspected,
monitor hemoglobin and assess for blood type incompatibility. Assess for, and treat malaria. Case Studies. The following case
studies will help us to review this material. You are caring for baby Robert,
a three-day-old term baby, who is recovering from transient
tachypnea of the newborn, and is ready to go home today. When you are doing his
discharge physical exam, you not that his
sclera are jaundiced, but not his palms or soles. He otherwise looks well. Now with a comfortable
respiratory exam, feeding well, voiding
and stooling regularly. You send serum bilirubin
level and it comes back at 170 micromoles
per liter, which is 10 milligrams per deciliter. What should you do? This is a physiologic
jaundice and does not require any therapy at this point. You should proceed with
discharging the baby to home. And as with any other
patients, if the family observes progressive
jaundice, this is a danger sign that
requires that they should seek further medical attention. The next patient is
Sabina, a 1.9 kg 32 weeks gestational girl who
is four days old. She is being treated for a
presumed perinately acquired infection based on
her mother having presented with signs
of chorioamnionitis and respiratory symptoms. She is on half volume feeds. On rounds today, you notice
that her sclera are jaundiced. When you look at her
palms and the soles, they are also
slightly jaundiced. You sent off a serum
bilirubin level and it comes back at 15 mg/dL. What should you do? This is non-physiologic
jaundice. Based on the guidelines, you
should start phototherapy. What should you do if you cannot
run a bilirubin level given her history and her physical exam? You should start phototherapy
because it is presumably quite high, given the jaundice
of her palms and soles. When should you
measure the next level? According to the protocol,
because the level is less than 20 and she’s
on half volume feeds, the next level should
be measured in 12 hours. Once she is under the
phototherapy lights, what other parts of her
care should you focus on? You need to take her
temperature every three hours and increase her fluid
intake by 20 mL/kg per day to accommodate for the
increased insensible losses of the lights. After being under
phototherapy for two days, her bilirubin comes
back at 10 mg/dL. What do you do? You discontinue the phototherapy
and check another level once she has been off
phototherapy for 24 hours. That level comes
back at a 9 mg/dL. What do you do? Her jaundice has been
treated and you do not need to check it again unless
you see a physical exam findings concerning
for jaundice. This chart summarizes the
assessment and treatment of hyperbilirubinemia. Summary. Having completed
this chapter, you should now be able to
recognize risk factors for hyperbilirubinemia in full
term and premature infants. To understand how to assess
for hyperbilirubinemia on physical exam and
initiate laboratory testing. Determine, initiate, and
manage appropriate treatment for hyperbilirubinemia
in the neonate. Keep in mind the following key
points on hyperbilirubinemia. Hyperbilirubinemia occurs when
an infant’s bilirubin levels become too high,
leading to jaundice. The major risk factors
for hyperbilirubinemia are prematurity, low birth
weight, hemolysis, sepsis, inborn errors of metabolism. Assessment for
hyperbilirubinemia can be conducted by measuring
serum bilirubin levels or by estimation based
on the physical exam. Hyperbilirubinemia is usually
treated with phototherapy. Treatment thresholds are defined
by serum bilirubin levels. Thank you so much for
your kind attention. Please help us improve the
content by providing us with some feedback.

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