Jaundice

هیپربیلی روبینمی

ساعت۲۴، ترخیص کمتر از late pretermنوزادان •هیپربیلی روبینمی شدید٪۲نوزادان ترم درجاتی از هیپربیلی روبینمی، ۶۰٪•,Rh or ABO ،(G6PD) deficiencyناسازگاری ها • hereditary spherocytosis

BIND: علایم عصبی همراه با هیپر بیلی روبینمی •

اورژانس مدیکال : هیپر بیلی روبینمی علامت دار•

The best method for predicting hyperbilirubinemia is a timed total serum bilirubin (TSB) measurement, analyzed in the context of an infant’s gestational age and direct antibody test (DAT)

• Transcutaneous bilirubin (TcB) can be used as an initial screening tool

Alerting Signs:

At risk for jaundice

Routine screening for bilirubin levels:

• All infants at 24-48h of age

• Before discharge from hospital when they are less than 24 h old

For these at-risk infants, entry into the Jaundice Sequence occurs when thescreening bilirubin value is known

Infants with risk factors for hemolysis or who present with visible jaundice before 24 h of age require a

bilirubin measurement sooner

At risk for jaundice

Infants at increased risk for severe hyperbilirubinemia include:

• Late-preterm infants (34 to 36 w) who are discharged within 48 h of birth

• Infants born to mothers with known RBC antibodies

• Infants with significant bruising or cephalohematoma

• Infants of Asian, Middle Eastern, and Mediterranean backgrounds

• Infants with a sibling who had severe hyperbilirubinemia

Visible jaundice

• Jaundice may be noticeable with bilirubin at 85 μmol/L, but it can also remainundetected at levels as high as 204 μmol/L, even by experienced clinicians

• False negative assessments: In late preterm newborns and early dischargeand in infants with darker skin tones

• Bilirubin levels should be measured by TcB or TSB in all infants with visiblejaundice

Bilirubin at treatment level• Phototherapy thresholds

• Exchange transfusion thresholds

• Predictive nomogram for hyperbilirubinemia

For infants born at less than 35 weeks gestation, GA-specific phototherapygraphs are required to direct management

Phototherapy thresholds (term and late preterm infants)

Exchange transfusion thresholds(term and late preterm infants)

Predictive nomogram for hyperbilirubinemia

Core Steps

Organization of Care

Response

Bilirubin is below the phototherapy threshold

Bilirubin is at or above the phototherapy threshold and below the exchange transfusion threshold

Phototherapy treatment

Phototherapy is a well-established and effective intervention for managing hyperbilirubinemia that has significantly reduced the need for exchange transfusions in infants with severe or even critical hyperbilirubinemia

• Breastfeeding should be continued as infants receive phototherapy

• Supplemental fluids: should only be administered to infants who are at exchange transfusion threshold

• The goal of treatment is to maximize the rate of bilirubin clearance to prevent or minimize the neurotoxic effects of severe hyperbilirubinemia

Bilirubin is at or above the exchange transfusion threshold

Volume expansion

• Supplemental fluids can markedly reduce the frequency of exchange transfusions in infants whose bilirubin levels are near or at exchange levels, even when they are not obviously dehydrated

• An IV bolus of 10 mL/ kg 0.9% NaCl (normal saline) is administered initially, followed by a continuous dextrose infusion to supplement feeding

BIND Score

Intensive phototherapy

Irradiance greater than 30 μW/cm2/nmshould be administered to infants at higher risk:• DAT-positive• Suspected to hemolysis• TSB at or above the exchange transfusion

threshold

• Infants with a positive DAT who are at or progressing to exchange transfusion levels despite intensive phototherapy may benefit from IVIG at a dose of 1 g/kg

• Level 3 consultation and direction before initiating this treatment is essential

Intravenous immunoglobulin

Next Steps

History: Antepartum

• Maternal blood group Rh negative or type O

• Blood group incompatibility or maternal RBC antibodies

• Evidence of hemolysis, fetal anemia studies, or intrauterine transfusions

• Intrauterine maternal infection

• Previous infants with severe hyperbilirubinemia

•Family history of inherited disorders causing jaundice

• Splenectomy

Intrapartum

• High-dose oxytocin use

• Prolonged time before umbilical cord clamping

Neonatal

• Preterm or late preterm gestation

• Instrumented delivery, cephalohematoma, excessive bruising

• Poor feeding, decreased urine or stool output, or other signs ofdehydration

Focused physical examination

General appearance:

◦ Unwell appearance or lethargy (possible sepsis or BIND)

◦ Extent of jaundice

◦ Plethora or ruddiness (polycythemia)

Focused physical examination

• Hydration status, intake and output, and fluid requirements:

◦ Current weight compared with birth weight and percentage of weight loss

◦ Feeding frequency, eagerness to feed, latch and suck, duration of feeds

◦ Frequency of wet diapers, absence of (or excessive) stool output

• Presence of hepatosplenomegaly, ecchymosis, or petechiae

• Presence of cephalohematoma, excessive bruising

• Neurologic signs

Blood work

CBC:

• Hgb

• Blood group-type: mother and infant

• Reticulocytes: may indicate ongoing hemolysis

• An elevated white cell count or left shift may be seen in jaundice associated with infection

Electrolytes

• Hypernatremia: jaundice associated with difficulty feeding, poor intake, and dehydration

• Hyponatremia: jaundice associated with excessive fluid losses and dehydration

Albumin

• A low serum albumin: increase risk for neurotoxicity by increasing free unconjugated bilirubin

• Serum albumin level: when bilirubin at or above exchange level, and in cases of hyperbilirubinemia in extremely premature infants

Specific Diagnosis and Management