Hyperbilirubinemia in the Newborn

What is hyperbilirubinemia in the newborn?

Hyperbilirubinemia happens when there is too much bilirubin in babys blood. Bilirubin is
made by the breakdown of red blood cells. Its hard for babies to get rid of bilirubin. It can build
up in their blood, tissues, and fluids. Bilirubin has a color. It makes a babys skin, eyes, and
other tissues to turn yellow (jaundice). Jaundice may first appear when baby is born. Or it may
also show up any time after birth.

Risk factors for jaundice

About 6 in 10 full-term newborns get jaundice. So do 8 in 10 premature babies. Babies

born to mothers with diabetes or Rh disease are more likely to have this condition.

jaundice within first 24 hrs of life

a sibling who was jaundiced as neonate
unrecognized hemolysis
non-optimal sucking/nursing
deficiency of G6PD
infection
cephalhematoma /bruising
E - East Asian/North Indian NJ

Pathophysiology
The majority of bilirubin is produced from the breakdown of Hb into unconjugated bilirubin (and
other substances). Unconjugated bilirubin binds to albumin in the blood for transport to the liver,
where it is taken up by hepatocytes and conjugated with glucuronic acid by the enzyme uridine
diphosphogluconurate glucuronosyltransferase (UGT) to make it water-soluble. The conjugated
bilirubin is excreted in bile into the duodenum. In adults, conjugated bilirubin is reduced by gut
bacteria to urobilin and excreted. Neonates, however, have less bacteria in their digestive tracts,
so less bilirubin is reduced to urobilin and excreted. They also have the enzyme -
glucuronidase, which deconjugates bilirubin. The now unconjugated bilirubin can be reabsorbed
and recycled into the circulation. This is called enterohepatic circulation of bilirubin.

Causes hyperbilirubinemia in the newborn

Breastfeeding failure jaundice

Many babies dont breastfeed well at first. This causes breastfeeding failure jaundice. Not
feeding well makes your baby dehydrated. It also causes your baby to urinate less. This makes
bilirubin build up in your babys body. Babies born between weeks 34 to 36 of pregnancy are
more likely to get this problem. These babies often dont have the coordination and strength to
breastfeed well. But this condition is also common in full-term newborns. It usually gets better
once a baby learns how to breastfeed well.

Breastmilk jaundice
About 1 in 50 breastfed babies get jaundice. This happens during their first week of life. It peaks
at about 2 weeks of age. It can last 3 to 12 weeks. This issue may be caused by a substance in
breastmilk. This substance may increase how much bilirubin the baby's body can reabsorb.

Physiologic jaundice
Etiology
1. Decreased RBC survival 90 days, increased RBC vol /Kg, polycythemia of NB
2. Poor hepatic uptake due to immature liver- decreased ligandin or Y- protein
3. Poor conjugation due to enzyme deficiency- UDPG-T activity
4. Increased enterohepatic circulation due to - High level of intst beta-glucoronidase - delayed
colonization by bacteria - Decreased gut motility
5. Decreased hepatic excretion of bilirubin

During the first few days of life, babies arent able to get rid of much bilirubin. This type
of jaundice happens as a response to a babys reduced ability to remove bilirubin.
Seen both in term and preterms
Self limiting
Develops after 24 hours
Peaks by day 4- 5 in terms and day 7-8 in preterms
Peak levels -12mg/dl in term & 15mg/dl in preterm
Gradually subsides by 10-14 days
No Treatment necessary

PATHOLOGICAL JAUNDICE
Suspect if..
Jaundice in first 24 hours
Rise of >5mg/24 hours or 0.5 mg/dl/hr
Jaundice beyond physiological limits
Conjugated bilirubin- >2mg or 20% of total
Beyond 2 weeks
Signs of underlying illness ++

Causes of jaundice
Appearing within 24 hours of age
First 24 hours. This type of jaundice is often serious. Your child will likely need treatment right
away.
Hemolytic disease of NB : Rh, ABO
Infections: TORCH, malaria, bacterial
G6PD deficiency

Appearing between 24-72 hours of life

Second or third day. This is often physiologic jaundice. Sometimes it can be a more serious type
of jaundice.
Physiological
Sepsis
Polycythemia
Intraventricular hemorrhage
Increased entero-hepatic circulation

After 72 hours of age

Toward the end of the first week. This type of jaundice may be from an infection.
In the second week. This is often caused by breastmilk jaundice.
Sepsis
Cephalhaematoma
Neonatal hepatitis
Extra-hepatic biliary atresia
Breast milk jaundice
Metabolic disorders (G6PD).

What are the symptoms?

If a newborn has jaundice, his or her skin and the white part of the eyes will look yellow. The
yellow color shows up first in the baby's face and chest, usually 1 to 5 days after birth.
A baby whose bilirubin level is high may:
Get more yellow.
Be sluggish and not suck well.
Be cranky or jittery.
Arch his or her back.
Have a high-pitched cry.
A high bilirubin level can be dangerous. Make sure to call a doctor right away if your baby has
any of these symptoms.

Assessment
1)HistoryAntenatal Drugs ,Trauma Family H/O of jaundice Liver disease, delayed feeding ,
Sepsis Sibling jaundice , Splenectomy in family

2. General exam
Cramers Index
1.Face-4-6 mg/dl
2.Chest &Upper trunk 8-10 mg/dl
3.Lower abdomen,thigh-12 -14mg/dl
4.Forearms &lower legs -15 -18 mg/dl
5.Palms & sloes->15-20 mg/dl

Examine
Gestation age-preterm, IUGR Cephalhematoma, bruising Pallor-hemolytic anemia
Patechiea -sepsis, erythroblastosis, cong infections HSM-hemolytic anemia, infections
Evidence of hypothyroidism, infections

3) Lab investigations 1. Hemoglobin, PCV with peripheral smear 2. Total Bilirubin (Total / Direct
& Indirect) - >12 mg /<24hr - <12 mg/ >24 hr 3. Bilirubin level Special tests TORCH titres -
Thyroid function tests Metabolic work up - Sepsis screen USG / X ray abdomen Blood
group and Rh typing Reticulocyte count

Complications of hyperbilirubinemia in newborn?

High levels of bilirubin can travel to your babys brain. This can cause seizures and brain
damage. This is called kernicterus. If untreated, hyperbilirubinemia can result to kernicterus or
the deposition of bilirubin in the brain. Usually occurs if the bilirubin levels are 25mg/dl or higher
in term infants . Toxicity starts at 8-12 mg/dl in sick or low birth weights.

Clinical Features of Kernicterus ACUTE FORM

Phase 1(1st 12 days): poor sucking, stupor, hypotonia, seizures
Phase 2 (middle of 1st wk): hypertonia of extensor muscles, opisthotonos, retrocollis, fever
Phase 3 (after the 1st wk): hypertonia (hypotonia in Spitzer)

CHRONIC FORM
First year: hypotonia, active deep tendon reflexes, obligatory tonic neck reflexes, delayed motor
skills
After 1st yr: movement disorders (choreoathetosis, ballismus, tremor), up ward gaze,
sensorineural hearing loss

Management
Treatment will depend on your childs symptoms, age, and general health. It will also depend on
how severe the condition is.

Phototherapy
Phototherapy - Primary treatment - infant is unclothed and is exposed to 20 watt daylight or blue
fluorescent light at 30 inches.
. Principle Bilirubin absorbs light maximally in the blue range (420470 nm). Phototherapy
detoxifies bilirubin by converting it to photoproducts that are less lipophilic than bilirubin and that
can then be excreted without further metabolism

Side effects of phototherapy Increased insensible water loss: Frequent Breast feeding. Loose
green stools: weigh often and compensate with breast milk. Skin rashes: Harmless, no need to
discontinue phototherapy. Bronze baby syndrome: occurs if baby has conjugated
hyperbilirubinemia. If so, discontinue phototherapy. Hypo or hyperthermia: monitor temperature
frequently.

Fiber optic blanket

A fiber optic blanket is another form of phototherapy. The blanket it put under your baby. It may
be used alone or with regular phototherapy.

Exchange transfusion
Management Double volume exchange transfusion -160-180 ml/kg - the quickest way of
clearing the bilirubin from circulation. It is still the most effective and reliable method to reduce
serum bilirubin . The procedure involves the incremental removal of the patient's blood and
simultaneous replacement with fresh donor blood, saline or plasma.

Phenobarbital given to mothers at 30-60 mg/kg/day 2 to 3 wks prior to delivery or to infants at 5

mg/kg/day after birth is effective in reducing neonatal jaundice.

Hydration with breastmilk

The American Academy of Pediatrics says that you should keep breastfeeding a baby with
jaundice. If your baby is dehydrated from light therapy, you may need to supplement with
pumped breast milk or formula. You may also need to do this if your baby has lost too much
weight.

Treating any underlying cause of the condition this may include treating an infection.

Nursing considerations of Hyperbilirubinemia

Assessment:
observing for evidence of jaundice at regular intervals. Jaundice is common in the first week of
life and may be missed in dark skinned babies Blanching the tip of the nose

Nursing diagnosis
See the high risk infant plan of care.:
Body T., risk for imbalanced T. related to use of phototherapy
Fluid volume, risk for deficient related to phototherapy
Interrupted family process related to situational crisis, re hospitalization for the therapy. NJ -

The goals of planning

Infant will receive appropriate therapy if needed to reduce serum bilirubin levels.
Infant will experience no complications from therapy.
Family will receive emotional support
Family will be prepared for home phototherapy (if prescribed)