HYPERBILIRUBINEMIA IN

NEONATES
Mentor:
dr. Pulung M. Silallahi, Sp.A
Written by:
Sarah Fajriah (1102011254)
PEDIATRIC DEPARTMENT
RADEN SAID SUKANTO POLRI HOSPITAL- JAKARTA
FACULTY OF MEDICINE YARSI

BILIRUBIN
Bilirubin is a tetrapyrrole and a breakdown product
of heme catabolism.
Most bilirubin (70%-90%) is derived from
hemoglobin degradation and, to a lesser extent,
from other hemo proteins.
In the serum, bilirubin is usually measured as both
direct bilirubin (DBil) and total-value bilirubin (TBil)

BILIRUBIN
Unconjugated
Bilirubin: BIL I

Indirect bilirubin
Water- insoluble
Bind to albumin for transport
Free fat-soluble components
Free components are toxic to
the brain

Conjugated
Bilirubin :BIL II

Direct bilirubin
Water soluble
Insoluble fat
Not toxic to the brain

HYPERBILIRUBINEMIA
HYPERBILIRUBINEMIA
Hyperbilirubinemia is an increase plasma levels of bilirubin 2
standard deviations or more from the level expected based on
the age of the baby or more than 90 percentile.

Clinical Symptoms:
Jaundice/Icterus:
Newborn icterus notable once total
bilirubin > 5-6 mg/dL (versus older
children/adults once > 2 mg/dL)
Progresses cranially to caudally
Visual assessment is subjective,
inaccurate, and dependent on observer
experience.

Hyperbilirubinemia
Elevated levels of bilirubin due to imbalance in
production,
transport,
uptake,
conjugation,
excretion, and reabsorption
Most
concerning
due
to
risk
for
encephalopathy/kernicterus if not treated rapidly

Hyperbilirubinemia
Disorders of Production: Increased RBC destruction

Isoimmunization:

Rh, ABO, other component incompatibilities

RBC Biochemical defects:

G6PD, pyruvate kinase deficiency

RBC Structural Abnormalities:

Spherocytosis, elliptocytosis, infantile pyknocytosis

Infection:

Bacterial, viral, protozoal

Sequestration:

Bruising, cephalohematomas, hemangiomas

Polycythemia:

IDM, delayed cord clamping

Hemoglobinopathy

Hyperbilirubinemia
Disorders of Hepatic Uptake:
Gilbert Syndrome
Other Causes:
Breastfeeding Jaundice
Lack of volume

Breast Milk Jaundice

Unknown mechanism
Possibly unidentified component in breast milk
that causes increased enterohepatic recirculation?

Infant of Diabetic Mother

Neonatal
Hyperbilirubinemia
Physiologic vs. Pathologic
Jaundice < 24 hrs is always pathologic
Indirect vs. Direct (Unconjugated vs.
Conjugated)

Hyperbilirubinemia can be due to physiological

or pathological process, or a combination of both
Newborn babies (neonates) appear yellow when
the serum bilirubin levels approximately 6mg / dl
Jaundice will appear in adults when the serum
bilirubin> 2 mg / dl

Jaundice Physiologic
Appear on the second and third day
Indirect bilirubin levels do not exceed 10 mg/dl in term
neonates.
Speed bilirubin levels do not exceed 5mg/dl per day.
Direct bilirubin levels do not exceed 1 mg/dl.
Jaundice disappeared in the first 10 days.
Does not have relation with pathological states.

Jaundice Physiologic

Jaundice Pathologic
Jaundice occurs in the first 24 hours.
Bilirubin level exceeds 10 mg% in neonates at term or
exceed 12.5% in preterm neonates.
Appointment of bilirubin more than 5 mg% per day.
Jaundice settled after the first 2 weeks.
Direct bilirubin levels exceeding 1 mg%.
Having a relationship with hemolytic process.

Jaundice Physiologic Vs Jaundice Pathologic

Babies have Jaundice in the First Week of

Life
Increased production of bilirubin
turnover cytochrome
A decrease in red blood cell age (70 to 90
days)
Decrease the excretion of bilirubin
A decrease in uptake in the liver
Decrease conjugation by the liver
Increased bilirubin enterohepatic circulation
Excretion of bilirubin improved after 1 week

Clinical Examination
Clinical examination can be done by using
adequate lightning.
One way of checking the degree of yellow in
neonates clinically , easy and simple is the
assessment according to Kramer

Indirek
Zone
1

Part of the Body

Head and Neck

Bilirubin Serum
uumol/l
100

Navel-Neck

150

Navel-Thigh

200

Arm + Leg

250

Hand + Foot

>250

Management of hyperbilirubinemia
Stimulate bilirubiun conjugated process by using
fenobarbital.
Decrease ehterohepatic circulation by giving oral food.
(Mengurangi
peredaran
enterohepatik
dengan
pemberian makanan oral dini)
phototherapy
Exchange transfuion
Inhibit the production of bilirubin
Inhibit hemolysis

Management of Indirect
Hyperbilirubinemia:
Indications for Phototherapy (Term/Near-Term Infants):

* Bhutani curves (as seen in AAP recommendations and YNHH NBSCU Guidelines)

Management of Indirect
Hyperbilirubinemia:
Indications for Phototherapy (Pre-Term Infants):
Gestational Age (weeks)

Total bilirubin level (mg/dL)

32 34 6/7

28 31 6/7

< 28

* Based on data from YNHH NBSCU Guidelines

Complication of Phototheraphy

Significant complications are rare

Separation of mother and baby
Increased insensible water loss and
dehydration in premature infants
Bronze-baby syndrome (infants with
cholestatic jaundice)

Cut of levels:
15 mg/dl (12 mg) in term infants
10 mg/dl in premature babies

Management of Indirect
Hyperbilirubinemia:
Indications for Exchange Transfusion (Term/Near-Term Infants):

* Adapted from AAP recommendations and YNHH NBSCU Guidelines

Treatment of Indirect Hyperbilirubinemia:

Exchange Transfusion:
Double-volume exchange
2 x blood volume = 2 x 80
cc/kg = 160 cc/kg

Takes about 1-1.5 hours

Exchange at rate of
~5cc/kg/3 min
Volume withdrawn/infused
based on weight

Kernicterus
Acute Bilirubin
Encephalopathy/Kernicterus:
Irritability, jitteriness, increased high-pitched
crying
Lethargy and poor feeding
Back arching
Apnea
Seizures
Long-term: Choreoathetoid CP, upward gaze
palsy, SN hearing loss, dental dysplasia