Neonatal Jaundice - Associates in Newborn Medicine

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neonatology neonatal jaundice Table 5. Major Clinical Features of Chronic Postkernicteric Bilirubin Encephalopathy ● Extrapyramidal abnormalities, especially athetosis ● Gaze abnormalities, especially of upward gaze ● Auditory disturbance, especially sensorineural hearing loss ● Intellectual deficits, but minority in mentally retarded range Reprinted with permission from Maisels MJ. Jaundice. In: MacDonald MG, Seshia MMK, Mullett MD, eds. Neonatology: Pathophysiology and Management of the Newborn. Philadelphia, Pa: Lippincott Co; 2005: 768–846. infants discharged before age 72 hours. The infant described in the case was a 36 weeks’ gestation, breastfed male who was discharged at age 30 hours. Two of the risk factors that have been shown repeatedly to be very important are a gestational age less than 38 weeks and breastfeeding, particularly if nursing is not going well. Almost every recently described case of kernicterus has occurred in a breastfed infant, and infants of 35 to 36 weeks’ gestation are about 13 times more likely than those at 40 weeks’ gestation to be readmitted for severe jaundice. These so called “near-term” infants receive care in well-baby nurseries, but unlike their term peers, they are much more likely to nurse ineffectively, receive fewer calories, and have greater weight loss. In addition, the immaturity of the liver’s conjugating system in the preterm newborn makes it much more difficult for the infants to clear bilirubin effectively. Thus, it is not surprising that they become more jaundiced. In addition, the infant’s TSB was 7.5 mg/dL (128.3 mcmol/L) at age 25 hours, a value very close to the 95th percentile (Fig. 2). Another TSB measurement should have been obtained within 24 hours and a follow-up visit scheduled no less than 48 hours after discharge. In addition, when the doctor’s office was told that the infant was not nursing well, was sleepy, and was jaundiced, the infant should have been seen immediately. The mother was describing the first stage of acute bilirubin encephalopathy (Table 4). Appropriate Follow-up is Essential If the infant in the case had been seen within 48 hours of discharge (before he was 4 days old), significant jaundice certainly would have been noted, bilirubin would have been measured, and he would have been treated with phototherapy, thus preventing the disastrous outcome Table 6. Risk Factors for Development of Severe Hyperbilirubinemia in Infants >35 Weeks’ Gestation (In Approximate Order of Importance) Major Risk Factors ● Predischarge TSB or TcB level in the high-risk zone (Fig. 2) ● Jaundice observed in the first 24 h ● Blood group incompatibility with positive direct antiglobulin test, other known hemolytic disease (eg, G-6PD deficiency), elevated ETCOc ● Gestational age 35 to 36 wk ● Previous sibling received phototherapy ● Cephalhematoma or significant bruising ● Exclusive breastfeeding, particularly if nursing is not going well and weight loss is excessive ● East Asian race* Minor Risk Factors ● Predischarge TSB or TcB in the high- to intermediate-risk zone (Fig. 2) ● Gestational age 37 to 38 wk ● Jaundice observed before discharge ● Previous sibling had jaundice ● Macrosomia in an infant of a diabetic mother ● Maternal age >25 y ● Male sex Decreased Risk (These factors are associated with decreased risk of significant jaundice, listed in order of decreasing importance.) ● TSB or TcB in the low-risk zone (Fig. 2) ● Gestational age >41 wk ● Exclusive formula feeding ● Black race* ● Discharge from hospital after 72 h *Race as defined by mother’s description. TSBtotal serum bilirubin, TcBtranscutaneous bilirubin, G-6PDglucose-6-phosphate dehydrogenase, ETCOcend tidal carbon monoxide concentration corrected for ambient carbon monoxide Reprinted with permission from Maisels MJ, Baltz RD, Bhutani V, et al. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114:297–316. that occurred. The AAP now recommends that any infant discharged at less than 72 hours of age should be seen within 2 days of discharge. Infants who have many risk factors might need to be seen earlier (within 24 h of discharge), which would have been appropriate for this infant. Such follow-up is critical to protect infants from Pediatrics in Review Vol.27 No.12 December 2006 447 Downloaded from http://pedsinreview.aappublications.org by J Michael Coleman on June 4, 2010
neonatology neonatal jaundice Table 7. The Ten Commandments for Preventing and Managing Hyperbilirubinemia 1. Promote and support successful breastfeeding. 2. Establish nursery protocols for the jaundiced newborn and permit nurses to obtain TSB levels without a physician’s order. 3. Measure the TSB or TcB concentrations of infants jaundiced in the first 24 h after birth. 4. Recognize that visual diagnosis of jaundice is unreliable, particularly in darkly pigmented infants. 5. Interpret all TSB levels according to the infant’s age in hours, not days. 6. Do not treat a near-term (35 to 38 wk) infant as a term infant; a near-term infant is at much higher risk of hyperbilirubinemia. 7. Perform a predischarge systematic assessment on all infants for the risk of severe hyperbilirubinemia. 8. Provide parents with information about newborn jaundice. 9. Provide follow-up based on the time of discharge and the risk assessment. 10. When indicated, treat the newborn with phototherapy or exchange transfusion. TSBtotal serum bilirubin, TcBtranscutaneous bilirubin Reprinted with permission from Maisels MJ. Jaundice in a newborn. How to head off an urgent situation. Contemp Pediatr. 2005;22: 41–54, with permission. Adapted from Pediatrics. 2004;114:297–316. severe hyperbilirubinemia and kernicterus. Nevertheless, clinical judgment is required at the time of discharge. If a 41-weeks’ gestation, formula-fed, nonjaundiced infant is discharged and has no significant risk factors (Table 6), a follow-up visit after 3 or 4 days is acceptable. The absence of risk factors and any decision for a later follow up should be documented in the chart. If, on the other hand, a 36-weeks’ gestation breastfed newborn is discharged on a Friday, he or she should be seen no later than Sunday. If follow-up cannot be assured and there is a significant risk of severe hyperbilirubinemia, the clinician may need to delay discharge. If weekend follow-up is difficult or impossible, a reasonable option is to have the infant brought to a laboratory for a bilirubin measurement (or a transcutaneous bilirubin measurement). Management of Jaundice in the Infant Interpreting Serum Bilirubin Levels TSB (or transcutaneous bilirubin [TcB]) concentrations generally peak by the third to fifth day after birth (Fig. 2 and Fig. 1-E). (The latter figure is available only in the online edition of this article.) In the past, when newborns remained in the hospital for 3 or 4 days, jaundiced babies could be identified before discharge and appropriately evaluated and treated. Today, because almost all infants delivered vaginally leave the hospital before they are 48 hours old, the bilirubin concentration peaks after discharge. Because the TSB has not yet peaked at the time of discharge, the AAP provides stringent guidelines for follow-up of all infants discharged before 72 hours of age: They should be seen within 2 days of discharge. In addition, it is essential that all TSB values be interpreted in terms of the infant’s age in hours and not in days. Although clinicians often talk about a TSB concentration on day 2 or day 3, Figure 2 (and Figure 1-E in the online edition) shows how misleading this thought process can be. A TSB of 8 mg/dL (136.8 mcmol/L) at 24.1 hours is above the 95th percentile and calls for evaluation and close follow-up, whereas the same level at 47.9 hours is in the low-risk zone (Fig. 2) and probably warrants no further concern. Yet, both values occur on postnatal day 2. In the case, the TSB value at 25 hours was 7.5 mg/dL (128.3 mcmol/L), very close to the 95th percentile. Consideration should have been given to additional investigations to try to determine why the infant was jaundiced, a subsequent TSB should have been measured within 24 hours, and follow-up should have been scheduled no later than 48 hours after discharge. When to Seek a Cause for Jaundice In some infants, the cause of hyperbilirubinemia is apparent from the history and physical examination findings. For example, jaundice in a severely bruised infant needs no further explanation, nor is there a need to investigate why a 5-day-old breastfed infant has a TSB value of 15 mg/dL (256.5 mcmol/L). On the other hand, if the TSB concentration is above the 95th percentile or rising rapidly and crossing percentiles (Fig. 2 and Fig.1-E in the online edition), and this cannot be readily explained by the history and physical examination results, certain laboratory tests should be performed (Table 8). Predicting the Risk of Hyperbilirubinemia Before discharge, every newborn needs to be assessed for the risk of subsequent severe hyperbilirubinemia. This can be accomplished by using clinical criteria (Table 6) or measuring a TSB or TcB concentration prior to discharge. In the case described, the infant had several risk factors for hyperbilirubinemia, and his TSB measured at 26 hours was in the high intermediate-risk zone (Fig. 2), 448 Pediatrics in Review Vol.27 No.12 December 2006 Downloaded from http://pedsinreview.aappublications.org by J Michael Coleman on June 4, 2010
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Neonatal Jaundice - Associates in Newborn Medicine

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