10/04/62 4 Enzyme beta glucuronidase deconjugate direct bilirubin to indirect bilirubin Enterohepatic circulation PATHOGENESIS OF JAUNDICE ASSOCIATED WITH BREAST-FEEDING Breast Feeding jaundice Breast milk jaundice Type of milk Breast milk Breast milk Time onset 2-4 days 4-7 days Duration Within 1 week Maybe 8-12 weeks Mechanism Increase enterohepatic circulation Varies Management Proper BF Education Continue BF Avoid to stop BF *** Management Nomogram 95th percentile 75th percentile 40th percentile
10/04/62 5 Risk Zones as a Predictor of Hyperbilirubinemia TSB Before Discharge Newborns Newborns who later developed a TSB level > 95th percentile High risk 172 (6%) 68 (39.5%) High intermediate risk 356 (12.5%) 46 (12.9%) Low intermediate risk 556 (19.6%) 12 (2.26%) Low risk 1,756 (61.8%) 0 Total 2,840 126 Risk factors for develop severe Hyperbilirubinemia Risk Factors Major risk Minor risk Decrease risk Predischarge TSB/TCB High risk zone High intermediate risk zone Low risk zone Visible jaundice First 24 hours Before discharge GA 35-36 weeks 37-38 weeks ≥ 41 weeks Previous sibling Receive phototherapy Jaundice , No phototherapy Blood groups Hemolytic disease Blood group incompatibility With + DAT Other known hemolytic disease ( e.g., G6PD def. ) Feeding & BW Exclusive breast fed Excessive wt. loss Breast fed Exclusive Bottle fed Race East Asian Hispanic Black Other factors Cephalohematoma or Significant bruising Discharge from hospital before 36 hours Macrosomic IDM, Male gender Maternal age ≥ 25 years Discharge from hospital after 72 hours Female gender Treatment • Phototherapy • Exchange transfusion • Adjunctive therapy – Phenobarbital – Metalloporphyrins – Albumin – IVIG Guideline for Phototherapy Infant born at GA ≥ 35 wks Risk factors : Isoimmune hemolytic disease, G6PD deficiency, Asphyxia, Lethargy, Temperature instability, Sepsis, Acidosis, Albumin level < 3 g/dL AAP, CPG, Subcommittee on Management of Hyperbilirubinemia in infant ≥ 35 wks ,PEDIATRICS 2004 Guideline for Phototherapy Infant born at GA ≥ 35 wks • Use total bilirubin . Do not subtract Direct bilirubin • Provide conventional phototherapy at TSB level 2 – 3 mg / dL below those shown • Provide intensive phototherapy at TSB level fall above appropriate risk – group line for infant at particular age • Incubator / Warmer should be lined with aluminum foil / white material -> Increase efficacy of phototherapy • Infant who receive phototherapy and have cholestatic jaundice may develop bronze – baby syndrome
10/04/62 6 Guideline for Exchange Transfusion Infant born at GA ≥ 35 wks Risk factors : Isoimmune hemolytic disease, G6PD deficiency, Asphyxia, Lethargy, Temperature instability, Sepsis, Acidosis, Albumin level < 3 g/dL AAP, CPG, Subcommittee on Management of Hyperbilirubinemia in infant ≥ 35 wks ,PEDIATRICS 2004 Guideline for Exchange Transfusion Infant born at GA ≥ 35 wks • Use total bilirubin . Do not subtract Direct bilirubin • TSB rises to these level despite intensive phototherapy • If TSB is at or approaching exchange level, send blood for immediate type and crossmatch • For re-admitted infants, if TSB level > exchange level repeat TSB level every 2 – 3 hr and consider exchange if TSB remain above levels indicate after intensive phototherapy for 6 hr • Measure serum albumin and calculate B / A ratio Bilirubin/Albumin ratio Risk Category B / A Ratio at Which Exchange Transfusion Should be Considered B / A Ratio at Which Exchange Transfusion Should be Considered TSB (mg/dl)/ Alb(g/dl) TSB (μmol/L)/ Alb (μmol/L) Infants ≥ 38 0/ 7 wk 8 0.94 Infants 35 0/7 – 36 6 /7 wk and well or ≥ 38 0/ 7 wk if Higher risk or isoimmune hemolytic disease or G6PD deficiency 7.2 0.84 Infants 35 0/7 – 37 6 /7 wk if Higher risk or isoimmune hemolytic disease or G6PD deficiency 6.8 0.80 Indication of Phototherapy and Exchange Transfusion in LBW infants Okumura A et al, Kernicterus in preterm infants, Pediatrics 2009