OPNF Hyperbilirubinemia Presentation 1) Definitions: a) Jaundice: _____________ discoloration of the skin and sclera caused by an elevated _________ level. b) Bilirubin: Metabolic end product of ____ breakdown. c) Always assess for jaundice in good lighting. Jaundice is not a reliable indicator for bilirubin level. 2) Bilirubin Physiology: a) Synthesis: Red blood cell breakdown Heme Biliverdin Bilirubin b) Bilirubin is _____ soluble. c) Transport: Bilirubin Free floating OR binds to Albumin and transports directly to the liver Taken up into the hepatocytes d) Metabolism (conjugation): Bilirubin is converted and becomes _____ soluble and secreted into bile and excreted then into the digestive track. e) Clearance/Excretion: i) Conjugated bilirubin changes into urobilinogen and excretes in urine. ii) Urobilinogen converts into stercobilinogen and excreted in the stool f) Enterohepatic circulation: Beta-glucuronidase from the lining of the small intestine deconjugates the bilirubin allowing it to be reabsorbed into circulation 3) Basics of Hyperbilirubinemia: a) Hyperbilirubinemia: _________ ___________ _________________ b) Physiologic Pathologic Jaundice after 24-48hr Jaundice within the first 24hr Requires no treatment Requires evaluation & treatment Peak: Day 3 in term, Day 5-6 in preterm Bili increases > 5mg/dL each day Resolved by 14 days of life Jaundice lasting longer than 14 days Normal infant appearance Can be anemic, discolored stools/urine Normal physiology of increased RBC Cause varies, any process that is destruction, reduced hepatic uptake, exaggerated enterohepatic reabsorption & decreased clearance c) Causes of Hyperbilirubinemia: i) Increased bilirubin production ii) Increased enterohepatic circulation iii) Decreased clearance of unconjugated bilirubin iv) Metabolic conditions v) Inborn errors of metabolism 4) Diagnosis a) Gold standard is the ___________________ which is the plasma level of bilirubin bound to albumin. b) Know mother’s blood type, specifically if mom is O or Rh negative. c) Coombs: a positive coombs indicates possible antibody-mediated hemolysis. d) Use an hour specific ___________. e) Rate of Rise = Current bili – Previous bili Number of hours between labs f) A rate of rise greater than or equal to ____ is considered elevated. g) Transcutaneous bili used on forehead or sternum, not on excessively hairy skin or over birthmarks, should not be used if a baby is undergoing phototherapy or exposed to sunlight. May be affected by skin pigmentation. 5) Types of Hyperbilirubinemia: a) Benign neonatal hyperbilirubinemia b) Significant hyperbilirubinemia c) Severe neonatal hyperbilirubinemia d) Extreme hyperbilirubinemia e) Bilirubin Induced Neurologic Dysfunction (BIND) i) Acute Bilirubin Encephalopathy ii) Chronic Bilirubin Encephalopathy formerly known as “______________” f) Breastmilk Jaundice g) Breastfeeding Jaundice 6) Treatment a) Phototherapy i) Use Nomogram to determine risk and need for treatment and recommended f/u b) IVIG c) Exchange transfusion 7) AAP Guidelines a) Promote and support successful breastfeeding i) Breastfeed __ to ___ times per day. Goal of __ to __ wet diapers per day b) Establish nursery protocols for the identification and evaluation of hyperbilirubinemia c) Measure the TSB or TcB level on infants jaundiced in the first 24 hours. d) Recognize that visual estimation of the degree of jaundice can lead to errors, particularly in darkly pigmented infants. e) Interpret all bilirubin levels according to the infant’s age in hours. f) Recognize that infants at less than 38 weeks’ gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring. g) Perform a systematic assessment on all infants before discharge for the risk of severe hyperbilirubinemia. h) Provide parents with written and verbal information about newborn jaundice. i) Provide appropriate follow-up based on the time of discharge and the risk assessment. j) Treat newborns, when indicated, with phototherapy or exchange transfusion. .