Case-Based Approach to the Jaundiced Newborn

jmaisels@Beaumont.edu
 Disclosures
• I have no relevant financial rela7onships with
the manufacturers of any commercial products
and/or providers of commercial services
discussed in this CME ac7vity
• I do not intend to discuss an unapproved/
inves7ga7ve use of a commercial product/
device in my presenta7on
 Objec<ves
• At the end of this session par7cipants will:
•  Know how to iden7fy the relevance of a par7cular bilirubin level in a
newborn
•  Describe the use and limita7ons of the Bhutani nomogram
•  Know how to determine the rate of rise in serum bilirubin and why
this is relevant
•  List the risk factors for hyperbilirubinemia and know which are the
most important
•  Recall the posi7ve and nega7ve risks of an African American infant
for the development of severe jaundice
•  Know how phototherapy works and where it works
 Case
•  African-American male newborn
•  SVD at 40 3/7 weeks, to 36 yo G3P2002, group
O+ve mom
•  Apgars 9,9, 3633g AGA
•  Formula–fed, doing well

 Black male 40 weeks, formula-fed

•  ? Jaundiced at 20 hours
•  TcB 6.0 mg/dL
•  What to do?
What Does the Bhutani Nomogram Do for You?
25

20

95 th%ile
High Risk Zone
Serum Bilirubin (mg/dl)

ne 75 th%ile
Zo
isk
15
dia te R
te rme 40 th%ile
In ne
High is k Zo
iat eR
r med
Inte
10 Low

Low Risk Zone

0
0 12 24 36 48 60 72 84 96 108 120 132 144
Postnatal Age (hours)

Reproduced with permission from Pediatrics, 103; 6 - 14:© 1999 by the AAP
Does the Bhutani nomogram represent the
natural history of jaundice in the newborn?
•  At 36 hours TcB = 10.2 mg/dL
25

20

95 th%ile
High Risk Zone
Serum Bilirubin (mg/dl)

e 75 th%ile
k Zon
15 te Ris
rm edia
Inte ne 40 th%ile
Hig
h
is k Zo
te R
edia
In term
10 Low

Low Risk Zone

0
0 12 24 36 48 60 72 84 96 108 120 132 144
Postnatal Age (hours)

What to do now ? Which phototherapy line to use for this

infant?

Reproduced with permission from Pediatrics, 114; 297 – 316 :© 2004 by the AAP and Pediatrics 103; 6 - 14:© 1999 by
the AAP
Most likely cause of this infant’s jaundice?

•  Poor clearance of bilirubin

•  Hemolysis
•  Both
•  How do you know?
•  Can you test for hemolysis?
What is an excess bilirubin rate of rise?

•  0 -24 hours
•  24-48 hours
•  >48 hours
• Any jaundice risk factors in this infant?
• Any nega7ve jaundice risk factors?
Excluding hemolysis what are the
important risk factors for
developing hyperbilirubinemia ?
How important is gesta7on?
Repeat bilirubin at 40
hours was 13 mg/dL

Do you start
phototherapy?

Which line do you use?

Reproduced with permission from Pediatrics, 114; 297:© 2004 by the AAP


How does phototherapy work?

 Phototherapy – Where does it work?
•  Blanches the skin (Sister Ward)
•  Can measure this with TcB – 65% ↓ in skin
bilirubin in 2.5 hours (Donneborg Acta Paediatr 2010;99:1131)
•  Can we improve efficacy of phototherapy
by exposing unblanched skin to light?

 Turning the Baby

Supine

Plenty of skin bilirubin Blanched skin

Prone

Does this improve

efficacy ?
Plenty of skin bilirubin
Assuming your next bilirubin was obtained at
48 hours and was 8mg/dL and you are
discharging the infant, how do you know
when to schedule the follow-up and what to
do when you see the baby?