PEG SU

1 - 2 JUNE 2024

Prolonged Jaundice in Infants:

Guideline Update

Bagus Setyoboedi

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”

UKK
Gastrohepatologi
 PEG SU

KASUS

Bayi laki-laki umur 1 bulan dengan keluhan

kuning
• Kuning sejak umur 3 hari
• Air kencing seperti teh dan tinja kuning
pucat
• Ikterus, pembesaran hati 3x3x3 cm

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

JAUNDICE

• Yellowish discoloration of skin , mucous

membranes , and sclera
• The normal TSB level is < 1 mg/dl
• Neonatal clinical jaundice, if the TSB:
✓ > 5 mg/dL in FT NB
✓ > 7 mg/dL in preterm NB

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Jaundice Pathophysiology

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

No acute ill

BC BC ± Bu

Bu = unconjugated bilirubin, Bc = conjugated bilirubin, Bu + Bc = total bilirubin

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Neonatal Hyperbilirubinemia:
• TSB level is > 2mg /dl
• Common condition among NB babies most of the are benign problem
• Untreated severe unconjugated hyperbilirubinemia → potentially
neurotoxic
• Conjugated hyperbilirubinemia → often signifies a serious underling
illnesses

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

• Persistent (prolonged) jaundice → jaundice lasts longer than 14 to 21 days

→ 15% cases
• Can be unconjugated or conjugated hyperbilirubinemia → difficult to
differentiate clinically
• In the beginning: no physical findings that can differentiate between
unconjugated and conjugated hyperbilirubinemia
• Most causes of unconjugated hyperbilirubinemia are relatively benign
• Conjugated hyperbilirubinemia is NEVER normal and should always be
investigated → hepatobiliary disorder

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Bu Bc ± Bu
•Physiological dark urine
•Breast Milk acholic stools
•Hemolysis
-Rh
-ABO
•Hypothyroidism
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

CHOLESTASIS

Conjugated bilirubin
exceeds 1.5 to 2.0 mg/dl
Conjugated bilirubin >
20% of the total bilirubin

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Incidence of Cholestatic Disorders

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Others
15%

Neonatal Hepatitis
35%

INH
24%

(Bazlul Karim AS, Kamal M, Cholestatic jaundice during

infancy: experience at a tertiary-care center in Bangladesh,
Indian J Gastroenterology, 2005 Mar-Apr;24(2):52-4.)
Biliary Atresia
26%

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Bc ± Bu
dark urine

acholic stools

BEWARE!!! •hepatosplenomegaly
•bilirubinuria
•conjugated bilirubin
•abnormal LFTs

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Conjugated Hyperbilirubinemia

REFER
URGENTLY

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Kasai Procedure

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Kasai Procedure

❖ < 30-45 days → > 80% success

❖ < 60 days → improves outcome
❖ Complications: 40-93% cholangitis
(≥ 45 days →3.5x)
❖ 40-50% of “bile drainage” does
not improve
❖ > 60% require liver transplantation
❖ Success rate: multifactorial

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Serinet dkk, 2009; Superina dkk, 2011; Bijl dkk, 2013; Chardot dkk, 2013;
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE” Decharun dkk, 2015; Asai dkk, 2015; Yang dkk, 2022; Shiau dkk, 2023
 PEG SU

Liver Transplantation

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

Screening

www.perinatalservicesbc.ca

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU
Stool Color Charts

Ghazy et al, 2020

Gu et al, 2015 Omid et al, 2021

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM www.perinatalservicesbc.ca

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG
Screening?
SU

Arshad et al., 2023

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG
Screening? SU

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG
Screening? SU

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG
Screening? SU
Siph.sby

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG SU

GOALS OF TIMELY EVALUATION

❖ Test at 2 weeks (fractionated bilirubin levels at 2–3 weeks of age)

❖ Immediate intervention to address the underlying condition if
cholestasis is identified
❖ Further investigation of efficacy and feasibility of management for
neonatal cholestasis

EARLY DIAGNOSIS & PROMPT TREATMENT

(before 1-2 months old)
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
 PEG
Screening? SU

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”
PEG SU

TERIMA KASIH

UKK
Gastrohepatologi