Neonatal Jaundice:

S l i
Solving the
h CControversies
i
Assoc. Prof. Pimol Wongsiridej, MD.
Division of Neonatology,
Department of Pediatrics
FROM GUIDELINES TO CLINICAL
PRACTICE
 FOCUS OF AAPs 2004
GUIDELINE

z universal systematic
y assessment for the
risk of severe hyperbilirubinemia
z Close follow
follow-up
up
z Prompt intervention when indicated
 Key elements of the
recommendations:

z Promote and support successful breastfeeding

z Establish nursery protocols for the identification
and evaluation of hyperbilirubinemia
z Measure the total serum bilirubin (TSB) or
transcutaneous bilirubin (TcB) level on infants
jaundiced in the first 24 hours
z Recognize that visual estimation of the degree of
jaundice can lead to errors,
errors particularly in darkly
pigmented infants
z Interpret all bilirubin levels according to the
infants age in hours
 Key elements of the
recommendations:

z 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
z Perform a systematic assessment on all infants
before discharge for the risk of severe
hyperbilirubinemia
yp
z Provide parents with written and verbal
information about newborn jaundice
z Provide appropriate follow-up based on the time
of discharge and the risk assessment
z Treat newborns, when indicated, with
phototherapy or exchange transfusion
 Risk factor
assessment

Visual
assessment:
accuracy

Bilirubin
measurement

Follow up plan

Treatment
SCREENING INFANT AT RISK
FOR SIGNIFICANT
HYPERBILIRUBINEMIA
 Case 1.

z A 3-day-old
y infant,, born at 39 weeks byy
cesarean section, has no visibly apparent
jjaundice on the morning g of discharge.
g Is it
medically necessary to measure a bilirubin
g
before discharge?
 Screening methods available

z Jaundice assessment
z Bilirubin measurement
z Clinical risk assessment
z Combination
 Visual assessment of jaundice
extent

zQ
Questions in clinical p
practice??
Good correlation with bilirubin level ?
Predicting
g risk of significant
g neonatal
hyperbilirubinemia??
z Riskin A et al. J Pediatr 2008;152:782-7
;
z Karen T et al. Arch Dis Child Fetal
Neonatal Ed 2009;94:F317F322
Authors Riskin A et al Karen T et al
J Pediatr Arch Dis Child Fetal
2008;152:782-7) Neonatal Ed
2009;94:F317F322

Objectives: 1. Estimating bilirubin concentration

2. Predicting
g risk of significant
g
hyperbilirubinemia

Settings (Haifa Univ. of Pennsylvania

Medical Center (Haifa,
Israel) nursery
Study design Prospective cohort
Patients 3,532 observations of 522 term and late
1,129 newborns (GA preterm newborns
>35 weeks)
Authors Riskin A et al Karen T et al
Interventio Nurses and 5 Nurses using 5
5-point
point grading
n: neonatologists using Kramers scale
Kramers scale
Paired TSB within 5- Paired TcB or TSB within 8 h
10 minutes of jaundice assessment
Significant High intermediate risk TcB or TSB any time after
hyperbiliru and high risk zone of birth exceeded or was within 1
binemia Bhutanis normogram mg/dl (17 mmol/l) of hour-
definition specific phototherapy
treatment threshold
recommended by AAP
Mean age 62 + 24 hours 47 h + 9 hours
at time of
assessmen
t
Authors Riskin A et al Karen T et al
Results Good correlation weak correlated with bilirubin
between BiliEye and concentration among infants
actual TSB <38 wks compared
p with
infants >38 wks
unreliable poor overall accuracy for
as a screening tool to predicting risk of significant
detect significant hyperbilirubinaemia (c-
hyperbilirubinemia statistic = 0.65)
b f
before discharge
di h
complete absence of jaundice
had high sensitivity (95%)
and excellent NPV (99%) for
ruling out the development of
significant hyperbilirubinaemia
Modified Kramer scale : progression of
jaundice and intensity skin of color
correlated
l t d to
t TcB
T B levels
l l

Bhutani et al. Pediatr Clin North Am 2004; 51:84361.

 Case 1.

z A 3-day-old
y infant,, born at 39 weeks byy
cesarean section, has no visibly apparent
jjaundice on the morning g of discharge.
g Is it
medically necessary to measure a bilirubin
before discharge?
g
z Answers:
No clinically apparent jaundice
more than 60 h old and above 38-week
gestation
gestat o
visual assessment alone may be appropriate
clinical risk factor assessment performed
early newborn follow-up arranged
Clinical risk factors for severe
neonatal hyperbilirubinemia
Clinical risk factors for severe
neonatal hyperbilirubinemia
Clinical risk factors for severe
neonatal hyperbilirubinemia
 Case 2:

z You are taking

g care of a healthy
y 2-day-old
y
infant born at 39 3/7-week gestation. The
nurse pperformed the p
predischarge
g TcB
was 17 mg/dl at 46 h. What would your
action be?
BILIRUBIN MEASUREMENT
z Invasive methods for the measurement of
total serum bilirubin
z transcutaneous bilirubin measurement
 Predischarge bilirubin
screening
g

z Purpose
p of Predischarge
g bilirubin
screening (age 18 to 48 h)
identifies infants with bilirubin levels >75th
percentile for age in hours
tracks infants with rapid rates of bilirubin rise
(>0.2 mg per 100 ml per h)
 Total serum bilirubin
measurement

zp
powerful and significant
g screening
g tool in
term and late preterm infants
 Possible errors

z Pre-analytical
y errors
related to blood procurement procedure
rapidity
p y and conditions of transportation
p to the
laboratory
z Analytical
y errors
haemolysis, when collecting blood from a heel
p
prick,
, release of haemoglobin
g and other
intracellular compounds interfere with
chemical-based measurement of bilirubin
Nomogram for designation of risk in 2840 well newborns at 36 or
more weeks gestational age with birth weight of 2000 g or more
or 35 or more weeks gestational age and birth weight of 2500 g or
more based on the hour-specific serum bilirubin values
Outcome of newborns in the low-risk
zone
n =1756 (61.8%)
Outcome of newborns in the lower
intermediate-risk zone
n = 556 (19.6%
Outcome of newborns in the
upper intermediate-risk zone
n = 356 (12.5%)
Outcome of newborns in the high
risk zone
n = 172 (6.0%)
Predictive abilities of the 40th, 75th,
and the 95th percentile-based risk
zones
TRANSCUTANEOUS BILIRUBIN
MEASUREMENTS
 Benefit of TcB as point of care

z non-invasive
z Reduce Turnaround time, to access results
z fewer readmissions
z decrease hospitalization charges
z reducing number of skin punctures
 drawback

z increased operational
p costs
z May increased number of newborns
treated with phototherapy prior to
discharge
 TcB measurement sites

z measured on the forehead and sternum,,

TcB is similar to TsB
z sternum (r
(r=0.953):
0.953): better correlation
between TcB and serum compared to the
forehead (r
(r=0.914)
0.914) Maisels et al
z Point of care testing
g refers to any
y test
performed outside of laboratory by clinical
personnel and close to the site of p
p patient
care
TcB Devices comparison
TcB Devices comparison
 BiliCheck

z has been used as a screening

g device in
preterm infants
z cautious when skin
z measurements are performed in the
presence of peripheral
z oedema and/or a poor peripheral
ci c lation
circulation
z reduced the number of blood samples by
40%.
 TcB Devices comparison

z multiracial p
population
p of 289 neonates
z gestational age 35 to 41 weeks
z Devices: Bilicheck
Bilicheck, BiliMed
BiliMed, JM-103
z TSB>14 mg/dl used as cut-off
z correlation analysis : good results for
Bilicheck (r = 0.86) and JM-103 (r = 0.85)
but poor for BiliMed (r = 0,70)
bilicheck: underestimate TSB
JM-103: overestimate TSB

Raimondi et al. BMC Pediatrics 2012, 12:70

 Case 2:

z You are taking

g care of a healthy
y 2-day-old
y
infant born at 39 3/7-week gestation. The
nurse pperformed the p
predischarge
g TcB
was 17 mg/dl at 46 h. What would your
action be?

z Answers:
TcB measurement is above 12 mg/dl, a TSB
measurement should be performed
Nomogram for transcutaneous
bilirubin measurements among
healthy newborns

9397 TcB levels were measured in 3984 healthy infants

Maisels MJ, Kring E. Transcutaneous bilirubin levels in the first 96 h in a normal newborn
population of > or 35 weeks gestation. Pediatrics 2006;117:11691173.
 Use of TcB Measurements

z Not substitute for TSB

z TSB should always be obtained when
therapeutic intervention is being considered
z TcB tends to underestimate TSB, particularly at
higher TSB
z MeasureTSB if
TcB
T B at 70% off the
h TSB llevell recommended
d d for
f
phototherapy
TcB abo
abovee the 75th pe
percentile
centile on Bh
Bhutani
tani nomog
nomogram
am
or 95th percentile on a TcB nomogram
TcB >13 mg/dL at follow
follow-up
up after discharge
 AAPs 2009 Guideline: Update
and Clarification

z Clarifications
2 categories of Risk factors
z Update
Universal predischarge TSB/TcB Screening
after age 18 h and prior to discharge
Algorithm for management and follow up
 TABLE 1 Important Risk Factors
yp
for Severe Hyperbilirubinemia

Predischarge TSB or TcB measurement in the

high-risk or high-intermediaterisk zone
Lower gestational age
Exclusive breastfeeding, particularly if nursing
is not going well and weight loss is excessive
Jaundice observed in the first 24 h
Isoimmune or other hemolytic disease (eg,
G6PD deficiency)
d fi i )
Previous sibling with jaundice
C h l h
Cephalohematoma
t or significant
i ifi tbbruising
i i
East Asian race
z Guidance for work up and follow-up plan
 TABLE 2 Hyperbilirubinemia
y Risk Factors
Neurotoxicity

Isoimmune hemolytic disease

G6PD deficiency
Asphyxia
Sepsis
Acidosis
Albumin < 3.0 mg/dL

z Guide for making decision to initiate

phototherapy or exchange transfusion
 Usefulness of risk zone and
clnical risk factors

z When combined with the bilirubin risk

zone, most predictive clinical risk factors
are
Lower gestational age
Exclusive breastfeeding
g
Effect of gestation on risk
Algorithm for management and
p
follow up
Algorithm for management and
p
follow up
Algorithm for management and
p
follow up
Transcutaneous
bilirubinometer
(TcB)

Bilicheck

JM 103
 TcB

z Minolta AirShields Jaundice Meter,, JM103

R = 0.8 (p < 0.001)
Underestimate TSB
z Mean difference 0.7 1.6 mg/dL (95% CI
0.85 - 0.55 mg/dL)

Sanpavat S, et al. J Med Assoc Thai. 2004

 TcB

z SpectRx,
p , Bilicheck
R = 0.95 (p < 0.05)
Overestimate TSB
z mean difference 0.35 + 0.63 mg/dl (p > 0.05)

Janjindamai W, et al. J Med Assoc Thai.

2005
z web-based bilirubin decision
z support tool (BiliTool; http://bilitool.org
SIRIRAJ NEW CPG FOR
JAUNDICE
THANK YOU