hyperbilirubinemia yale university新生儿高胆红素血症耶鲁大学课件

MELISSA NELSON, MD NEONATAL-PERINATAL FELLOW YALE-NEW HAVEN HOSPITAL Neonatal Hyperbilirubinemia Lecture Objectives: Describe bilirubin metabolism Understand clinical significance of hyperbilirubinemia Learn diagnostic approach and further work-up Distinguish indirect vs. direct hyperbilirubinemia Develop differential diagnoses for each type Understand management options for each type Apply this knowledge to several clinical cases Bilirubin: Biologically active end product of heme metabolism Bilirubin Metabolism: * Unconjugated bilirubin is bound to albumin in plasma (hydrophobic) Hyperbilirubinemia: Imbalance of bilirubin production and elimination In order to clear from body must be: Conjugated in liver Excreted in bile Eliminated via urine and stool Clinical Significance of Hyperbilirubinemia: Most common reason that neonates need medical attention “Physiologic jaundice” is a normal phenomenon during transition Becomes concerning when levels continue to rise Unconjugated bilirubin is neurotoxic Hyperbilirubinemia Apgars 9,9 Pregnancy and delivery without complications Currently DOL #2 (48h of life) Nurses noted that she looks like this and call you to the Well- Baby Nursery to evaluate her: Case #1: What else would you want to know? How is she feeding? How is it going? Is she stooling and voiding? How often? What is her current weight? How is she doing otherwise? Does she have any risk factors? Has she had her TcB checked? Has she had blood bilirubin levels checked? Case #1: Her mother is breastfeeding her. She thinks it is going well but this is her first baby and she is not sure if her milk is in yet. She is feeding for 20 minutes every 4 hours. Voided once and stooled several times since birth. Current weight is 2850 g (about 11% less than BW). She seems less active and is sleeping more today. No known risk factors. Mother and baby are both B positive. Total/direct bilirubin is 18/1 mg/dL. Case #1: What is your working diagnosis? BREASTFEEDING JAUNDICE Case #1: What would you do next? Initiate phototherapy Monitor serial bilirubin levels Encourage increased frequency of feedings (q 2-3h ATC) and consider supplementation prn Request lactation consult Bhutani Curve: Phototherapy Indication Case #2: Late pre-term baby boy born at 35 weeks BW 2500g; Apgars 8,9 Pregnancy and delivery without complications Currently DOL #1 (12 h of life) Nurses noted that he looks like this and called you into Room 1 to evaluate him: Case #2: What else would you want to know? How is he feeding? How is it going? Is he stooling and voiding? How often? What is his current weight? How is he doing otherwise? Does he have any risk factors? Has he had his TcB checked? Has he had blood bilirubin levels checked? Case #2: He is taking Neosure formula 2 ounces q 2-3 hours. Voided twice and stooled several times since birth. Current weight is 2500 g (same as BW). He is less active and sleeping more today. Mother is O positive and baby is A positive. Total/direct bilirubin is 18/1 mg/dL. Coombs positive. Case #2: What is your working diagnosis? ABO INCOMPATIBILITY Case #2: What would you do next? Exchange transfusion Bhutani Curve: Phototherapy Indication Exchange Transfusion Indication Case #3: Pre-term baby boy born at 28 weeks Currently DOL 21 BW 900 g; Apgars 5,8 Noted to have scleral icterus Bilirubin levels 7.2/3.4 mg/dL Case #3: What else would you want to know? Does he have any risk factors? How has he been acting clinically? Has he been receiving TPN? Any enteral feeds? Has he had any signs of infection? Does he have any syndromic features? What were his newborn screen results? Case #3: No known risk factors. He has been acting well without infectious symptoms. He had NEC on DOL #4 and has an ostomy and mucous fistula. He has been on TPN since then. No features concerning for syndromes. Newborn screening results were normal. Case #3: What is your working diagnosis? TPN-ASSOCIATED CHOLESTASIS Case #3: What would you do next? Try to advance enteral feeds and reduce TPN as soon as clinically possible Start “cholestasis protocol” Monitor bilirubin levels with LFTs every 2 weeks Consider further work-up if bilirubin levels do not improve over time once off TPN Summary: Hyperbilirubinemia is a common and potential serious issue in neonates Important to recognize and diagnose early in order to initiate prompt treatment when possible References/Further Reading: Yale-NHH NBSCU Guidelines: “Indications for phototherapy and exchange transfusion” Lange: “Neonatology: Management, Procedures, On-Call Problems, Diseases and Drugs” Fanaroff and Martin chapters on hyperbilirubinemia Keren R et al. Visual assessment of jaundice in term and late preterm infants. Arch Dis Child Fetal Neonatal Ed. 2