Medical Care of

neonatal jaundice
Dr.SAMER JENIDI

Medical Care

Phototherapy transfusion

Exchange

Drugs

Diet

Phototherapy

Phototherapy

Is the primary treatment . Was discovered serendipitously in England in the 1950s .

Why Phototherapy is effective?

Three reactions can occur when
bilirubin is exposed to light : 1- photooxidation 2- Configurational isomerization 3- Structural isomerization

Phototherapy effect photooxidation

Was

believed to be responsible for the beneficial effect of phototherapy. Although bilirubin is bleached through the action of light, the process is slow and is now believed to contribute only minimally to the therapeutic effect of phototherapy.

Phototherapy effect Configurational isomerization

Is a very rapid process that changes some of the predominant bilirubin isomer to water-soluble isomers .

The isomer constitutes 20% of circulating bilirubin after a few hours of phototherapy. This proportion is not influenced significantly by the intensity of light.

Phototherapy effect

Structural isomerization
Consists of intramolecular cyclization, resulting in the formation of lumirubin. This process is enhanced by increasing the intensity of light. During phototherapy, lumirubin may constitute 2-6% of the total serum bilirubin concentration

Phototherapy effect

Bear in mind

when initiating phototherapy :

lowering of the total serum bilirubin concentration is only part of the therapeutic benefit.

75-80% of the total bilirubin is present in a form that can enter the brain.

So

So

Phototherapy reduces the risk of bilirubin-induced neurotoxicity as soon as the lights are turned on.

Factors That Affect the Dose and Efficacy of Phototherapy

Wavelength Irradiation level Distance Bilirubin concentration Nature and character of the light source

Factors That Affect the Dose and Efficacy of Phototherapy

Wavelength
Irradiation level Distance Bilirubin concentration Nature and character of the light source

Wavelength
- Bilirubin absorbs light primarily around 450 nm. typically 425 to 475 nm - In practice, light used in wavelengths :

white, blue, and green

Factors That Affect the Dose and Efficacy of Phototherapy

Wavelength

Irradiation level
Distance Bilirubin concentration Nature and character of the light source

Irradiation level

A dose-response relationship exists

30-40 mW/cm2/nm. 6 mW/cm2/nm

Factors That Affect the Dose and Efficacy of Phototherapy

Wavelength Irradiation level

Distance
Bilirubin concentration Nature and character of the light source

Distance

Distance should not be greater than

50 cm (20 in)
and can be less if the infant's temperature is monitored.

Energy delivered decreases with increasing distance .

Factors That Affect the Dose and Efficacy of Phototherapy

Wavelength

Irradiation level Distance

Bilirubin concentration
Nature and character of the light source

Bilirubin concentration
The

efficiency of phototherapy increases with : - serum bilirubin concentration. - skin surface

Factors That Affect the Dose and Efficacy of Phototherapy

Wavelength Irradiation level Distance Bilirubin

Nature and character of the light source

Nature and character of the light source

- Quartz halide spotlights - Green light - Blue fluorescent tubes

Narrow-spectrum Ordinary
- White (daylight) fluorescent tubes - White quartz lamps - Fiberoptic light

The purpose of phototherapy

is

to avoid neurotoxicity.

Historical data

derived from infants with hemolytic jaundice suggest that :

total serum bilirubin levels greater than (20 mg/dL) were associated with increased risk of neurotoxicity, at least in full-term infants.

Autopsy findings
suggested that :

Immature infants were at risk of bilirubin encephalopathy at lower total serum bilirubin levels than mature infants.

But .

Unfortunately, because the endpoint of bilirubin neurotoxicity is permanent brain damage,

a randomized study to reassess the guidelines is

ethically unthinkable.

Indications for phototherapy

In

most neonatal wards, total serum bilirubin levels are used as the primary measure of risk for bilirubin encephalopathy. Test for serum albumin have failed to gain widespread acceptance.

Indications for phototherapy

A

number of guidelines for the management of neonatal jaundice have been published with significant disparity . This disparity illustrates how difficult to translate clinical data into sensible treatment guidelines.

Indications for phototherapy

The 2004 AAP guidelines represent a significant change from the 1994 guidelines.
The

emphasis on

preventive action and risk evaluation

is much stronger.

Indications for phototherapy

Physicians in different ethnic or geographic regions must consider factors that are

unique to their medical practice settings. Such factors may include : - racial characteristics - prevalence of congenital hemolytic disorders - environmental concerns

Key points in the practice

-

Maximizing energy delivery Maximizing the available surface area.

Key points in the practice

1 - Maximizing energy delivery : - Distance should be no greater than 50 cm and may be reduced down to 10-20 cm if temperature
homeostasis is monitored to reduce the risk of overheating. - Cover the inside of the bassinet with reflecting material; white linen works well. - Hang a white curtain around the phototherapy unit and bassinet.

These simple expedients can multiply energy delivery by several fold.

Key points in the practice

2- Maximizing the available surface area.

The infant should be naked except for diapers and the eyes should be covered to reduce risk of retinal damage.

Intermittent Versus Continuous Phototherapy ?

Clinical studies have produced conflicting

results. Individual judgment should be exercised.

If

the infants bilirubin level is approaching the exchange transfusion zone , phototherapy should be administered continuously until a satisfactory decline in the serum bilirubin level occurs or exchange transfusion is initiated.

What about insensible water loss?

New data suggest that if temperature homeostasis is maintained, fluid loss is not increased significantly by phototherapy.
In infants who are fed orally, the preferred fluid is milk, since milk serves as a vehicle to transport bilirubin out of the gut.

Timing of follow-up serum bilirubin ?

- In infants admitted with extreme serum bilirubin values ( 30 mg/dL):
monitoring should occur every hour or every other hour.--------- Reductions in serum bilirubin values (5 mg/dL/h).

- In infants with more moderate elevations of serum bilirubin :

monitoring every 6-12 hours .

Expectations regarding efficacy of phototherapy ?

- Bilirubin concentrations are still rising----- a significant reduction of the rate of increase . - Bilirubin concentrations are close to their peak----- phototherapy should result in measurable reductions in serum bilirubin levels within a few hours.

In general, the higher the starting serum bilirubin

concentration, the more dramatic the initial rate of decline.

When discontinuation of phototherapy?

When serum bilirubin levels fall

(1.5-3 mg/dL)
below the level that triggered the initiation of phototherapy. Serum bilirubin levels often rebound , and follow-up tests should be obtained within 6-12 hours after discontinuation.

What about prophylactic Phototherapy ?

No purpose

In general, the lower the serum bilirubin level, the less efficient the phototherapy.

Phototherapy complications

Phototherapy is very safe,

and it may have no serious longterm effects in neonates .

Phototherapy complications
Insensible

water loss is not as important as previously believed. Loose stools. Retinal damage Effects on cellular genetic material in vitro and animal data have not been shown any implication for treatment of human neonates. However, most hospitals use cut-down diapers during phototherapy .

Phototherapy complications

Skin blood flow is increased-- redistribution of blood flow may occur in small premature infants--

Increased incidence of patent ductus arteriosus (PDA) has been reported But this effect is less pronounced in modern servocontrolled incubators.

Phototherapy complications
Hypocalcemia

in premature infants . It

has been suggested that this is mediated by altered melatonin metabolism.

Deteriorationof

certain amino acids in

total parenteral nutrition (TPN) solutions Shield TPN solutions from light as much as possible.
Accidents have been reported, including

burns resulting from failure to replace UV filters.

Exchange transfusion

What are indications of Exchange transfusion?

Avoiding

bilirubin neurotoxicity when other therapeutic modalities have failed.

In addition, even in the absence of high serum bilirubin levels, the procedure may be indicated in infants with erythroblastosis .

Exchange transfusion
has been performed because of :
- Cord hemoglobin - Cord bilirubin - Rapid rate of increase in bilirubin <11 g/dL > 4.5 mg/dL >1 mg/dL/h

- More moderate rate of increase in bilirubin > 0.5 in the presence of moderate anemia Hb=11-13 - Hemolytic jaundice with bilirubin > 20 or a rate of increase that predicted this level (fear of 20) .
.

Why Exchange transfusion become a rare procedure ??

Immunotherapy in Rh-negative women So ,ABO incompatibility has become the most frequent cause of hemolytic disease in industrialized
countries.

Effective

phototherapy

Recently, immunotherapy has been introduced as treatment in the few remaining sensitized infants.

Results are promising

So.. When exchange transfusion

should be performed ? When phototherapy does not significantly lower serum bilirubin levels
Intensive phototherapy is strongly

recommended in preparation for an exchange transfusion. do not await laboratory

test results in these cases .

Does nonhemolytic jaundice cause Neurotoxicity ?

Many

physicians believe that hemolytic

jaundice represents a greater risk for neurotoxicity than nonhemolytic jaundice, although the reasons for this belief are not obvious .

In animal studies, bilirubin entry into the brain was not affected by the presence of hemolytic anemia..

DRUGS

What about Phenobarbital ?

an inducer of hepatic bilirubin metabolism

Several studies have shown that phenobarbital is effective . Phenobarbital may be administered : - pre-natally in the mother or - post-natally in the infant. However, concerns exist regarding the long-term effects of phenobarbital on these children.

What about IV immunoglobulin

(500 mg/kg) ?
Significantly

reduce the need for exchange transfusions in infants with isoimmune hemolytic disease.

The mechanism is unknown . Experience is somewhat limited, but it does not appear risky .

New therapy :
Mesoporphyrins and Protoporphyrins

Currently under development Inhibition of bilirubin production through blockage of

heme oxygenase.

Apparently, heme can be excreted directly through the bile .

This approach may virtually eliminate neonatal jaundice as a clinical problem.

But

Important questions
before the treatment can be applied
- Long-term safety ?.
- Complete understanding of putative role for bilirubin in light of data suggesting that bilirubin may play an important role as a free radical quencher ( anti-oxidant ) ?.

DIETE

Temporary interruption of breastfeeding is it recommended ?

It is not recommended
unless serum bilirubin levels reach 20 mg/dL

Supplementation with dextrose solution

is it recommended ?

It is not recommended
because - it may decrease caloric intake - it may decrease milk production - it may accelerate entero_hepatic circulation and consequently delay the drop in serum bilirubin concentration

So .. What is the recommendation ?

Increase breastfeeding to 8-12 times per day

Breastfeeding can also be supported with manual or electric pumps and the pumped milk given as a supplement to the baby.

Some questions ???

When infants can be discharged ?

When they are :

- feeding adequately

and

- demonstrating a trend towards

lower values.

Auditory function tests prior is advisable in infants who have had severe jaundice.

How to manage infants released within the first 48 hours of life ?

In the era of early discharge in recent years, a number of infants have developed kernicterus ---

Infants need to be reassessed for jaundice within 1-2 days.

Use of hour-specific bilirubin may assist in selecting infants .

nomogram

Are infants need follow-up obsevation after Bilirubin falls?

Infants

with hemolytic jaundice require follow-up observation for several weeks because hemoglobin levels may fall lower than seen in physiologic anemia. Erythrocyte transfusions may be required if
infants develop symptomatic anemia.

FinallyWhat about Prognosis ?

Prognosis

is excellent if the patient

receives treatment according to accepted guidelines.

The increased incidence of kernicterus in recent years may be due to the

misconception that jaundice in the healthy full-term infant is not dangerous

and can be disregarded.

thanks