Joanna Seliga-Siwecka Depatment of Neonatology and Neonatal Intensive Care Warsaw Medical University

Transcription

1 Joanna Seliga-Siwecka Depatment of Neonatology and Neonatal Intensive Care Warsaw Medical University

2 Learning objectives Explain bilirubin physiology Define neonatal jaundice List main causes of hiperbilirubinaemia in neonates Give examples of treatment for neonatal jaundice

3 Where it all began

4 Figure 1 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 1. Miss Jean Ward, in 1956, with one of the earliest infants given phototherapy at Rochford General Hospital. Courtesy of BMJ Publishing Group. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 4

5 Figure 2 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 2. The first artificial light apparatus devised for cradle illumination of infants at Rochford General Hospital. The hemicylindrical stainless steel reflector, suspended on a height-adjustable moveable gantry, contains eight 24-in light blue 40-W fluorescent tubes spaced 2 in apart. A cot can be wheeled underneath the reflector, and the lights can be switched on separately to vary the amount of power delivered.3 Reprinted with permission. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 5

6 Today s key points 1. What is jaundice? 2. Why do babies have jaundice? 3. How and when do we treat jaundice? 4. Why are we sooooo afraid of jaundice?

7 Figure 3 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 3. Neonatal bilirubin metabolism. From Stokowski.7 Reprinted with permission. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 7

8 1. What is jaundice? Neonatal jaundice is one of the most common clinical phenomena encountered in newborns. It is caused by the accumulation in the skin and sclerae of the yellow-orange pigment bilirubin (4Z,15Zbilirubin-IX-alpha), the predominant isomer that is formed naturally from the degradation of heme in mammals.

9 1. What is jaundice? Hyperbilirubinemia causes jaundice and, in the newborn, reflects the relative lack of bilirubin glucuronidation by the immature liver during the transitional period after birth.

10 Table 1 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c TABLE 1. Mechanisms of Hyperbilirubinemia Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 10

11 Figure 3 Fundamentals of Phototherapy for Neonatal Jaundice Increased bilirubin production Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c Impaired conjugation or excretion Inadequate / poor feeding FIGURE 3. Neonatal bilirubin metabolism. From Stokowski.7 Reprinted with permission. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 11

12 1.What is jaundice? Neonatal jaundice is caused by the accumulation in the skin and sclerae of the yellow-orange pigment bilirubin Hyperbilirubinemia causes jaundice and, in the newborn, reflects the relative lack of bilirubin glucuronidation by the immature liver during the transitional period after birth.

13 2. Why do babies have jaundice? Increased production of bilirubin Decreased erythrocyte life span (90 days versus 120) Inadequate erythropoesis Policythemia Decreased activity UDPG-T Increased hepato-enteric circulation ß-glucoronidase Impaired enteric flora Delayed / Poor feeding

14 3. How and when do we treat jaundice? Phototherapy Exchange transfusion Immunoglobulins

15 Guidelines for phototherapy in hospitalized infants of 35 or more weeks gestation. Note: These guidelines are based on limited evidence and the levels shown are approximations. et al. Pediatrics 2004;114: by American Academy of Pediatrics

16 Risk factors Isoimmune hemolytic disease Sigificant lethargy Asphyxia Temperature instability Acidosis Sepsis Albumin levels < 3mg/dl

17 Figure 4 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 4. The mechanism of phototherapy. When bilirubin molecules absorb light, 2 main photochemical reactions occur: Native 4Z, 15Z-bilirubin converts to 4Z, 15E bilirubin (also known as photobilirubin) and to lumirubin. Unlike 4Z, 15Z bilirubin, photobilirubin can be excreted via the liver without conjugation, but its clearance is very slow and its conversion is reversible. In the bowel (away from the light), photobilirubin is converted back to native bilirubin. Lumirubin is not reversible. So, although much less lumirubin than photobilirubin is formed, lumirubin is cleared from the serum much more rapidly, and it is likely that lumirubin formation is primarily responsible for the decline in serum bilirubin that results from phototherapy. Small amounts of native bilirubin are also oxidized to monopyrroles and dipyrroles that can be excreted in the urine. This is a slow process and only a minor contributor to the elimination of bilirubin during phototherapy. Diagram courtesy of Mary Puchalski. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 17

18 Figure 5 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 5. Two halogen spotlight are used to provide more complete coverage. Note that the lights are not superimposed over the same area of skin but are used to provide coverage over different body surface areas on this large infant. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 18

19 Figure 6 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 6. The Bili-Bassinet (Natus Medical Incorporated) is a phototherapy delivery system that provides combination phototherapy. Courtesy of Olympic Medical. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 19

20 Figure 7 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 7. Phototherapy system that comprises a light-emitting diode and the option to switch between single or double phototherapy at the touch of a button (NeoBlue, Natus Medical Inc, San Carlos, California). Courtesy of Natus Medical Inc. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 20

21 Figure 8 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 8. Halogen spot light phototherapy system. Courtesy of GE Healthcare. Reprinted with permission. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 21

22 Figure 9 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 9. Phototherapy systems that incorporate fluorescent tubes. Conventional bank lights (A) can be positioned over an infant in a bassinet or incubator. Courtesy of Olympic Medical. An overhead system that combines blue and white tubes is both effective and caregiver friendly (B). Courtesy of Draeger Medical. With the BiliBed (C), the infant lays on a soft mattress of fluorescent tubes, receiving highintensity phototherapy from below. Courtesy of Medela, Inc. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 22

23 Figure 10 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 10. Fiberoptic blanket phototherapy system. Courtesy of GE Healthcare. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 23

24 Figure 11 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 11. Using a radiometer to measure irradiance level during phototherapy. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 24

25 Figure 12 Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 12. Properly positioned phototherapy eye shields. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 25

26 Case 1 Term infant (38 GA) Feeding well No symptoms of sepsis Not pyrexial At 36 hrs of age bilirubin 15 mg/dl

28 Case 2 Term infant (38 GA) Not feeding well No symptoms of sepsis Temperature instability At 48 hrs of age bilirubin 14 mg/dl

30 Case 3 Term infant (35 GA) feeding well No symptoms of sepsis Awake and reactive At 48 hrs of age bilirubin 12 mg/dl

32 Case 4 Term infant (35 GA) Poor feeding No symptoms of sepsis At 72 hrs of age bilirubin 12 mg/dl

34 4. Why are we so afraid of jaundice? Encephalopathy Kernicturus

35 Encephalopathy

36 Encephalopathy Acute bilirubin encephalopathy Phase 1 (first few days of life): Decreased alertness, hypotonia, and poor feeding are the typical signs. Phase 2 (variable onset and duration): Hypertonia of the extensor muscles is a typical sign. Patients present clinically with retrocollis (backward arching of the neck), opisthotonus (backward arching of the back), or both. Infants who progress to this phase develop long-term neurologic deficits. Phase 3 (infants aged >1 wk): Hypotonia is a typical sign.

37 Encephalopathy Chronic bilirubin encephalopathy Extrapyramidal abnormalities: Athetosis Visual abnormalities Auditory abnormalities Cognitive deficits Abnormalities of dentition: dental enamel hypoplasia

38 Learning objectives Explain bilirubin physiology Define neonatal jaundice List main causes of hiperbilirubinaemia in neonates Give examples of treatment for neonatal jaundice

39 Explain bilirubin physiology Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, Laura A. Advances in Neonatal Care. 11():S10-S21, October doi: /ANC.0b013e31822ee62c FIGURE 3. Neonatal bilirubin metabolism. From Stokowski.7 Reprinted with permission. Copyright 2011 Advances in Neonatal Care. Published by Lippincott Williams & Wilkins. 39

40 2. Define neonatal jaundice Neonatal jaundice is caused by the accumulation in the skin and sclerae of the yellow-orange pigment bilirubin

41 3. List main causes of hiperbilirubinaemia in neonates Increased production of blirubin Decreased erythrocyte life span (90 days versus 120) Inadequate erythropoesis Policythemia Decreased activity UDPG-T Increased hepato-enteric circulation ß-glucoronidase Impaired enteric flora Delayed / Poor feeding

42 4. Give examples of treatment for neonatal jaundice Phototherapy Exchange transfusion Immunoglobulins

43 Case 5 Term infant (36+2 GA) Poor feeding No symptoms of sepsis ABO incompatibility At 36 hrs of age bilirubin 12 mg/dl

45 Thank you