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Pediatrics👶🏻 > hyperbilirbiunimia
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hyperbilirbiunimia
 Flashcards

1
Q

Jaundice and Hyperbilirubinemia in the Newborn in general

A

Hyperbilirubinemia is a common and in most cases benign problem in neonates. Nonetheless, untreated severe, indirect hyperbilirubinemia is potentially neurotoxic, and conjugated-direct hyperbilirubinemia often signifies a serious illness. Jaundice is observed during the 1st wk of life in approximately 60% of term infants and 80% of preterm infants

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2
Q

Production of bilirubin

A

Bilirubin is produced mainly from old RBCs
o Old RBCs give rise to globin and haem
o Globin enter the amino acid pool of the body o Haem spilt into iron and biliverdin which change into unconjugated bilirubin
o Unconjugated (indirect) bilirubin has 3 criteria:

  • Fat solublep can cross Blood Brain Barrier (BBB)
  • Water insoluble p can not be excreted in urine
  • Detected by indirect Van Den Berg reaction
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3
Q

Conjugation of bilirubin

A

Conjugation of bilirubin stimulated by . glucoronyl transferase enzyme give rise to conjugated or cholebilirubin which is Cholebilirubin water soluble (excrectable in urine) and lipid insoluble (cannot cross BBB)

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4
Q

Defective conjugation: Glucoronyle transferase enzyme may be:

A

o Absent➡️ Criggler – Najjar syndrome type I

o Deficient➡️ Criggler – Najjar syndrome type II p Gilbert syndrome

o Immature➡️ Physiologic jaundice

o Under stimulated➡️ Hypothyroidism, hypoglycemia, hypoxia

o Inhibited➡️ Breast milk jaundice, Lucy- Driscoll syndrome

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5
Q

Non hemolytic causes (normal reticulocyte count.) of over production

A

😱 Extra vascular hemorrhage : Cephalhematoma & Internal hemorrhage
😱 Elevated RBCs load (Polycythemia) ➡️⬆️ RBCs turnover
😱 Enhanced enterohepatic circulation of bilirubin 2 ry to gastro intestinal stasis e.g. congenital pyloric stenosis and breast feeding jaundice

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6
Q

Clinical features of indirect hyperbilirubinemia

A

🍊 Skin and sclera: bright yellow / orange
🍊 Color of urine: usually normal.

🍊 Color of stool : may be dark
🍊 Possible Concurrent problems:(Absent in physiologic jaundice)
* Risk of kernicterus if indirect bilirubin exceeds the binding sites on

albumin or with leaky blood brain barrier
* Risk of anemia: if hemolysis exists

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7
Q

toxic effects⬆️ of indirect bilirubin

A

1- factors that reduce the retention of bilirubin in the circulation (hypoproteinemia, displacement of bilirubin from its binding sites on albumin by competitive binding of drugs such as sulfisoxazole and moxalactam, herbal tea, acidosis, increased free fatty acid concentration secondary to hypoglycemia, starvation, or hypothermia),
2 -factors that increase the

permeability of the blood-brain barrier or nerve cell membranes to bilirubin or the susceptibility of brain cells to its toxicity such as asphyxia, prematurity, hyperosmolality, and infection

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8
Q

Timing of Clinical jaundice indirect

A
  • 🍊In the 1 stday of life➡️ Hemolytic disease of newborn (Rh or ABO incompatibility (until prove otherwise).
  • 🍊In the 2 nd - 3 rd day of life
  • Physiologic jaundice
  • Criggler Najjar syndrome
  • Hemolytic anemia
  • 🍊By the 4 th –7 th days
  • Physiologic jaundice in premature
  • Hemolytic anemia
  • 🍊After the 1 st week
  • Breast milk jaundice
  • Hemolytic anemia
  • 🍊Persistent > 3 rd week
  • Criggler-Najjar syndrome
  • Physiologic jaundice in hypothyroid infant
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9
Q

Timing of direct hyperbilirubinemia

A
  • 🍐In 1 st day of life
  • TORCH infection
  • 🍐In the rest of 1 st week of life
  • Neonatal sepsis
  • TORCH infection
  • 🍐Persistent during 1 st month
  • Neonatal hepatitis (metabolic or infections )
  • Congenital biliary atresia.
  • Inspissated bile syndrome
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10
Q

Physiologic Jaundice

Icterus Neonatorum

A

⬆️ indirect bilirubin production from breakdown of fetal RBC combined with transient limitationin conjugation of bilirubin by the immature liver. It is a diagnosis of exclusion.

🍊In Term infant, it usually started in the 2nd-3rd day of life, peaking in 2nd-4th day & gradually it resolve after 5th-7th day. It rarely reachs > 12 mg/dl.
🍊In Preterm infant, it started in the 3rd-4th day of life, peaking in 4th7th day & gradually it resolve after 7th-9th day. It rarely reachs > 15 mg/dl. Thus it tends to be slower & longer duration with higher level.

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11
Q

Factors that suggest non-physiologic jaundice include:-😱😱😱

A
  1. Jaundice appears in the 1st day of life.
  2. TSB > 12 mg/dl in term or > 15 mg/dl in preterm infant.
  3. TSB that rapidly increasing > 5 mg/dl/day.
  4. Direct bilirubin > 2 mg/dl at any time.
  5. Jaundice that persist > 10-14 days.
  6. Other factors include: family hx of hemolytic disease, pallor, hepatomegaly, splenomegaly, vomiting, lethargy, poor feeding, excessive weight loss, abnormal vital signs, light-colored stools, dark urine positive for bilirubin, failure of phototherapy to lower bilirubin, and signs of kernicterus.
    7-• failure of phototherapy to lower bilirubin, vomiting, lethargy, poor feeding, excessive weight loss,
  • apnea, bradycardia, abnormal vital signs including hypothermia,
  • light-colored stools, dark urine positive for bilirubin, and signs of kernicterus
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12
Q

Physiologic Jaundice

Icterus Neonatorum

A

Physiologic jaundice is benign conditions that usually require no Rx except if other risk factors are presented e.g. prematurity; therefore it may need phototherapy.

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13
Q

Breast Milk Jaundice. Incidence

A
  • Affects 2-4 % of adequately breast fed, healthy full term.

- Recurrence rate 70% in subsequent pregnancies

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14
Q

Breast Milk Jaundice clinical picture

A

-Instead of the usual fall of serum bilirubin by the end of first week it continues to rise
_ Peaking at 10-15 days of age With a maximal level of 10-30 mg/dl
_ Decline slowly over weeks
_ If breast feeding is interrupted for 24-48 hours, bilirubin level drops quickly

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15
Q

Breast milk jaundice etiology

A

Unknown ; Breast milk may contain:

  • Pregnandiole Ļ inhibit glucoronyle transferase enzyme.
  • F glucoronidase Ļenhance entero hepatic circulation of bilirubin
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16
Q

Breast Milk Jaundice dx

A

By Exclusion (Normal liver functions &CBC) + Therapeutic trial

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17
Q

Gilbert Disease

A

Etiology

  • Autosomal dominant disorder.
  • Decreased hepatic glucoronyle transferase level.
    Clinical picture - Mild hyperbilirubinemia ,usually need no treatment
18
Q

Kernicterus definition

A

Yellowish staining of the cerebellar & cerebral nuclei (especially basal ganglia) due to deposition of unconjugated bilirubin resulting in neuronal necrosis.

19
Q

Kernicterus etiology

A

A. Level of serum unconjugated bilirubin exceeding critical values

  • > 10 mg/dl in the 1 st day
  • > 15 mg/dl in the 2 nd day
  • > 25 mg/dl afterwards

However kernicterus may occur at a lower levels in presence of risk factors:

a. Increased blood brain barrier permeability
- Prematurity & very low birth weight
- Acidosis
- Sepsis
- Asphyxia

  • Anemia
    b. Defective albumin/ bilirubin binding
  • Hypoalbuminemia < 3 gm /dl
  • Hypothermia

B. Duration of exposure to the high bilirubin level:

The longer the duration the more risk of kernicterus.

20
Q

Clinical picture of kernicterus

Acute

A

Usually appear 2-5 days after birth in term infants and by the 7th day in preterm

A. Acute bilirubin encephalopathy

🌝Early signs
o Lethargy, poor feeding and Lost Moro reflex are common initial signs
o High pitched cry and hypotonia with diminished tendon reflexes
o Respiratory distress
o Seizures
🌝Few days later
o Hypertonia of extensor muscles
o Opisthotonos with a bulging fontanel
o Fever
😐Many infants usually die during these phase
😐 Survivors from previous phase go onto lucid interval for few months p there’s apparent recovery or few symptoms.

21
Q

Kernicterus chronic bilirubin encephalopathy

A

Chronic bilirubin encephalopathy

  • Picture of Cerebral Palsy become apparent by the 1 st -3 rd year of life
  • Type : chorio asthetoid or spastic cerebral palsy
  • Clinical features:

Mental retardation

Squint

Seizures

Sensorineural deafness

Developmental delay Chorio asthetoid movements

Speech impairment

22
Q

Management of kernicterus

A

a- 🌝Prevention
* Adequate treatment of indirect hyperbilirubinemia (see before)
* Prevention and treatment of risk factors: e.g. sepsis, acidosis, asphyxia, …
b- 🌝Treatment
🌕Acute
o Immediate Exchange Transfusion is mandatory once kernicterus is suspected
o Extensive phototherapy while waiting for exchange and after exchange
o Close monitoring of TSB and serum albumin to tailor further management plan
o Investigate for and treat risk factors e.g. sepsis ,anemia, cephalhematoma
🌕Chronic Not curable, need only supportive treatment for cerebral palsy.

23
Q

TREATMENT OF HYPERBILIRUBINEMIA

A
  • 1-Phototherapy.
  • 2- metalloprotoporphyrin
  • 3- intravenous immunoglobulin
  • 4-Exchange Transfusion
24
Q

Phototherapy

Idea 💡

A

Exposure to blue-green spectrum (wavelengths 430-490 nm) ➡️ photo oxidises and isomerizes bilirubin ➡️ convert insoluble unconguated bilirubin to non toxic, soluble forms ➡️⬆️ excretion via urine and bile

25
Q

Phototherapy indications

A
  1. Treat moderately severe indirect hyperbilirubinemia in order to reduce need for exchange transfusion (In healthy full term at TSB 15-25 mg/dl and at lower levels in pretem and neonate with risk factors for kernicterus)
  2. During waiting for exchange transfusion.
26
Q

Side effects of phototherapy 💡💡

A
  1. Loose stool
  2. Skin rash and erythema of skin
  3. Hyperthermia
  4. Dehydration due to insensible water loss
  5. Damage to exposed eye or genitalia
  6. If used in direct hyperbilirubinemia ➡️ Bronzed baby syndrome
27
Q

bronze baby syndrome

A

dark grayish-brown discoloration of the skin sometimes noted in infants undergoing phototherapy. Almost all infants observed with this syndrome have had a mixed type of hyperbilirubinemia with significant elevation of direct-reacting bilirubin and often with other evidence of obstructive liver disease. The discoloration may be due to photoinduced modification of porphyrins, which are often present during cholestatic jaundice and may last for many months.

28
Q

intravenous immunoglobulin

A

0.5-1g/kg/dose repeted in 12hr reduced the needs for exchange transfusion in both ABO and Rh hemolytic disease by reduced hemolysis

29
Q

Exchange transfusion indications

A

1- In Rh and ABO incompatibility

  • Cord bilirubin > 5 mg/dl(normally <3 mg/dl)
  • Cord hemoglobin < 10 gm/dl
  • Rapid rise of bilirubin (> 1 mg/dl/hour) despite phototherapy
  • Early signs of kernicterus
  • Previous baby with kernicterus or severe erythroblastosis fetalis

2- In other causes: with high bilirubin level & phototherapy ineffective

30
Q

Exchange transfusion idea 💡

A
  • Remove excess unconjugated lipid soluble bilirubin.

- Remove antibodies from the circulation

31
Q

Exchange transfusion procedure

A

o Amount = double the neonate blood volume (2v85 ml/kg).
Weight285
o Small amounts (10-20 ml) are removed and replaced by equal amounts of the new blood through umbilical vein catheter

32
Q

Complications of acute complications

A

🙊Acute complications
noted in 5–10% of infants, include transient bradycardia with or without calcium infusion, cyanosis, transient vasospasm, thrombosis, apnea with bradycardia requiring resuscitation, and death. Infectious risks include CMV, HIV, and hepatitis. Necrotizing enterocolitis is a rare complication of exchange transfusion.

🙊chronic complications
observed carefully for the development of anemia and cholestasis. Late anemia may be hemolytic or hyporegenerative.
Portal vein thrombosis and portal hypertension

33
Q

Conjugated Hyperbilirubinemia definition

A

Rise of total serum bilirubin with the conjugated fraction > 15% of total Or > 2 mg/dl

34
Q

Causes of Conjugated Hyperbilirubinemia

A

1.Defective secretion of conjugated bilirubin by hepatocytes

a .Genetic - Rotor and Dubin Johnson syndrome

b. Acquired: (Neonatal hepatitis) due to:
* Infections : - Congenital infections e.g. TORCH
- Neonatal sepsis.
- Viral hepatitis : Echo, Herpes, EBV, Rarely HBV, HCV.
- Idiopathic neonatal hepatitis
* Metabolic : - E 1 antitrypsin deficiency (13 %)
- Galactosemia
- Tyrosinemia.’
2. Defective excretion due to bile flow obstruction

– Intrahepatic:

  • Congenital intrahepatic biliary atresia.
  • Intrahepatic biliary paucity (hypoplasia) e.g. Allagile syndrome – Extrahepatic:
  • Congenital extrahepatic biliary atresia.
  • Inspissated bile syndrome (Bile plug)
35
Q

Clinical feature Conjugated Hyperbilirubinemia

A
  1. Color of sclera p Greenish or muddy yellow
  2. Color of urine p Dark (bilirubinuria).
  3. Color of stool p Pale (or clay).
  4. Possible concurrent associations:
    - Hepatosplenomegaly.
    - Liver cells dysfunction.
    - Malabsorption and failure to thrive
    - Underlying systemic disease e.g. inborn error of metabolism, sepsis, TORCH.
    - No risk of kernicterus.
36
Q

Investigations of direct hyperbilirubinemid

A
  • Liver function tests.
  • Liver scan (HIDA scan, us scan,
  • Liver biopsy.
  • Metabolic screen for inborn errors of metabolism.
  • TORCH screen.
  • Sepsis screen
37
Q

Mechanisms of Hyperbilirubinemia in Sepsis?

A
  1. Hemolysis
    a. In normal red cells
    b. In RBCs with red cell enzyme defects (G6PD)
    c. Pathologic changes to RBCs secondary to infection d. Drug-induced hemolysis
  2. Hepatic dysfunction
    a. Decreased bilirubin uptake
    b. Decreased canalicular transport
    c. Decreased clearance of conjugated bilirubin d. Hepatic ischemia
    i. Hypotension
    ii. Prolonged Hypoxia
    e. Hepatocellular injury (mild reactive hepatitis to overt hepatocellular
    necrosis)
  3. Cholestasis
    Can be direct or indirect or both
37
Q

Hyper bilirubinemia within the first 24 hr of life

A 
😵erythroblastosis fetalis,
😰 concealed hemorrhage,
😁 sepsis,
😰 cytomegalic inclusion disease
😵, rubella, or 
👻congenital toxoplasmosis. 
🥸🥸🥸Hemolysis is suggested by a rapid rise of serum bilirubin (>0.5 mg/dL/hr), anemia, pallor, reticulocytosis, hepatosplenomegaly, and a positive family history
38
Q

Jaundice that first appears on the 2nd or 3rd day is

A

🤗usually “physiologic” but may represent a more severe form.

😓Familial nonhemolytic icterus (Crigler-Najjar syndrome)
🤯 breast-feeding jaundice are seen initially on the 2nd or 3rd day..

39
Q

Jaundice appearing after the 3rd day and within the 1st wk

A

😓bacterial sepsis or urinary tract infections; it may be due to other infections, notably syphilis, toxoplasmosis, cytomegalovirus, or enterovirus.
😑Jaundice secondary to extensive ecchymosis or hematoma may occur during the 1st day or later, especially in premature infants.
😐Polycythemia may lead to early jaundice

40
Q

Jaundice that is noted initially after the 1st wk of life

A

-prolonged physiological jaundice due to hypothyroidism 😤

breast milk jaundice, septicemia, congenital atresia of the bile ducts, hepatitis, galactosemia, hypothyroidism, CF, paucity of bile ducts, congenital hemolytic anemia (spherocytosis), or possibly the crises of other hemolytic anemias (such as pyruvate kinase and other glycolytic enzyme deficiencies or hereditary nonspherocytic anemia), or hemolytic anemia due to drugs (as in congenital deficiencies of the enzymes glucose-6phosphate dehydrogenase [G6PD], glutathione synthetase, reductase, or peroxidase

Pediatrics👶🏻 (55 decks)

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