Neonatal Hyperbilirubinemia Savannah Keller

What is bilirubin?

Bilirubin is the bi-product of broken down red blood cells in the human body.
HYPERBILIRUBINEMIA = excess bilirubin in the blood

Bilirubin is normally filtered through the liver and kidneys and excreted in the urine. In newborn babies, the liver is not fully functioning within the first several days of life. Unable to filter the free bilirubin, it will build up throughout the body. Bilirubin has a yellow pigment that causes jaundice in the skin and sclera of eyes.

Question #1: What percent of healthy babies will develop Jaundice???

A. 10-20%

B. 30-40%

C. 50-60%

D. 70-80%

Hyperbilirubinemia risk: Kernicterus
  • When too much bilirubin accumulates in the bloodstream, it will not be excreted
  • Bilirubin will cross the Blood Brain Barrier and deposit in the brain tissue
  • Bilirubin has neurotoxic effects -- damaging the cells of the basal nuclei
  • Left untreated, it causes irreversible bilirubin induced encephalopathy, hearing loss, and death
  • Kernicterus

SYMPTOMS

Early stage
  • Extreme jaundice
  • Poor feeding and sucking
  • Extreme lethargy and sleepiness
  • Low muscle tone (hypotonia)
Middle Stage
  • Irritable
  • High pitched cry
  • Bulging on "soft spot" fontanel
  • Arched back and hyperextended neck (hypertonia)
Late Stage
  • Extreme muscle rigidity
  • Hearing loss
  • Seizures
  • Stupor, coma, death
Long Term Impact
  • Hearing loss
  • Cerebral Palsy
  • Impaired mental development
  • Kernicterus (irreversible brain damage)

CAUSES

1. Physiologic: "normal" response to life

In utero, fetus relies on the mother's placenta to safely remove bilirubin from the circulatory system. At birth, the babies' immature liver cannot process the BR.

2. Breast Feeding Failure Jaundice

If a breastfed baby becomes dehydrated waiting for their mother's breast milk to come in, they will produce less urine and BR will accumulate. This occurs in healthy, full term babies, and once feedings increase, the jaundice should fade.

3. Hemolysis: Mom/Baby Blood Incompatibility

Hemolysis is simply the breakdown of red blood cells. This commonly occurs when the mom and the baby have different blood types.

Hemolysis (RBC breakdown) > Clearance = JAUNDICE

TWO TYPES OF INCOMPATIBILITY

1. ABO Incompatibility: Even in healthy pregnancies it is common for the mother to have a different blood group than the baby. This will occur if the mother is type O and the baby is either A, B or AB.

2. Rhesus (Rh) Incompatibility: A more specific indicator that notes the "minor" blood type as either Rh (+) or Rh (-). Pregnancies are at risk when the mother is Rh(+) and the baby is Rh(-).

In both cases of incompatibility, when the mother's and babies' blood mixes in utero, the mother's immune defense system will identify the babies' red blood cells as foreign and develop antibodies against them. Once the baby is born, these antibodies will attack the babies' blood cells. This hemolysis of red blood cells causes hyperbilirubinemia.

Question #2: Which type of incompatibility is more severe?

A. ABO

B. Rh

Rh incompatibility is more severe then ABO, and more likely to place a newborn at risk for HDN (hemolytic disease of a newborn) associated complications.

WHY?
  • ABO is limited only to cases in which the mother is type O and baby is type A, B or AB
  • A limited amount of ABO antibodies will cross into the placenta
  • Newborn RBCs have less surface expression of the anti-A and Anti-B antigens
  • However, the Anti-IgG antibodies (Rh type) can readily cross the placenta and yield a more severe immune response.
Question #3: Which lab test is used to detect the presence of maternal antibodies against the babies' blood??

A. Rh screening test

B. Direct Antibody Test

C. Coomb's test

D. PKU test

The "Coombs Test" = Direct Antibody Test

Rh is one of the tested antibodies.

Indirect Coomb's Test: Part of a routine prenatal check up. Tests the mother's blood for the presence of antibodies that could attack the babies' RBCs. ***Indirectly predicts the risk of future HDN complications.

Direct Coomb's Test: Performed post delivery from the umbilical cord sample. Directly tests the babies' blood for the presence of antibodies (specifically Rh)

A positive Coomb's result.... What's DAT mean???
  • Antibodies against the babies' blood type are present
  • Increased risk for hemolysis
  • Increased risk for hyperbilirubinemia and jaundice
  • Increased risk for an HDN (hemolytic disease of newborn)
Interventions:

1: LOOK for Jaundice!

2. Monitor serum levels. Continue to monitor and plot babies' bilirubin if they are at a moderate to high risk.

Transcutaneous Test (TcB)Nurse swipes a handheld device across the babies' forehead.

Serum Test (SBR): Laboratory test from the umbilical cord or a heel stick blood sample.

3. Encourage breastfeeding or Formula boosts: If an exclusively breastfed baby is not feeding well for during days 1-3 you could try to increase hydration with a formula feeding before the mother can effectively breastfeed.

4. Phototherapy Lights: Blue wavelength light is absorbed into the babies' skin and aids in the breakdown of unconjugated bilirubin into a less toxic, water-soluble compound. The newborn must be naked except for an eye-shield and a diaper. For extra strength light therapy, the newborn can lay on top of a fiberoptic pad.

Serum BR should decrease by 1-2mg/dL every 4-6 hours spent under the lights.

5. Exchange transfusion: Although these are rarely indicated, if phototherapy is not effective, this procedure will rapidly decrease the serum bilirubin levels. Th exchange transfusion will remove any red blood cells that have been hemolyzed and replace them with donor red blood cells without the antibody against their blood type.

This procedure poses risks for air embolism, infection, vasospasm, and even death. It will only be performed if other options have been exhausted and are unsuccessful at lowering the SBR.

6. RhoGam immunoglobin

Question #4: In which scenario will a mother receive the RhoGam immunoglobin?

A. Mother is A+ and the baby is B+

B. Both the mother and baby are A+

B. Mother is A- and the baby is B-

D. Mother is A- and the baby is A+

When a mother is Rh- and the baby is Rh+ the mother will receive the RhoGam shot to protect the current fetus and any future embryos from the risk of hemolysis related conditions. She will receive a shot around week 28, week 34 and post delivery.

7. Education!!!! Sometimes jaundice appears several days after birth, after parents have already taken their baby home. Although this is uncommon with vigorous screening for bilirubin levels in the hospital, babies with poor feeding can develop jaundice. Parents need to know when it is necessary to call their provider.

Sources

Cherepnalkovski, A., Krzelj, V., & Zafirovska-Ivanovska, B. (2015). Evaluation of Neonatal Hemolytic Jaundice: Clinical and Laboratory Parameters. Macedonian Journal of Medical Sciences,3(4), 694-698.

Dean, L., MD. (2005). Hemolytic disease of the newborn. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2266/

Gee, K., MD (Ed.). (2015, April 27). Bilirubin encephalopathy. Retrieved from https://medlineplus.gov/ency/article/007309.htm

Hyperbilirubinemia and Jaundice. (2017). Retrieved from http://www.stanfordchildrens.org/en/topic/default?id=hyperbilirubinemia-and-jaundice-90-P02375

Kaplan, M., & Hammerman, C. (2005). Understanding severe hyperbilirubinemia and preventing kernicterus: Adjuncts in the interpretation of neonatal serum bilirubin. Clinica Chimica Acta,356(1-2), 9-21.

Kaplan, M., MBChB, Bromiker, R., MD, & Hammerman, K., MD. (2014). Hyperbilirubinemia, hemolysis, and increased bilirubin neurotoxicity. Seminars in Perinatology,38(7), 429-437.

Kernicterus. (2017). Retrieved from http://www.birthinjuryguide.org/birth-injury/types/kernicterus/

Medscape. (2016, January 2). Hemolytic Disease of Newborn Workup. Retrieved from http://emedicine.medscape.com/article/974349workup?pa=r8pAhe1XFd7eSQ%2FYW9y14bvGbBwTn3xMQQZ2Gi6JZDp3WffG%2FXJHu%2FFixEK2hMalyMooj%2FJ9Um1bHjm2S3mol%2FFDqoONiUtlOtdX6maZcRI%3D

My baby is Coombs positive. What’s D.A.T.? (2016, April 26). Retrieved from http://childrensmd.org/browse-by-age-group/baby-coombs-positive-whats-d-t/

Peeters, B., Geerts, I., Van Mullem, M., Micalessi, I., Saegeman, V., & Moerman, J. (2016). Post-test probability for neonatal hyperbilirubinemia based on umbilical cord blood bilirubin, direct antiglobulin test, and ABO compatibility results. European Journal of Pediatrics,175(5), 651-657.

Ulrich, T., Ellsworth, M., Carey, W., Carey, C., & Soma, D. (2015). Predictive Ability of Direct Antibody Testing in Infants Born to Mothers with Rh(D) and Other Minor Red Blood Cell Antibodies. American Journal of Perinatology,32(10), 987-992.

Credits:

Created with images by PublicDomainPictures - "adorable baby bath" • amrufm - "Baby Zara first look" • DariuszSankowski - "knowledge book library"

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