Hyperbilirubinemia

Question 1

How is bilirubin produced?

Answer 1

produced from the breakdown of heme-containing proteins

-75% from erythrocyte HGB breakdown, 25% from other protein breakdown

Question 2

bilirubin found in amniotic fluid is concerning for what?

Answer 2

• some bilirubin is normal

- increased amounts concerning for hemolytic disease or intestinal obstruction

Question 3

what are other properties of bilirubin?

Answer 3

• potent antioxidant

- protection from oxygen see radicals

Question 4

what drugs knock bilirubin off albumin?

Answer 4

• salicylates, sulfonamides, sodium benzoate
• AMPICILLIN
• INDOMETHACIN

Question 5

other conditions that can knock bilirubin off albumin?

Answer 5

• hypoxia, acidosis
• hypothermia
• infection
• free fatty acids (IL, starvation)

Question 6

at what level is hyperbilirubinemia visually apparent?

Answer 6

-when levels are > 5-7 mg/dL

Question 7

what can cause hyperbilirubinemia in the first 24 hours of life?

Answer 7

• hemolytic disease
• congenital infection
• polycythemia

Question 8

when does physiologic jaundice peak?

Answer 8

• DOL 3 in term

- DOL 5 to 6 in preterm

Question 9

definition of pathologic jaundice

Answer 9

any of the following criteria:

• appears in 1st 24 hours of life
• increasing level > 5 mg/dL/d
• level > 12.9 mg/dL in term or >15 mg/dL in preterm
• lasts longer than 1 week in term or longer than 2 weeks in preterm

Question 10

if a baby is jaundiced longer than you think they should be, then check these two conditions:

Answer 10

• hypothyroidism

- hypopituiarism

Question 11

what is the recommended follow-up after discharge for hyperbili?

Answer 11

-the rule of 2s: within 2 days, within 2 weeks

Question 12

describe breast milk jaundice

Answer 12

• late onset, DOL 4-7
• incidence 10-30% from 2-6 weeks of life
• levels 12-20 mg/dL for up to 8 weeks
• caused by ingredients in breast milk

Question 13

describe breast feeding jaundice

Answer 13

• early onset, DOL 2-4
• caused by inadequate frequency and/or intake of milk
• prevention with frequent breast feeding 8-12 times/day until milk supply established

Question 14

Treatment of breast milk/feeding jaundice (AAP)

Answer 14

• interruption of breast feeding not encouraged in healthy infants
• levels should decrease by 72 hours, if not, must look for other causes

Question 15

Which population is at the greatest risk for kernicterus?

Answer 15

late preterm infant

poor feeding potential, decreased BBB, discharged early

Question 16

chronic problems from kernicterus?

Answer 16

• hearing loss
• cerebral palsy
• gaze abnormalities
• intellectual deficits

Question 17

describe the initial phase of kernicterus

Answer 17

• slight stupor/lethargy
• hypotonia
• paucity of movement
• poor suck
• high pitched cry

Question 18

describe the intermediate phase of kernicterus

Answer 18

• moderate stupor
• irritability
• hypertonia
• reverse C shaped arching (retrocollis)
• fever

Question 19

describe the advanced phase of kernicterus

Answer 19

• deep stupor to coma
• pronounced retrocollis
• no feeding

Question 20

What bili level is diagnostic of direct hyperbili?

Answer 20

> 2 mg/dL

Question 21

What can cause direct hyperbilirubinemia?

Answer 21

• liver cell injury (TPN cholestasis, infection, drugs)
• bile flow obstruction (biliary atresia, etc.)
• excessive bilirubin load (maternal/fetal blood group incompatibility)

Question 22

When should drugs be started for direct hyperbili?

Answer 22

when level is > 2 mg/dL