What to Do when the Lights Don t Work- Neonatal Hyperbilirubinemia

Transcription

1 What to Do when the Lights Don t Work- Neonatal Hyperbilirubinemia Dr G Elske Hildes-Ripstein Dept of Child Health and Pediatrics University of Manitoba, College of Medicine Annual Scientific Assembly; April 19/2018

2 No Conflict of Interest to declare

3 Objectives Review current delivery of phototherapybiliblankets/fibreoptic light source Trouble-shoot nonresponse to phototherapy Recognize when to consult pediatrics/neonatology for NICU admission +- exchange transfusion

4 Why Treat Hyperbilirubinemia?

5 Acute Bilirubin Encephalopathy

6 Kernicteris Bilirubin staining: kernicteris From Neuropathology web.org T2 signal in globus pallidus

7 Still a Problem in Canada? Yes! *Sgro, CMAJ 2006 : 1/2480 critical hyperbilirubinemia. CPS Surveillance (excludes Rh) Ethnicity: 55.4% White, Asian 24.3%,Aboriginal 7.6%,Black 5.2%, Middle Eastern 4.0%, Latin American 2.8%, Other 1% Etiology: 20%- ABO incompatibility; 10% G6PD; 67% unidentified etiology Treatment: 22.1% exchange transfusion; 99.7% recieved phototherapy Outcome: 20% abn neuro outcome at discharge(hearing loss, seizures,motor)

8 Universal Bilirubin Screening >24 hours age and od until discharge Identifies infants at higher risk of needing phototherapy Can plan close follow-up as necessary Can start phototx earlier (see only in white skinned infant at 160mmol/L and poor concordance between observers) Better outcomes for infants ie decreased incidence of critical bilirubin >425mmo/L Decreased Bilirubin Encephalopathy + Kernicteris

9 Bhutani Nomogram of Risk level for subsequent hyperbilirubinmia

10 Transcutaneous Bilirubin Measurement How accurate? best with same machine, on same infant, same site, experienced user Useful to avoid continuous heel pokes/blood draws in infants and premature infants when assessing total neonatal bilirubin (direct + indirect) frequently Often used interchangeably with total Serum bilirubin for establishing whether should consider phototherapy not used to start or during phototx Can use again > 16 hrs post phototx

11 Initiating Phototherapy at hr specific threshold Risks; Minimal Increased temperature/increased water loss, bonding issues? other unknown? (4 decades of neonatal tx NO serious adverse clinical effects in infants.) Benefits; Effective >80% in avoiding Exchange transfusion Contraindications; if bilirubin is conjugated and use phototx get bronzed baby syndrome Porphyria or Photosensitizing drugs

12 Guidelines for phototherapy in infants of 35 or more weeks GA Subcommittee on Hyperbilirubinemia et al. Pediatrics 2004;114: by American Academy of Pediatrics

13 Initiating Phototherapy-other investigations? Consider Etiology of Hyperbilirubinemia Other investigations needed? -serum Tbili and Dbili base treatment decisions on serum levels only - Signs of Sepsis? septic work up or partial septic w/u needed? - Hemolysis? CBC+ smear, Direct Antibody Test (coombs), Blood type, G6PD

14 Appropriate Phototherapy Devices Phototherapy bed: Medela Bilibed Phototherapy*: 30 μw/cm2/nm Phototherapy Blanket: Ohmeda Biliblanket Plus*: μw/cm2/nm (setting can be dialed up or down) Ohmeda Bilisoft biliblanket (with cover)**: Small pad 50 μw/cm2/nm; Large pad 35 μw/cm2/nm Spot light phototherapy: Ohmeda Giraffe Spot PT lite**: μw/cm2/nm when source 15 inches above infant NOTE: The phototherapy units below do NOT provide adequate amounts of phototherapy. Air-Shields Vickers Phototherapy bank of overhead lights*: Average microwatts, minimum 10 μw/cm2/nm

15 Bili Blanket Use

16 Nonresponse to phototherapy 1. Interpretation; Bilirubin stays same level or even rises 2. Infant spends no time skin exposed to fiberoptic light source (biliblanket) 3. Load of unbound bilirubin too large for enterohepatic circulation/disposal a) hemolysing rapidly b) significant bruising or large cephalohematoma c)slow enteral transit time (1 st day feeding and small amounts) d)exclusive Breast feeding (inhibition of bilirubin conjugation) e) relatively low albumin levels (physiologic)

17 Interpretation of bilirubin level Same or rising bilirubin level in spite of phototherapy Depends on infant s hour of age ie whether on sloped part of trajectory or plateau Eg 257 mmol/l in 39 week GA infant at 24h Interpretation; Needs phototherapy initiated Eg 257 mmol/l in 39 week GA infant at 48 h or 72 h Interpretation; 72 may discontinue

18 Guidelines for phototherapy in infants of 35 or more weeks GA Subcommittee on Hyperbilirubinemia et al. Pediatrics 2004;114: by American Academy of Pediatrics

19 Interpretation of bilirubin level Same or rising bilirubin level in spite of phototherapy Depends on infant s hour of age ie whether on sloped part of trajectory or plateau Eg 171 mmol/l in 39 week GA infant at 36h Interpretation; No phototherapy needed Eg 257 mmol/l in 39 week GA infant at 48 h Interpretation; start phototherapy Eg 302 mmol/l in 39 week GA infant at 72 h Interpretation; following usual trajectory-response

20 Guidelines for phototherapy in infants of 35 or more weeks GA Subcommittee on Hyperbilirubinemia et al. Pediatrics 2004;114: by American Academy of Pediatrics

21 Infant has inadequate time or inadequate skin exposed to light Small baby and large diaper (Diaper covering much of back) Hat; therefore (large)amount of skin on head not in contact with light Interruptions/difficulty with holding or feeding baby with fiberoptic lights in place Not understanding medical need for phototherapy

22 (Non) Delivery of Phototherapy What s wrong with this picture????

23 Checklist for Optimal administration of Phototherapy Light Source (wavelength nm; blue green light region) Light Irradiance (>30µW/cm2/nm) and ensure uniformity over footprint Body Surface Area- expose maximal skin (reduce light blockage; hat,tape, diaper,probe) Continuity of therapy- No interruption for feeding, nursing or parental care/bonding until documented decrease in bilirubin 4-6 hours

24 3. Load of unbound bilirubin too large for enterohepatic circulation/disposal a) hemolysing rapidly; bilirubin rising >8mmol/hr b) significant bruising or large Cephalohematoma plus c) slow enteral transit time (1 st day feeding and small amounts) plus d) exclusive Breast feeding (inhibition of bilirubin conjugation by glucuronyl transferase) plus e) relatively low albumin levels (physiologic) OR COMBINATION MANY FACTORS!

25 Additional Management Options Dehydration? Supplemental enteral feeds (EBM, DBM, formula) Preferred as encourages passage of stool and decreased reabsorption bilirubin) or IV fluids 0-24 h; 65 cc/kg/day (9cc/h for 3.5 kg- 25cc q 3h) 24-48h; 80 cc/kg/day 48-72h; 100cc/kg/day 72-96h; 120cc/kg/day h; 150cc/kg/day

26 2 nd Phototherapy Source Giraffe Spotlight

27 Additional Management Options (2) Consider Sepsis Low albumin (< 22)? Consider IV infusion of albumin to increase protein binding and prevent from crossing Blood Brain Barrier If isoimmune hemolysis or within 35mmol Exchange level; give IVIG

28 When to consult for Advice/Transfer Trajectory or slope of serial bilirubins rising ie brisk hemolysis- may need cardiorespiratory support if severe anemia Needs Exchange Transfusion or close to hour specific Exchange Level for Gestational Age/ neurotoxic risk factors Other management options not available at institution needed; ie use of IVIG infusion, giraffe spot light (requires 1:1 or 1:2 nursing)

29 QUESTIONS? COMMENTS?

30 DSM Lab Update on Reporting Serum Bilirubin Effective April 17/18 for infants 30 days to 3 months Report a Direct Bilirubin for every value over 17 mmol/l. If Dbili >20% Tbili; comment.. Elevation of DBili is pathologic. Prompt evaluation for neonatal cholestasis needed discus with Ped GI or Peds. < 30 days only ordered Bilirubin test done ie Tbili only is default (Direct only if ordered)

31 References 1. Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or more Weeks of gestation. Bhutani V.K. and Comittee on Fetus and Newborn; Pediatrics 2011;128;e Management of Hyperbilirubinemia in the Newborn Infant 35 or more weeks of gestation. American Academy of Pediatrics; Subcommittee on Hyperbilirubinemia. Pediatrics 2004;114(1): Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks gestation). Canadian Pediatric Society Position Statement (FN ) Paediatrics and Child Health 2007;12 Suppl B 1-12.

32 WRHA Home Phototherapy Program Enrollment Criteria -term infant >48 hours old -TSB requiring photo but not exceeding level by> 50mmol -Coomb s test or DAT neg -no significant dehydration (wt loss <10%) -passing urine and stool -no co-morbidities; clinically stable -Pt lives within Winnipeg (PHN program for daily F/Uclinical assessment of hydration, wt and daily TSB ) -parent s consent