Yellow baby. Subtitle

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1 Yellow baby Subtitle

2 Management of neonatal hyperbilirubinemia - What is the evidence for the numbers we use? Prevention of kernicterus / BIND what bilirubin values should we treat???? BIND lo er alues tha harm? e k o to e safe a ause babies with higher values remain well are we over zealous in inv and treatment Is bilirubin the real test???? Are there other factors

3 Different guidlelines guidleines of various countries- numbers.pdf

4 Common ABE High values > 5 over threshold Not falling Continuing to rise Preterm Hemolysis Sick Low birth weight

5 Is there e ide e for

6 Bilirubin and brain

7 Bilirubin pump out Conversion to non toxic

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16 No e ide e to support e ha ge kernicterus Although no recent data from RCTs support the effectiveness of ET, there is consensus that it is effective in reducing TSB and in preventing bilirubin neurotoxicity. Therefore, it is categorized as likely beneficial.

17 Reversal of BERA after exchange

18 hospital PT: Cochrane review 2001: PT is categorized as beneficial.

19 Paediatr Int Child Health May High-intensity light-emitting diode vs fluorescent tubes for intensive phototherapy in neonates. Sherbiny HS1, higher success rates of intensive phototherapy treated with super LED (group 2) than in those treated o e tio all group % s %, P =.. Significantly higher 'bilirubin decline' rates were reported in both haemolytic and non-haemolytic subgroups treated with the super LED bed compared with a similar sub-population in the conventionally treated group. Comparable numbers of neonates in both groups developed rebound jaundice (8% vs 10% of groups 1 and 2, respectively). Side-effe ts ere ild i oth groups, ut higher rates of h perther ia % s %, P =., deh dratio % s %, P =. a d ski rash % s %, P =. ere reported i the fluores e t tubes-treated group compared with the LED group. CONCLUSIONS: Super LED is a safe rescue treatment for severe neonatal hyperbilirubinaemia, and its implementation may reduce the need for exchange transfusion.

20 Pediatr Dermatol Jan-Feb;33(1):62-8. doi: /pde Epub 2015 Dec 8. Neonatal Blue Light Phototherapy and Melanocytic Nevus Count in Children: A Systematic Review and Meta-Analysis of Observational Studies. Lai YC1, Yew YW1,2. Author information RESULTS: Five studies with a total of 2,921 subjects were included, of whom 642 underwent NBLP. With random-effects modeling, those who had previous NBLP did not have a significantly higher mean number of melanocytic nevi (WMD = 0.32 [95% confidence interval -0.67, 1.31], p = 0.53). CONCLUSION: There was no evidence that prior NBLP exposure significantly increased the number of melanocytic nevi. Available evidence has not revealed any cause for major concern for NBLP

21 Title anmanagement of neonatal hyperbilirubinemia - What is the evidence for the numbers we use? d Content Layout with List all paediatri ia s a d eo atologists ha e their e pert opi io s on almost all matters concerning the management of hyperbilirubinaemia

22 Fear of 20 story Although there is no strong evidence, beside the kernicterus registries, on the relationship between hyperbilirubinaemia and adverse outcomes, both guidelines agree that children with bilirubin levels above 340 lmol L should e treated.

23 No evidence linking kernicterus

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25 Evidence of risk factors for SH Does risk factor assessment accurately identify infants who may benefit from bilirubin testing?

26 Study 1 newman 2005 Nested case control Cases - all term and near-term infants with a 30 days after birth a i u TSB g/dl in the first controls were randomly sampled from the cohort in the study period AUC value of 0.84 (95% CI: ) Newman 2005 (Study 2) retrospectively included all infants discharged before 48 hours after birth who had a TSB measured before 48 hours in the study period TSB g/dl at 48 hours or older after birth AUC value of 0.69 (no data for the 95%CI)

27 Study 2 keren Retrospective - Pre and post discharge values outcome of significant hyperbilirubinemia was defined as a post-discharge TSB greater than 95th percentile on the hour-specific bilirubin nomogram, which is earl ide ti al to the phototherap threshold ur e re o e ded for ediu risk i fa ts i the AAP s li i al pra ti e guideli e Keren 2005 reported an AUC value of 0.71 (95% CI: 0.66, 0.76) for their risk score

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29 Does bilirubin testing accurately identify infants who may benefit from phototherapy? Ability of early TSB measurements to predict high late TSB measurements

30 Skin does it represent blood / tissue!!??!!

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35 Clinical benefits of tcb screening Decrease in readmission for severe hyperbilirubinemia

36 Decrease in Severe Hyperbilirubinemia

37 Zhonghua Er Ke Za Zhi Nov;53(11): [Predictive value of hour-specific transcutaneous bilirubin nomogram for neonatal hyperbilirubinemia: a national multicenter study]. During h, h and h after birth, the TcB before discharge were in the high-risk zone, its prevalence was 49.4%, 67.3%, 80.4%, its likelihood ratio was 6.20, 13.0, and 27.8, respectively

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39 Tcb after start PT Fourteen studies were identified. The pooled estimates of correlation coefficients (r) during phototherapy were: covered sites 0.71 (95% CI , 11 studies), uncovered sites 0.65 (95% CI ), 8 studies), forehead 0.70 (95% CI , 12 studies) and sternum 0.64 (95% CI , 5 studies). Two studies also provided results as Bland-Altman difference plots (mean TcBTSB differences and 30 µmol/l, respectively). The correlation coefficient improved marginally in the postphototherapy phase (r = 0.72, 95% CI , 4 studies) Neonatology. 2016;109(3): doi: / Epub 2016 Jan 21. Effect of Phototherapy on the Reliability of Transcutaneous Bilirubin Devices in Term and NearTerm Infants: A Systematic Review and Meta-Analysis. Nagar G1, Vandermeer B, Campbell S, Kumar M.

40 Combination of risk and bilirubin values

41 Production more / excretion uniformly slow

42 More source in meconium than we think!

43 Genetic differences

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50 Arch Pediatr Mar; [How to assess clinical practice guidelines with AGREE II: The example of neonatal jaundice]. DISCUSSION: The NICE guideline is the most valuable guideline regarding the AGREE II score. NICE showed that, despite a strong and rigorous methodology, there is no evidenced-based recommended code of practice (RCP). Comparing RCPs, we found no major differences. CONCLUSION: The NICE guideline showed the best quality. The AGREE II instrument should be used as a framework when developing clinical practice guidelines to improve the quality of the future guideline

51 jaundice-in-newborn-babies-under-28-days pdf

52 What should we do? Educated parents a te atal / la tatio / efore dis harge Educating professionals about screening in hospital / post discharge Non invasive TcB decrease sampling TSB + risk factors Better phototherapy Risk of PT BIND NNJ emergency - encephalopathy / 24 hrs / preterm / high value - high risk What is the best resource / guideline

53 Science and application

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55 Hyperbilirubinemia in jj Gunn rats results from a deficiency of hepatic UGT1A1, similar to that seen in human patients with Crigler-Najjar type I and analogous to the decreased conjugating activity seen in human neonates during the first days of life As in severely jaundiced newborns, the high levels of UCB in plasma of jj Gunn rat pups, with B/A ratios exceeding 1.0 at d2 and d9, resulted in accumulation of UCB in the tissues in the early neonatal period; in jj Gunn pups, this causes marked cerebellar hypotrophy from d9 onward In heterozygous (Jj) Gunn rats, the milder, early, temporary hyperbilirubinemia did not impair cerebellar growth, suggesting that the 0.36 B/A ratio found at d2 may be safe. It is interesting that d2 jj rats showed no signs of bilirubin toxicity suggesting that it takes time for UCB to accumulate in the central nervous system and/or for neurotoxicity to develop

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