What to Do when the “Lights” Don’t Work-

Neonatal Hyperbilirubinemia

Dr G Elske Hildes-RipsteinDept of Child Health and Pediatrics

University of Manitoba, College of Medicine

Annual Scientific Assembly; April 19/2018

No Conflict of Interest to declare

Objectives

• Review current delivery of phototherapy-biliblankets/fibreoptic light source

• Trouble-shoot “nonresponse “ to phototherapy

• Recognize when to consult pediatrics/neonatology for NICU admission +-exchange transfusion

Why Treat Hyperbilirubinemia?

Acute Bilirubin Encephalopathy

Kernicteris

From Neuropathology –web.org T2 signal in globus pallidus

Bilirubin staining: kernicteris

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)

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

Bhutani Nomogram of Risk level for subsequent hyperbilirubinmia

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

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

Guidelines for phototherapy in infants of 35 or more weeks’ GA

Subcommittee on Hyperbilirubinemia et al. Pediatrics

2004;114:297-316

©2004 by American Academy of Pediatrics

Initiating Phototherapy-other investigations?

• Consider Etiology of HyperbilirubinemiaOther 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

Appropriate Phototherapy Devices

Phototherapy bed: Medela Bilibed Phototherapy*: 30 μW/cm2/nm Phototherapy Blanket: Ohmeda Biliblanket Plus*: 33.75 – 56.25 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**: 30-40 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 13-14 microwatts, minimum 10 μW/cm2/nm

Bili Blanket Use

“Nonresponse” to phototherapy

1. Interpretation; Bilirubin stays same level or even rises2. Infant spends no time skin exposed to fiberoptic light

source (biliblanket)3. Load of unbound bilirubin too large for enterohepatic

circulation/disposala) hemolysing rapidlyb) significant bruising or large cephalohematomac)slow enteral transit time (1st day feeding and small

amounts)d)exclusive Breast feeding (inhibition of bilirubin

conjugation)e) relatively low albumin levels (physiologic)

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; improving @ 72 may discontinue

Guidelines for phototherapy in infants of 35 or more weeks’ GA

Subcommittee on Hyperbilirubinemia et al. Pediatrics

2004;114:297-316

©2004 by American Academy of Pediatrics

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 hInterpretation; start phototherapy

Eg 302 mmol/L in 39 week GA infant at 72 h

Interpretation; following usual trajectory-response

Guidelines for phototherapy in infants of 35 or more weeks’ GA

Subcommittee on Hyperbilirubinemia et al. Pediatrics

2004;114:297-316

©2004 by American Academy of Pediatrics

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

(Non) Delivery of Phototherapy

What’s wrong with this picture????

Checklist for Optimal administration of Phototherapy

• Light Source (wavelength 460-490nm; 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

3. Load of unbound bilirubin too large for enterohepatic circulation/disposal

a) hemolysing rapidly; bilirubin rising >8mmol/hr

b) significant bruising or large Cephalohematomaplus

c) slow enteral transit time (1st 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!

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

• 96-120h; 150cc/kg/day

2nd Phototherapy Source

Giraffe Spotlight

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

When to consult for Advice/Transfer

• Trajectory or slope of serial bilirubins rising iebrisk 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)

QUESTIONS? COMMENTS?

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 ieTbili only is default (Direct only if ordered)

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;e1046

2. Management of Hyperbilirubinemia in the Newborn Infant 35 or more weeks of gestation. American Academy of Pediatrics; Subcommittee on Hyperbilirubinemia. Pediatrics 2004;114(1):297-316

3. 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 (FN2007-02) Paediatrics and Child Health 2007;12 Suppl B 1-12.

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/U-clinical assessment of hydration, wt and daily TSB )

-parent’s consent