Rosen & Barkin's 5-Minute Emergency Medicine Consult (479 page)

• Evaluation for obstructive liver disease (direct hyperbilirubinemia)
  
• MRI scan of brain with abnormal globus pallidus is pathognomonic of kernicterus; not indicated for emergency management.
  

• See “Etiology.”
  
• Essential to differentiate unconjugated from conjugated hyperbilirubinemia.
  

TREATMENT

0.9% normal saline 20 mL/kg bolus if signs of volume depletion.

• Treatment guidelines for infants ≥35 wk gestation based on TSB plotted vs. age in hours for infants by risk group (below).
  
• Higher risk are 35–37 6/7 wk + risk factors.
  
• Medium risk are ≥38 wk + risk factors, or 35–37 6/7 wk and well.
  
• Lower risk are ≥38 wk and well.
  
• Risk factors: Isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, albumin <3 g/dL
  
• Depending upon the risk group, hospitalization for
  intensive
  PT is indicated when TSB (mg/dL) is above:
  

• BiliTool is an online calculator (
  http://bilitool.org/
  ) for risk stratification.
  
• Intensive
  PT involves use of high level of irradiance delivered to as much of infant’s surface area as possible (overhead light source and
  bili blanket
  beneath) per light source manufacturer. Eyes must be shielded.
  
• Intensive
  PT should decrease TSB >0.5 mg/dL/h. Begin as soon as possible.
  
• Indications for
  exchange transfusions
  (ET) are also determined by age in hours and risk stratification, and lack of response to PT in consultation with neonatology. Exchange requires irradiated blood and albumin infusion.
  
• ET
  is often recommended regardless of TSB level if infant shows signs of ABE. NICU admission and monitoring.
  
• If isoimmune hemolytic disease, consider IV immunoglobulin 0.5–1 g/kg over 2 hr if TSB level is nearing exchange criteria.
  
• If any delay in admission/transfer, initiate
  intensive
  PT in ED.
  
• Treat comorbid disease (sepsis, liver dysfunction, polycythemia, hypothyroidism)
  
• Encourage increased frequency of feeding with breast milk or formula; supplemental dextrose–water is not useful. May need to enter supplementation or IV fluids.
  
• Breastfeeding failure and breast milk jaundice
  :
  
  • Most infants can continue to breastfeed.
    
  • Encourage mothers to nurse at least 8–12 times per day for 1st several days.
    
  • Supplementation with formula and/or IV fluids may be temporarily required.
    
  • 2–3 day cessation of breastfeeding is recommended for infants with breast milk jaundice and levels not responding to PT.
    
  • Encourage mother to maintain lactation by use of breast pump or manual expression during period of cessation.
    
• Physiologic jaundice
  : Reassurance and arrange appropriate follow-up
  

IV immunoglobulin 0.5–1 g/kg over 2 hr in isoimmune hemolytic disease if TSB level is nearing exchange criteria and not responding to intensive PT.

• Phenobarbital increases bilirubin conjugation and excretion slowly; may adversely impact cognitive development; not routinely used
  
• Ursodeoxycholic acid increases bile flow and is useful in the treatment of cholestatic jaundice.
  

FOLLOW-UP

• Infants requiring
  intensive
  PT
  
• Evidence of significant anemia, sepsis, dehydration, or evidence of obstructive liver disease requires hospitalization for diagnostic evaluation and treatment
  
• Rapid transport to NICU; transport PT if transport time >30 min
  

• Stable infant with hyperbilirubinemia not requiring PT
  
• Stable term infant with uncomplicated nonhemolytic hyperbilirubinemia with no risk factors and TSB 2–3 mg/dL below levels recommended for
  intensive
  PT; may have
  home
  PT arranged if appropriate timely follow-up can be ensured.
  
• Direct communication with primary care provider and neonatal consultant.
  

Breastfeeding failure: Lactation consultants are available at many hospitals.

Follow-up with primary care provider:

• Within 12 hr: Stable infant with hyperbilirubinemia not requiring PT and with no risk factors
  
• Within 8 hr: Stable infant with uncomplicated nonhemolytic hyperbilirubinemia with home PT arranged
  

• TSB must be interpreted according to the newborn’s age in hours, not days, and with regard for risk factors for severe hyperbilirubinemia.
  
• PT needs to be initiated when the TSB exceeds the threshold level.
  
• Infant feeding and hydration must be assessed and corrected.
  

• Maisels MJ, Bhutani VK, Bogen D, et al. Hyperbilirubinemia in the newborn infant > or = 35 wk gestation: An update with clarifications.
  Pediatrics
  . 2009;124:1193–1198.
  
• Schwartz HP, Haberman BE, Ruddy RM. Hyperbilirubinemia: Current guidelines and emerging therapies.
  Pediatr Emerg Care
  . 2011;27(9):884–889.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Neonatal Sepsis
  
• Online access to AAP guidelines available at:
  http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/2970
  Factors, in order to prevent
  BIND dysfunction
  .
  

CODES

• 774.6 Unspecified fetal and neonatal jaundice
  
• 774.7 Kernicterus of fetus or newborn not due to isoimmunization
  
• 774.39 Other neonatal jaundice due to delayed conjugation from other causes
  

BASICS

• Life-threatening infection of the newborn, rarely occurring as late as 3 mo of age
  
• Overwhelmingly bacterial:
  
  • Rarely viral or fungal infection
    
  • Organisms usually present in the maternal perineal flora
    
• Occurs in 3–5 newborns per 1,000 live births
  
• Risk factors:
  
  • Perinatal:
    
    • History of recent fever (>37.5°C)
      
    • UTI
      
    • Chorioamnionitis
      
    • Prolonged rupture of membranes (>18 hr)
      
    • Foul lochia
      
    • Uterine tenderness
      
    • Intrapartum asphyxia
      
  • Neonatal:
    
    • Prematurity
      
    • Fetal tachycardia (>180 beats/min)
      
    • Male
      
    • Twinning (especially 2nd twin)
      
    • Developmental or congenital immune defects
      
    • Administration of IM iron
      
    • Galactosemia
      
    • Congenital anomaly (urinary tract, asplenia, myelomeningocele, sinus tract)
      
    • Omphalitis