Nelson 22nd Edition Updates Neonatal Jaundice

Definition of Rapid Rise in TSB

As per AIIMS protocol 3rd edition, a rise in TSB > 0.3 mg/dl/hr on Day 1 and > 0.2 mg/dl/hr beyond 24 hr is a rapid rise and indicates pathological jaundice.

Screening for Jaundice

AAP 2022 and the AIIMS protocol edition recommend universal TSB or TcB screening for all neonates between 24 and 48 hours of life or prior to discharge if it occurs earlier.

High-risk neonates

AAP 2022 and AIIMS protocol 3rd edition mentions risk factors to identify neonates having a high risk of significant jaundice These include

• Lower gestational age (< 40 weeks)
• Hemolytic disease
• History of PT in parents or siblings
• Scalp hematoma or significant bruising
• Exclusive breastfeeding with suboptimal milk intake
• Down syndrome
• Macrosomic infant in diabetic mother
• Mentioned in AAP 2022 but not in AIIMS protocol.
• Jaundice in 1st 24hr after birth
• Family history or ancestry of inherited RBC disorders
• Pre-discharge TcB/TSB is close to the PT zone or any PT given before discharge.

Also read: Types Of Liver Transplantation In Children

Renaming by AAP

AAP 2022 suggests that the term breastfeeding jaundice may be misleading and says, 'Because this type of jaundice, especially when excessive, is almost always associated with inadequate milk intake rather than breastfeeding per se, it is more correctly described as Suboptimal intake hyperbilirubinemia

Regarding TcB

According to AIIMS neonatal protocols, TcB measurement is a good screening tool for NNJ, even if it can't replace TSB measurement. AAP 2022 as well as the AIIMS protocol recommend that TSB be done for any TcB value within 3 mg/dl of the phototherapy threshold or if the absolute value of TcB is > 15 mg/dl. TcB can be used in all gestations and mixed-race populations. TcB is less reliable in dark-skinned individuals and those to whom PT has given. If, however, >24 hr after stopping PT, TcB can be used to rebound TSB measurement.

Novel Methods

According to AIIMS neonatal protocols, novel methods for bilirubin measurement are being evaluated. Spectrophotometry, Optical imaging of conjunctiva., Exhaled CO Spectroscopy (Heme metabolism-equimolar concentration of CO): If the ETCO in newborns is > 2ppm, it indicates ongoing hemolysis.

Also read: Mitochondrial Hepatopathies

New AAP Thresholds

AAP 2022 has introduced separate new charts/normograms based on age, TSB values, and the presence/absence of neurotoxicity risk factors.

ET: Risk factors

Risk factors

• Gestational age < 38 weeks
• S. Albumin < 3g/dl
• Sepsis
• Isoimmune hemolytic disease.
• Significant clinical instability in the last 24 hours.

Home-based PT

AAP 2022 says that home-based PT can be used in the following criteria are met in a neonate

Gestational age 38 weeks and above

• Postnatal age > 48hr
• Adequate feeding
• No neurotoxic risk factors
• No previous PT
• TSB can be measured daily and LED apparatus is available
• TSB value more than 1mg/dl above the PT cut-off

Also read: Neonatal Cholestasis: Causes, Diagnosis, and Treatment in Infants

TSB response with PT

According to AIIMS Neonatal Protocols

The rate of decline in TSB with PT depends on the spectral power (average, irradiance across the surface area) and the cause of jaundice. Effective PT causes a decrease in TSB by at least 2 mg/dl within 4-6 hr. If there is a lack of fall or rise despite PT, suspect ongoing hemolysis. PT may be discontinued once TSB falls 2 mg/dl below the PT threshold as per the new AAP 2022 recommendations. Rebound TSB is measured at least 12 hours after PT is discontinued (preferably 24 hours). In those with risk factors, do rebound TSB after 6 hours.

Contraindications to PT

Absolute contraindication: porphyria (CEP = congenital erythropoietic porphyria/Gunthers disease). The patient may develop severe vesciculo-bullous rashes, blistering upon PT, and can lead to death. The presence of conjugated bilirubin is not a contraindication of PT

PT is not totally benign

According to the AIIMS Protocol, PT is not as harmless as previously thought. PT may be subclinically carcinogenic and genotoxic. Oxidative injury to cell membranes and DNA may occur, especially in ELBW neonates. Thus minimize PT to only when and where it is needed.

DVET In NNJ

New DVET normograms given by AAP in 2022 should be used. DVET replaces 85% of circulating RBCs and TSB falls by about 50% immediately post-procedure. The push-pull technique should use the umbilical venous route. Individual aliquot volume should not exceed 10% of blood volume, with a maximum of 20 ml for a 3 kg infant. Measure TSB at 2 and 6 hr after DVET and then every 12 hours till PT can be discontinued. Overall mortality in DVET is 0.5-2%

Escalation of Care

A new "Escalation of Care" bilirubin threshold has been introduced in both AAP 2022 and the AIIMS Protocol. If a neonate has a TSB value of 2 mg/dl below the DVET threshold, give intensive PT and IV hydration. If isoimmune hemolytic disease, 0.5–1 g/kg IVIG can also be considered. AIIMS Protocol does not use IVIG.

Also read: Gastrointestinal Foreign Bodies in Children: Bezoars & Ingestion

ABE & Kernicterus

Preterm neonates may not manifest signs of ABE. So keep high suspicion. MRI in ABE & Kernicterus shows the hallmark findings of B/L symmetric high-intensity signal in the globus pallidus. All neonates with BIND or high NNJ with risk factors should undergo ABR audiometry to rule out HL. Tetrad of Kernicterus: Extrapyramidal CP (Choreo athetoid/Dyskinetic CP)

• SNHL
• Upward gaze palsy
• Dental enamel dysplasia.

Hope you found this blog helpful for your NEET SS Pediatrics Hpatology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.

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