Bilirubin in the Neonate... (normal or alarming?)

[Delacroix22]

OK so I have been confused on this for a while

I have heard that a newborn should never be jaundiced... and yet I have heard that it is normal.

Reading MTB2 it says this

Transient Hyperbilirubinemia
"Over 60% of all newborn infants are jaundiced. This is due to the infant's spleen removing RBCs carrying HgbF. This results in a physiological release of hemoglobin and in turn a rise in bilirubin"

Then...

Pathologic Jaundice in the Newborn
Hyperbilirubinemia is considered pathological when

• it appears on first day of life
• [. . . . etc etc etc]

So essentially my confusion is.... Should a newborn infant NEVER be jaundiced within the first 24 hours, this is always pathological. And when they say transient hyperbilirubinemia of the newborn... by "newborn" they mean an infant with jaundice but NOT on the first day, the transient condition takes time to develop?

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[Morzh]

Yes, always pathologic in first 24 hours. After 24 hours jaundice may or may not be pathologic - you need to measure their bili and plot it on the infamous bhutami nomogram (copied below). There are algorithms to follow after that. For Step 2 I think the most important thing is having a good differential for hyperbilirubinemia of the newborn.

 

[Phloston]

OK so I have been confused on this for a while

I have heard that a newborn should never be jaundiced... and yet I have heard that it is normal.

Reading MTB2 it says this

Transient Hyperbilirubinemia
"Over 60% of all newborn infants are jaundiced. This is due to the infant's spleen removing RBCs carrying HgbF. This results in a physiological release of hemoglobin and in turn a rise in bilirubin"

Then...

Pathologic Jaundice in the Newborn
Hyperbilirubinemia is considered pathological when

• it appears on first day of life
• [. . . . etc etc etc]

So essentially my confusion is.... Should a newborn infant NEVER be jaundiced within the first 24 hours, this is always pathological. And when they say transient hyperbilirubinemia of the newborn... by "newborn" they mean an infant with jaundice but NOT on the first day, the transient condition takes time to develop?

Yeah, it's pathologic if appearing on the first day of life.

 

[Delacroix22]

Thanks guys!

 

[turtledove2324]

I am starting my week in newborn nursery tomorrow and I'm confused about the Bhutani nomogram. Once you plot the bilirubin level against age, and say the baby is in the low intermediate risk zone, what do you do with that information? And on the phototherapy nomogram, if the baby's bili level is ABOVE the dotted line, is that an indication for phototherapy? If below the line, phototherapy is not required? I'm lost as to how to interpret these graphs.

 

[WheezyBaby]

I am starting my week in newborn nursery tomorrow and I'm confused about the Bhutani nomogram. Once you plot the bilirubin level against age, and say the baby is in the low intermediate risk zone, what do you do with that information? And on the phototherapy nomogram, if the baby's bili level is ABOVE the dotted line, is that an indication for phototherapy? If below the line, phototherapy is not required? I'm lost as to how to interpret these graphs.

I hate the bhutani nomogram. I find it much simpler to make your own clinical decision making based on light and transfusion thresholds and bili trends. Bhutani risk stratifies (and gives you an idea of frequency of bili checks), but you can do that yourself. There are risk factors for hyperbilirubinemia and separate (though with some overlap) risk factors for neurotoxicity. The neurotoxicity risk factors alter your light / transfusion threshold, your hyperbili risk factors do not. From the AAP, we have plots of light and exchange transfusion thresholds (http://peditools.org/bili/index.php). If you exceed the threshold, start therapy. Even if you don't exceed the threshold, if you follow the trend in bili and you're progressively closing the gap on lights without sign of plateau, it wouldn't be unreasonable to start lights. If they're ever symptomatic of bilirubin induced neurological dysfunction, start lights.

For testing purposes though, I'd know that crossing lines on the Bhutani is bad.