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Paediatrica Indonesiana VOLUME 49
March
NUMBER 2
Case Report
Management of hyperbilirubinemia in near-term newborns according to American Academy of Pediatrics Guidelines: Report of three cases Naomi Esthernita Dewanto1, Rinawati Rohsiswatmo2
A
ll neonates have a transient rise in ELOLUXELQ OHYHOV DQG DERXW RI LQIDQWV EHFRPH YLVLEO\ MDXQGLFHG 0RVW MDXQGLFH LV EHQLJQ KRZHYHU EHFDXVHRIWKHSRWHQWLDOEUDLQWR[LFLW\RIELOLUXELQ newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia DQGLQUDUHFDVHVDFXWHELOLUXELQHQFHSKDORSDWK\ or kernicterus. Ten percent of term infants DQG RI QHDUWHUP LQIDQWV KDYH VLJQLILFDQW hyperbilirubinemia and require phototherapy. 7KH $PHULFDQ $FDGHP\ RI 3HGLDWULFV $$3 recommends procedures to reduce the incidence of severe hyperbilirubinemia and bilirubin HQFHSKDORSDWK\ DQG WR PLQLPL]H WKH ULVNV RI XQLQWHQGHG KDUP VXFK DV PDWHUQDO DQ[LHW\ GHFUHDVHG EUHDVWIHHGLQJ DQG XQQHFHVVDU\ FRVWV or treatment. 4 The guidelines provide a framework for the prevention and management of hyperbilirubinemia LQ QHZERUQ LQIDQWV RI ZHHNV RU PRUH RI JHVWDWLRQDO DJH WHUP DQG QHDUWHUP QHZERUQV This case report details the management of three QHZERUQV RI RU PRUH JHVWDWLRQDO DJH DW WKH 6LORDP/LSSR&LNDUDQJ+RVSLWDO7DQJJHUDQJ:HVW -DYD,QGRQHVLDDFFRUGLQJWRWKH$$3JXLGHOLQHV
Case 1 $EDE\JLUOZDVERUQVSRQWDQHRXVO\WRD\HDUROG PRWKHUDWZHHNJHVWDWLRQZLWKPLQRUULVNIDFWRUV 7KH ELUWK ZHLJKW ZDV J ELUWK OHQJWK ZDV FPDQGKHDGFLUFXPIHUHQFHZDVFP7KH$SJDU VFRUHZDV DWILYHPLQXWHVDIWHUELUWKDQGDWVHYHQ minutes. This was the mother’s first pregnancy and both mother and baby had positive Rhesus blood JURXS 7KH EDE\ DSSHDUHG WR EH MDXQGLFHG DW KRXUVDIWHUELUWKZLWKDWRWDOVHUXPELOLUXELQ 7%6 OHYHORI PJGO6KHZDVEUHDVWIHGH[FOXVLYHO\DQG had no history of naftalene balls or drug exposure. $WKRXUVDIWHUELUWKWKH76%OHYHOLQFUHDVHGWR PJEXWWKHEDE\ZDVVWLOODFWLYHDQGKDGQRUPDO YLWDOVLJQV%\GD\WKH76%OHYHOKDGLQFUHDVHGWR PJGO GLUHFW ' LQGLUHFW , ELOLUXELQ
)URP7KH'HSDUWPHQWRI&KLOG+HDOWK6LORDP/LSSR&LNDUDQJ+RVSLWDO 7DQJJHUDQJ,QGRQHVLD 1' 1 7KH'HSDUWPHQWRI&KLOG+HDOWK0HGLFDO 6FKRRO8QLYHUVLW\RI,QGRQHVLD&LSWR0DQJXQNXVXPR+RVSLWDO-DNDUWD Indonesia (RR).2 5HSULQWUHTXHVWVWR 1DRPL'HZDQWR0''HSDUWPHQWRI&KLOG+HDOWK 6LORDP+RVSLWDO-O7KDPULQ/LSSR&LNDUDQJ7DQJJHUDQJ,QGRQHVLD 7HO )D[
Paediatr Indones, Vol. 49, No. 2, March 2009125
Naomi Esthernita Dewanto et al +\SHUELOLUXELQHPLDLQQHDUWHUPQHZERUQVDFFRUGLQJ$$3JXLGHOLQHV
PJGO HYHQWKRXJKWKH*3'OHYHODQG2$( 2WR Acoustic Emission) were normal. According to WKH $$3 JXLGHOLQHV WKH 76% OHYHO ZDV VWLOO EHORZ WKH FULWLFDO OHYHO IRU SKRWRWKHUDS\ VR WKH EDE\ ZDV GLVFKDUJHGZLWKRXWDQ\VSHFLILFWUHDWPHQW7KH76% OHYHORQWKHGD\DIWHUGLVFKDUJHZDVPJGODQG the baby was clinically normal.
Case 2 $EDE\ER\RIZHHNJHVWDWLRQZDVERUQE\FHVDUHDQ section due to a cephalopelvic disproportion. The EDE\·VELUWKZHLJKWZDVJWKHELUWKOHQJWKZDV FPDQGWKHKHDGFLUFXPIHUHQFHZDVFP7KH baby was classified as having minor risk factors with $SJDU VFRUH RI DW ILYH PLQXWHV DIWHU ELUWK DQG at seven minutes. The baby had the same blood W\SHDVWKHPRWKHU·VLHEORRGJURXS2DQG5KHVXV SRVLWLYH,WZDVWKHILUVWSUHJQDQF\IRUWKHPRWKHU \HDUVROG7KHEDE\ORRNHGMDXQGLFHGDWKRXUVROG EXWDVWKH76%OHYHODWKRXUVZDVPJGO ', PJGO KHZDVGLVFKDUJHG7KHEDE\ZDV breastfed and given hypoallergenic formula as needed. 7KHEDE\UHWXUQHGIRUHYDOXDWLRQRQGD\DQGKDGD 76%OHYHORIPJGO ', PJGO ZLWK DQRUPDO*3'OHYHO7KHUHIRUHQRLQWHUYHQWLRQZDV needed and all that was required was assurance and education to the parents. On the next visit at nine GD\VROGWKH76%OHYHOZDV PJGO ', PJGO DQGDQ2$(H[DPLQDWLRQUHYHDOHGWKDWWKLV was within normal limits.
Case 3 $ IHPDOH QHZERUQ RI ZHHNV JHVWDWLRQ ZDV ERUQ WRD\HDUROGPRWKHUE\YDFXXPH[WUDFWLRQ7KH EDE\·VELUWKZHLJKWZDV JELUWKOHQJWK FP DQG KHDG FLUFXPIHUHQFH FP 6KH KDG $SJDU VFRUHRIDWWKHILUVWILYHPLQXWHVDIWHUELUWKDQG at seven minutes. The baby had minor risk factors and was the third child of a mother without a history of miscarriage; she and the mother had the same EORRGW\SHLH2DQ5KHVXVSRVLWLYH7KH76%OHYHO PHDVXUHGDWKRXUVDIWHUELUWKZDVPJGO ', PJGO 7KHEDE\ZDVVHQWKRPHDWWZR days old and was breastfed exclusively. Measurement
126Paediatr Indones, Vol. 49, No. 2, March 2009
RIWKH76%OHYHODW KRXUVJDYHDYDOXHRIPJ GO ',PJGO 7KHFULWHULRQIRUFDUU\LQJRXW SKRWRWKHUDS\DW KRXUVDIWHUELUWKLVD76%OHYHORI >PJGO6LQFHWKHEDE\ZDVFDWHJRUL]HGDVORZ ULVN DKHDOWK\EDE\RI!ZHHNVJHVWDWLRQ ZLWKD 76% OHYHO DERYH WKH FULWLFDO OHYHO IRU LQWHUYHQWLRQ the baby was treated with phototherapy. The baby’s *3'OHYHOZDVQRUPDO&RRPE·VWHVWZDVQHJDWLYH and the OAE examination was normal for both ears. 7KH76%OHYHOZDVPHDVXUHGDJDLQWZRGD\VODWHUDQG KDGGHFUHDVHGWRPJGO ', PJGO and so the baby was discharged.
Discussion +\SHUELOLUXELQHPLD LV GHILQHG DV HOHYDWHG ELOLUXELQ OHYHO WRWDO VHUXP ELOLUXELQ ! PJGO WKDW FDQ EH LGHQWLILHG DV \HOORZ FRORU MDXQGLFH GXH WR accumulation of bilirubin.5 Bilirubin is the metabolism product of hemoglobin and other heme proteins. The LQLWLDOEUHDNGRZQSURGXFWLVXQFRQMXJDWHGELOLUXELQ LQGLUHFWELOLUXELQ ZKLFKLVIRXQGLQWKHEORRGERXQG to albumin. When the albumin is saturated with ELOLUXELQH[FHVVXQFRQMXJDWHGELOLUXELQFDQFURVVWKH EORRGEUDLQEDUULHUDVLWLVOLSLGVROXEOH8QFRQMXJDWHG ELOLUXELQ ERXQG WR DOEXPLQ LV FRQMXJDWHG LQ WKH liver (direct bilirubin) and is then excreted into the JXW YLD WKH ELOLDU\ WUDFW 6RPH RI WKLV FRQMXJDWHG DOEXPLQERXQGELOLUXELQLVUHDEVRUEHGIURPWKHJXW by enterohepatic circulation. Certain conditions can increase bilirubin production such as hemolytic GLVHDVHLPSDLUHGOLYHUXSWDNHELOLUXELQFRQMXJDWLRQ GLVWXUEDQFH DQG DQ LQFUHDVH LQ WKH HQWHURKHSDWLF cycle. These conditions maybe the cause of pathologic MDXQGLFHLQQHZERUQV ,QQHZERUQLQIDQWVMDXQGLFHFDQEHGHWHFWHGE\ EODQFKLQJWKHVNLQZLWKSK\VLFDOSUHVVXUHUHYHDOLQJWKH underlying color of the skin and subcutaneous tissue. 7KH DVVHVVPHQW RI MDXQGLFH PXVW EH SHUIRUPHG LQ D ZHOOOLJKWHGURRPSUHIHUDEO\LQGD\OLJKWQHDUDZLQGRZ -DXQGLFHLVXVXDOO\VHHQILUVWLQWKHIDFHDWD76%OHYHO RI!PJGODQGSURJUHVVHVFDXGDOO\WRWKHWUXQNDQG H[WUHPLWLHV +RZHYHU YLVXDO HVWLPDWLRQ RI ELOLUXELQ OHYHOVIURPWKHGHJUHHRIMDXQGLFHFDQOHDGWRHUURUV4 $WUDQVFXWDQHXVELOLUXELQ 7F% RU76%PHDVXUHPHQW VKRXOGEHSHUIRUPHGRQHYHU\LQIDQWZKRLVMDXQGLFHG GXULQJWKHILUVWKRXUVDIWHUELUWKRULIWKHMDXQGLFH
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appears excessive for the infant’s age. Researchers have designed and evaluated several strategies for formally assessing the risk of severe neonatal K\SHUELOLUXELQHPLD DQG WKH $$3 KDV UHFRPPHQGHG formal hyperbilirubinemia risk assessment for all newborns. Risk assessment strategies that provide an accurate estimation of risk can be used to target SUHYHQWLYH FDUH VXFK DV IXUWKHU WHVWLQJ DQG FORVHU IROORZXSIRUQHZERUQVDWWKHJUHDWHVWULVNRIGHYHORSLQJ severe neonatal hyperbilirubinemia and kernicterus. This strategy also avoids the cost and inconvenience of WHVWVDQGIROORZXSIRUORZULVNLQIDQWV7ZRVWUDWHJLHV that have been investigated and recommended by the $$3 LQFOXGH PHDVXULQJ ELOLUXELQ FRQFHQWUDWLRQ and plotting the results on a normogram that displays bilirubin percentiles with respect to postnatal age in hours; and 2) systematically identifying clinical risk factors associated with severe hyperbilirubinemia (Table 1). :KHQ HLWKHU RU ERWK RSWLRQV DUH XVHG DSSURSULDWHIROORZXSDIWHUGLVFKDUJHLVHVVHQWLDO4
Table 1. Risk factors for development of severe hyperbilirubinemia in infants of 35 or more weeks gestation in approximate order of importance4 Major risk factors Ŗ 2TGFKUEJCTIG65$QT6E$NGXGNKPVJGJKIJTKUM\QPG Ŗ ,CWPFKEGQDUGTXGFKPVJGſTUVJQWTU Ŗ $NQQF ITQWR KPEQORCVKDKNKV[ YKVJ RQUKVKXG FKTGEV CPVKINQDWNKP test; Ŗ QVJGTMPQYPJGOQN[VKEFKUGCUG Ŗ )GUVCVKQPCNCIGYGGMU Ŗ 2TGXKQWUUKDNKPITGEGKXGFRJQVQVJGTCR[ Ŗ %GRJCNQJGOCVQOCQTUKIPKſECPVDTWKUKPI Ŗ 'ZENWUKXGDTGCUVHGGFKPIRCTVKEWNCTN[KHPWTUKPIKUPQVIQKPIYGNN and weight loss is excessive. Ŗ 'CUV#UKCPTCEG Minor risk factors Ŗ 2TGFKUEJCTIG65$QT6E$NGXGNKUKPVJGJKIJKPVGTOGFKCVGTKUM zone Ŗ )GUVCVKQPCNCIGYGGMU Ŗ ,CWPFKEGQDUGTXGFDGHQTGFKUEJCTIG Ŗ 2TGXKQWUUKDNKPIYKVJLCWPFKEG Ŗ /KETQUQOKEKPHCPVYKVJFKCDGVKEOQVJGT Ŗ /CVGTPCNCIG [GCTUQNF Ŗ /CNGIGPFGT Decreased risks (these factors are associated with decreased risk QHUKIPKſECPVLCWPFKEGNKUVGFKPQTFGTQHFGETGCUKPIKORQTVCPEG Ŗ 65$QT6E$NGXGNKUKPVJGNQYTKUM\QPG Ŗ )GUVCVKQPCNCIG YGGMU Ŗ 'ZENWUKXGDTGCUVHGGFKPI Ŗ $NCEMTCEG Ŗ &KUEJCTIGFHTQOJQURKVCNCHVGTJQWTU
Figure 1.*QWTURGEKſEDKNKTWDKPPQOQITCO2TGFKU charge bilirubin level, expressed as a risk zone on the nomogram, is used to predict the development of severe hyperbilirubinemia.7
,Q&DVHWKHEDE\ORRNHGMDXQGLFHGIURPWKH IHHWWRWKHFKHVWDUHDDWKRXUV7KH76%OHYHODW WKDWWLPHZDV PJGO$FFRUGLQJWRWKHQRPRJUDP the baby was in the low intermediate risk zone (Figure 1). No intervention was needed according to the JXLGHOLQHKHQFHWKHEDE\ZDVGLVFKDUJHG Figure 2 ZHXVHGWKHRSWLRQRIPJGOEHORZWKRVHVKRZQ 7KH EDE\ZDVLQDORZHUULVNJURXSVKHORRNHGMDXQGLFHG DWKRXUVDQGWKH76%OHYHOFXWRIISRLQWZDV PJGO$FFRUGLQJWRWKHJXLGHOLQHKRVSLWDOL]HGLQIDQWV RIRUPRUHZHHNVRIJHVWDWLRQFDQEHGLYLGHGLQWR three groups i.e. infants at lower risk (> ZHHNV of gestation and well baby); infants at medium risk (> ZHHNV RI JHVWDWLRQ ULVN IDFWRUV RU ZHHNVRIJHVWDWLRQ$SJDUVFRUHDQGZHOOEDE\ LQIDQWV DW KLJKHU ULVN ZHHNV RI JHVWDWLRQ $SJDUVFRUHULVNIDFWRUV 7KHVHULVNIDFWRUV ZHUHLVRLPPXQHKHPRO\WLFGLVHDVH*3'GHILFLHQF\ DVSK\[LDVLJQLILFDQWOHWKDUJ\WHPSHUDWXUHLQVWDELOLW\ VHSVLVDFLGRVLVRUVHUXPDOEXPLQOHYHORI JGO LI measured).4 $Q KRXU VSHFLILF ELOLUXELQ QRPRJUDP (Figure 1) that has been recommended as an approach for predicting neonatal hyperbilirubinemia was developed based on the hypothesis that early bilirubin YDOXHVH[SUHVVHGDVDSHUFHQWLOHZLWKUHVSHFWLYHO\WR WKHLQIDQW·VDJHLQKRXUVDUHSUHGLFWLYHRIWKHLQIDQW·V ODWHUELOLUXELQYDOXHVDOVRH[SUHVVHGDVDSHUFHQWLOH with respectively to infant’s age in hours (hereafter UHIHUUHGWRDVWKHKRXUVSHFLILF76% Verger and colleagues stated that if the biological factors that determine bilirubin production
Paediatr Indones, Vol. 49, No. 2, March 2009127
Naomi Esthernita Dewanto et al +\SHUELOLUXELQHPLDLQQHDUWHUPQHZERUQVDFFRUGLQJ$$3JXLGHOLQHV
DQGHOLPLQDWLRQZKHQ76%OHYHOVSHDNGD\VDIWHU ELUWKDUHDOVRSUHVHQWLQWKHILUVWWZRGD\VDIWHUELUWK WKHQWKHKRXUVSHFLILF76%YDOXHPHDVXUHGSULRUWR GLVFKDUJH DUH FORVHO\ FRUUHODWHG ZLWK KRXUVSHFLILF YDOXH ZKHQ DW WKH SHDN 76% OHYHO 7KH FRQFHSW ZDV WKDW WKLV KRXUVSHFLILF ELOLUXELQ QRPRJUDP FRXOGEHXVHGOLNHDSHGLDWULFJURZWKFKDUWZLWKWKH expectation that children starting out on a certain percentile track will stay on or near that percentile track as time passes.,IDEDE\VWD\VLQWKHKLJKULVN ]RQH !3 WKH SRVVLELOLW\ WR VWD\ LQ WKDW ]RQH LV 0RUHRYHULIDEDE\LVLQWKHKLJKLQWHUPHGLDWH ULVN]RQHWKHUHLVWKHSRVVLELOLW\WKDWWKH76%OHYHO ZLOOULVHWRPRUHWKDQ3 LV ,IWKHEDE\LVLQ WKH ORZ WR LQWHUPHGLDWHULVN ]RQH VXFK DV LQ &DVH WKHUHLVWKHSRVVLELOLW\RI76%UHDFKLQJPRUHWKDQ 3 LV ,Q &DVH WKH 76% OHYHO DW KRXUV ZDV PJGO LQWKHKLJKLQWHUPHGLDWHULVN]RQHDVVKRZQ in Figure 1 but was still below the level where phototherapy is required (Figure 2 ,Q&DVHWKH 76%OHYHODWKRXUVZDVPJGO$FFRUGLQJWR the nomogram (Figure 1 WKHVH EDELHV ZRXOG VWD\ LQKLJKLQWHUPHGLDWHULVN]RQHDQGDFFRUGLQJWRWKH phototherapy guideline (Figure 2 QRLQWHUYHQWLRQ was needed. Although we used an option to do
Figure 2. Guidelines for phototherapy in infants of 35 or more weeks gestation4
Table 2. Time of follow up examination for infants based on age at discharge4 Infant age at discharge Before 24 hours Between 24 and 48 hours Between 48 and 72 hours
Time of follow up examination 72 hours 96 hours 120 hours
128Paediatr Indones, Vol. 49, No. 2, March 2009
SKRWRWKHUDS\ RI PJGO EHORZ WKH GDWD VKRZQ DV VWDWHGLQWKHJXLGHOLQHDVDQRSWLRQ VRWKHEDELHV were discharged at that time. All infants should be examined by a qualified health care professional in the first few days after discharge to assess the condition of the infant; this examination should include noting the presence or DEVHQFHRIMDXQGLFH7KHWLPLQJDQGORFDWLRQRIWKLV assessment depend on the length of stay in the nursery (Table 2)DQGSUHVHQFHRUDEVHQFHRIULVNIDFWRUVIRU hyperbilirubinemia.4 $ UHSRUW IURP 6KDDUH =DGHN 0HGLFDO &HQWHU LQ -HUXVDOHP ,VUDHO UHFRPPHQGHG WKDW DOO EDELHV VKRXOGEHVHHQZLWKLQGD\VDIWHUEHLQJGLVFKDUJHG IURP KRVSLWDO" IRU WKH DVVHVVPHQW RI MDXQGLFH DQG WKH VXFFHVV RI EUHDVWIHHGLQJ ,Q WKH FDVH RI PDOHV less formal bilirubin evaluation occurs in the case of males during the home visit by the ritual circumciser (mohel). This visit is frequently a source of referral for hyperbilirubinemia because according to the -HZLVKULWXDOODZDEDE\VKRXOGQRWEHMDXQGLFHGDW the time of ritual circumcision on the eighth day of OLIH7KLVLQMXQFWLRQH[WHQGVWRSDUHQWVRIEDE\JLUODV ZHOO$VDUHVXOWWKLVSRSXODWLRQLVDZDUHRIQHRQDWDO MDXQGLFH9 ,Q&DVHWKHEDE\ZDVVHQWKRPHDWKRXU after birth and returned at 91 hours after birth. :KHQ WKH EDE\ UHWXUQHG KH ZDV KRVSLWDOL]HG IRU SKRWRWKHUDS\ DV GHWHUPLQHG E\ IROORZLQJ WKH $33 guidelines (Figure 2; healthy babys born at > ZHHNVZLWKD76%OHYHORI>PJGODW KRXUV DIWHUELUWK ,Q&DVHVDQGWKH76%OHYHOVZHUH still below the criteria level for phototherapy (we used DQRSWLRQWRSURYLGHSKRWRWKHUDS\DW76%OHYHORI PJGO EHORZ WKRVH VKRZQ 7KH K\SHUELOLUXELQHPLD readmission rate to the pediatric ward and NICU GHFUHDVHGE\LQWKHILUVW\HDUDIWHUWKH&HGDU6LQDL 0HGLFDO&HQWHU/RV$QJHOHVVWDUWHGXVLQJJXLGHOLQHV EDVHGRQWKH$$3JXLGHOLQHV ,QEUHDVWIHGLQIDQWVZKRUHTXLUHSKRWRWKHUDS\ $$3 UHFRPPHQGV WKDW EUHDVWIHHGLQJ VKRXOG EH continued if possible. It is also an option to temporarily interrupt breastfeeding and use formula instead. 7KLVFDQUHGXFHELOLUXELQOHYHOVDQGRUHQKDQFHWKH efficacy of phototherapy. In breastfed infants who UHFHLYHSKRWRWKHUDS\VXSSOHPHQWDWLRQZLWKH[SUHVVHG breast milk or formula is appropriate if the infant’s LQWDNH VHHPV LQDGHTXDWH ZHLJKW ORVV LV H[FHVVLYH
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or the infant is dehydrated.4 A paramount step in following these recommendations is to promote and support successful breastfeeding and explain clearly WKDWMDXQGLFHDVVRFLDWHGZLWKEUHDVWIHHGLQJLVFDXVHG by inadequate breastfeeding rather than assuming WKDWMDXQGLFHLVDOZD\VDVVRFLDWHGZLWKEUHDVWIHHGLQJ When this information is used in explaining to a PRWKHU ZK\ KHU FKLOG LV MDXQGLFHG LW FHUWDLQO\ ZLOO UHGXFHDPRWKHU·VJXLOW\IHHOLQJVVXSSRUWODFWDWLRQ and prevent the vulnerable child syndrome in the future.11 2XUWKLUGFDVHZKRUHFHLYHGSKRWRWKHUDS\ still continued to be breastfed and the mother also expressed breast milk at home. Breast milk consumption is associated with QHRQDWDO K\SHUELOLUXELQHPLD ,QWHUPHGLDWH K\SHU ELOLUXELQHPLD 76% PJGO H[LVWV LQ RI H[FOXVLYHO\ EUHDVWIHG LQIDQWV DQG LQ RI LQIDQWV ZKR FRQVXPH IRUPXOD PLON 0RUHRYHU VHYHUH K\SHUELOLUXELQHPLD 76% OHYHO PJGO H[LVWV LQ RIEUHDVWIHGLQIDQWVDQGRILQIDQWVIHGZLWK formula milk. The cause of this condition is not well understood. There are some theories trying to explain WKH SDWKRSK\VLRORJ\ RI WKLV W\SH RI MDXQGLFH EDVHG RQ ELRFKHPLVWU\ %UHDVW PLON FRQWDLQV DOSKD EHWDSUHJQDQGLRODQGKDVOLSRSURWHLQOLSDVHDFWLYLW\ ZKLFKLQGLFDWHGE\LQFUHDVHGEHWDJOXFXURQLGDVH7KLV DOSKD EHWDSUHJQDQGLRO FDQ SURKLELW ELOLUXELQ FRQMXJDWLRQZKLOHEHWDJOXFXURQLGDVHFDQLQGXFHWKH UHDGVRUSWLRQRIELOLUXELQIURPWKHJXW)XUWKHUPRUH the increased fatty acid produced from triglyceride by lipase lipoprotein can disturb liver uptake and ELOLUXELQFRQMXJDWLRQ+\SHUELOLUXELQHPLDDVVVRFLDWHG with breast milk consumption can be divided into WZR W\SHV HDUO\ MDXQGLFH NQRZQ DV EUHDVWIHHGLQJ MDXQGLFHDQGODWHMDXQGLFHFDOOHGEUHDVWPLONMDXQGLFH Breastfeeding hyperbilirubinemia is usually due to inadequate breastfeeding in the early postpartum SHULRG%UHDVWPLONMDXQGLFHXVXDOO\DSSHDUVDIWHURQH ZHHNLQKHDOWK\DQGJURZLQJLQIDQWV RIWKHVH EDELHVKDYHD76%OHYHORI!PJGODWWKUHHZHHNVRI DJH,WLVQRWFOHDUKRZWKHVHWZRW\SHVDUHFRUUHODWHG EXWLQEDELHVZLWKEUHDVWPLONMDXQGLFHWKHUHDUHWZR SHDNVLQELOLUXELQOHYHORQHDWGD\DQGRQHDWGD\ )RXUWHHQSHUFHQWRIWKHVLEOLQJVRIWKHVHEDELHV have also been reported to have prolonged indirect K\SHUELOLUXELQHPLDRIXQNQRZQFDXVH7KHUHIRUHLW seems likely that genetic and environment factors also play a role in this pathophysiology.
Figure 3. Guidelines for exchange transfusion in infants of 35 or more weeks gestation4
$ 76% OHYHO WKDW GRHV QRW UHGXFH RU HYHQ increases after intensive phototherapy indicates the possibility of hemolytic disease. Exchange transfusion LVUHFRPPHQGHGLIWKH76%OHYHOLQFUHDVHVDVVKRZQ in Figure 3. )RUUHDGPLWWHGLQIDQWVZLWKD76%OHYHODERYH WKHH[FKDQJHOHYHOLWLVUHFRPPHQGHGWRUHSHDWWKH 76% PHDVXUHPHQW HYHU\ KRXUV DQG FRQVLGHU SHUIRUPLQJ DQ H[FKDQJH WUDQVIXVLRQ" LI WKH 76% level remains above the critical level after intensive phototherapy for six hours. Immediate exchange transfusion is recommended if there are signs of acute ELOLUXELQ HQFKHSKDORSDKW\ K\SHUWRQLD DUFKLQJ UHWURFROOLVRSLVWKRWRQRVIHYHUKLJKSLWFKHGFU\ RU LIWKH76%OHYHOLV>PJGODERYHWKLVOLQH .HUQLFWHUXVDOWKRXJKLQIUHTXHQWKDVVLJQLILFDQW PRUWDOLW\RIDWOHDVWDQGORQJWHUPPRUELGLW\RIDW OHDVW,WKDVEHHQVKRZQWKDWWKHSUHSRQGHUDQFHRI kernicterus cases occurs in infants with high bilirubin PRUHWKDQPJGO 15 Reports from many countries VKRZWKDWNHUQLFWHUXVDSSHDUVDW76%OHYHOVRI! PJGO LQ KHDOWK\ WHUP LQIDQWV 2QH VWXG\ E\ +DUULV et al evaluated breastfed neonates with bilirubin HQFHSKDORSDWK\ZLWKD76%OHYHORI!PJGOIRU period of two years and three months and reported that neurological disturbances were only temporary. 7KHSUHYHQWLRQRIELOLUXELQLQGXFHGEUDLQLQMXU\LV based on the detection of infants at risk for developing severe hyperbilirubinemia. The outcome in our babies was good; the babies were managed according to the $$3JXLGHOLQHVVXFKDVSHUIRUPLQJDVVHVVPHQWEHIRUH GLVFKDUJHSHUIRUPLQJIROORZXSDQGWKHQFDUU\LQJRXW intervention as soon as possible when it was needed. We also avoided unnecessary treatment.
Paediatr Indones, Vol. 49, No. 2, March 2009129
Naomi Esthernita Dewanto et al +\SHUELOLUXELQHPLDLQQHDUWHUPQHZERUQVDFFRUGLQJ$$3JXLGHOLQHV
,Q VXPPDU\ ZH PDQDJHG K\SHUELOLUXELQHPLF LQIDQWVEDVHGRQWKH$$3JXLGHOLQHVDQGWKHUHVSRQVH was good. The babies were clinically well and the OAE results were normal. We think that these guidelines DUHVDIHWREHDSSOLHGLQ,QGRQHVLDDOWKRXJKIXUWKHU education for parents and further evaluation using the BERA examination is necessary at least when the child is able to talk.
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130Paediatr Indones, Vol. 49, No. 2, March 2009
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