Jaundice in the newborn. Bilirubin is derived from hemoglobin. One gm of hemoglobin will produce 34 mg of bilirubin, so what you can see here is that you don’t need a heck of a lot of hemolysis going on to produce fair amounts of bilirubin. It enters the circulation in the unconjugated form and is bound by albumin. Then is transported to the liver where it is conjugated, excreted into the bile duct and then into the small intestine. One thing which is absolutely crucial for you to understand when thinking about jaundice in the newborn is the enterohepatic circulation where bilirubin is reabsorbed from the gut and the key thing is that it is reabsorbed in the unconjugated form. So that anything that produces a slowing of passage of stool through the GI tract will produce an unconjugated hyperbilirubinemia. When we talk about our differential diagnosis for unconjugated hyperbilirubinemia, a number of things that produce a slowing of passage of stool in the GI tract will be discussed.
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So why are bilirubin levels higher in newborns? A number of different reasons. Obviously there is large red blood cell load, not unusual to see hematocrits of 60 or 65. There is also a shorter red blood cell life span. There is a fair amount of hematopoietic tissue, which is being degraded. The liver is immature and especially in premature babies they are going to potentially have greater problems processing this bilirubin. Then there is also increased re-absorption via the enterohepatic circulation. Classically what we look at is unconjugated or indirect hyperbilirubinemia versus conjugated or direct. Conjugated hyperbilirubinemia is generally defined by conjugated bilirubin levels greater than 2, – this is key – and greater than 10% of the total serum bilirubin. Because what you may see, if you get very high levels of unconjugated bilirubin – say you are in the 20’s – you may see conjugated levels slightly above 2 and that doesn’t make it a conjugated hyperbilirubinemia if it’s not over 10% of the total serum bilirubin.
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So indirect hyperbilirubinemia: we’ll start with that. The most common cause of indirect hyperbilirubinemia is physiologic jaundice. The definition varies. It seems to be sliding upwards in recent years. It used to be classically thought of as full-term bilirubins less than or equal to 12 were thought of as physiologic. Premature babies, bilirubins less than or equal to 15, but I think what we see is that has crept up and especially in breast-fed babies. I think that a lot of people consider bilirubins up to 14 or 15 to be essentially physiologic hyperbilirubinemia.
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Keys about non-physiologic jaundice: generally people say that if it appears in the first 24 hours, if jaundice appears in the first 24 hours it’s not physiologic. If the conjugated bilirubin is greater than 2. So if you have a conjugated hyperbilirubinemia, that’s never physiologic. Then some people also use bilirubin increases more than 5 mg/dl per day. Not sure I’d stick to … you know, if you have a level that’s going up 5.1 per day I’m not sure I’d be terribly panicked about that, especially in the first day or two of life. But those are the things which define non-physiologic hyperbilirubinemia.
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