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KATA PENGANTAR

Puji dan syukur saya panjatkan kepada Tuhan Yang Maha Esa, karena atas berkatdan rahmat-Nya saya dapat menyelesaikan referat dengan judul Ikterus Terkait A I!

dalam kepaniteraan klinik Ilmu "esehatan Anak # $% "&dya emarang'

(anyak terima kasih saya sampaikan kepada guru saya, dr' )art&n& p'A, dr'

lamet *idi p'A, dan dr' )idayati p'A, atas segenap +aktu yang telah di urahkan untuk

membimbing saya selama pr&ses pembuatan makalah ini' $ apan terima kasih juga saya

sampaikan kepada kedua &rang tua saya, rekan-rekan kepaniteraan klinik Ilmu "esehatan

Anak peri&de . April /0 1 /2 3uni /0 atas segala bantuannya, baik m&ril maupun

materiil'

eperti pepatah tiada gading yang tak retak!, referat ini juga masih jauh dari

sempurna' 4leh karena itu, segala kritik dan saran akan sangat berguna bagi

penyempurnaan referat ini selanjutnya' Akhir kata, sem&ga referat ini bisa berguna bagi

pemba a'

emarang, . 3uni /0

Penulis

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DAFTAR ISI

"ATA PEN5ANTA#''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

%A6TA# I I''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' /

(A( I' PEN%A)$7$AN'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 8

(A( II' PEM(A)A AN''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 9

A' %efinisi''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 9

(' Epidemi&l&gi'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 9

:' Eti&l&gi''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ;

%' "lasifikasi'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 2

E' Pat&fisi&l&gi''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 2,2? Pada

&rang de+asa, ikterus akan tampak apabila serum bilirubin D / mg d7 >D < m&l 7?,

sedangkan pada ne&natus baru tampak apabila serum bilirubin D ; mg d7

> D.2 m&l 7?'

)iperbilirubinemia adalah istilah yang dipakai untuk ikterus ne&nat&rum setelah

ada hasil lab&rat&rium yang menunjukkan peningkatan kadar serum bilirubin' >2?

)iperbilirubinemia adalah keadaan kadar bilirubin dalam darah D 8 mg d7' Pada bayi

baru lahir, ikterus yang terjadi pada umumnya adalah fisi&l&gis, ke ualiF

Timbul dalam /9 jam pertama kehidupan'

(ilirubin t&tal indirek untuk bayi ukup bulan D 8 mg d7 atau bayi kurang

bulan D 0 mg d7'

Peningkatan bilirubin D ; mg d7 /9 jam'

"adar bilirubin direk D / mg d7'

Ikterus menetap pada usia D/ minggu'

Terdapat fakt&r risik&'

B. EPIDEMIOLOGI

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%i Amerika erikat, dari 9 juta bayi yang lahir setiap tahunnya, sekitar 2;G

mengalami ikterus' %ari tahun ==9 1 /00/, ,= G bayi baru lahir dira+at di rumah

sakit dengan hiperbilirubinemia' Insiden ini naik menjadi /0 G pada tahun /008

sampai /00;' Insiden kernikterus turun dari ;,. per 00'000 kelahiran hidup menjadi

,2 per 00'000 kelahiran hidup sebagai hasil dari langkah-langkah pen egahan agresif

dalam tahun-tahun ini menurut (urke et al '>;? ekitar dari /00 bayi ukup bulan yang

menyusu A I terdapat kenaikan bermakna dari bilirubin tak terk&njugasi antara umur 9

dan < hari, men apai kadar maksimal setinggi 0 1 80 mg d7 selama minggu ke-/

sampai ke-8' 3ika pemberian A I dilanjutkan, hiperbilirubinemia se ara bertahap

menurun dan kemudian dapat menetap selama 8 1 0 minggu pada kadar yang lebih

rendah' > 9?

%i Ind&nesia, didapatkan data ikterus ne&nat&rum dari beberapa rumah sakit

pendidikan' # $P :ipt& Mangunkusum& selama tahun /008, menemukan preHalensi

ikterus pada bayi baru lahir sebesar ;.G untuk kadar bilirubin di atas ; mg d7 dan

/=,8G dengan kadar bilirubin di atas / mg d7 pada minggu pertama kehidupan' #

%r' ardjit& melap&rkan sebanyak .;G bayi ukup bulan sehat mempunyai kadar

bilirubin di atas ; mg d7 dan /8,.G memiliki kadar bilirubin di atas 8 mg d7' %ata

yang agak berbeda pada # %r' "ariadi, di mana insidens ikterus pada tahun /008hanya sebesar 8, ri+ayat

keluarga?' Ikterus karena A I juga lebih sering ditemukan pada ras "aukasus' > =?

C. ETIOLOGI

e ara umum, peningkatan kadar bilirubin n&rmal terjadi pada setiap bayi baru

lahir >jaundi e fisi&l&gis?, karenaF

)em&lisis yang disebabkan &leh jumlah sel darah merah yang lebih banyak dan

berumur lebih pendek'

6ungsi hepar yang belum sempurna >jumlah dan fungsi en im glukur&nil

transferase, $%P5 T dan ligand dalam pr&tein belum adekuat?, sehingga akan

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menyebabkan ambilan bilirubin dan k&njugasi &leh hepat&sit di hepar belum

sempurna'

irkulus enter&hepatikus yang meningkat karena en im glu ur&nidase di usus

dan belum ada bakteri usus n&rmal'(ila ikterus terjadi dalam minggu pertama a+al kehidupan dan asupan A I

se ara kualitas dan kuantitas kurang, keadaan ini disebut sebagai breast feeding

jaundi e! dan ikterus disebabkan karena kekurangan A I'

Namun bila keadaan bayi sehat dan bayi menyusu A I se ara adekuat dan

reguler, keadaan ini disebut sebagai breast milk jaundi e!, dimana ikterus

kemungkinan disebabkan ada kandungan dalam A I yang menyebabkan terganggunya

metab&lisme bilirubin di hepar'

D. KLASIFIKASI

1. Breast Feeding Jaundice

(reastfeeding jaundi e >jaundi e ikterus karena kurang menyusu!?

disebabkan kekurangan asupan A I yang menyebabkan rendahnya pergerakan

>peristaltik? usus, sehingga usus tidak adekuat dalam membuang bilirubin daritubuh' >/0?)al ini bisa diatasi dengan pemberian A I se ara rutin dan adekuat'

Persalinan per Haginam akan membantu meningkatkan pr&duksi A I, sehingga

ne&natus dengan persalinan seksi& esarea lebih beresik& menderita ikterus

jenis ini' >11 ?

2. Breast Mi ! Jaundice

(ila breast feeding jaundi e merupakan gangguan mekanikal >input

kurang?, breast milk jaundi e merupakan gangguan bi&kimia' (reast milk

jaundi e terdapat pada bayi yang menyusu A I se ara teratur dan adekuat'

Mekanisme pasti bagaimana A I menyebabkan ikterus masih belum jelas,

namun diperkirakan terdapat kandungan dalam A I yang mengakibatkan

terganggunya metab&lisme bilirubin'

(reast milk jaundi e mun ul pada hari ke-8 dan ke-9 kehidupan,

men apai pun aknya pada usia 0-/ hari, tetapi bisa bertahan hingga / sampai8 bulan' (reast milk jaundi e adalah keadaan n&rmal' Namun biasanya

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menyusui tidak perlu dihentikan ke uali pada keadaan-keadaan tertentu seperti

pada f&t&terapi'

(reast milk jaundi e sering dikaitkan dengan fakt&r genetik karena

biasanya angg&ta keluarga yang lain mempunyai ri+ayat yang sama'

E. PATOFISIOLOGI

METABOLISME BILIRUBIN

(ilirubin merupakan pr&duk yang bersifat t&ksik dan harus dikeluarkan &leh

tubuh' ebagian besar bilirubin tersebut berasal dari degradasi hem&gl&bin darah dan

sebagian lagi dari hem bebas atau pr&ses eritr&p&esis yang tidak efektif' Pembentukan

bilirubin tadi dimulai dengan pr&ses &ksidasi yang menghasilkan biliHerdin serta

beberapa at lain' (iliHerdin inilah yang mengalami reduksi dan menjadi bilirubin

bebas atau bilirubin IJ K >gambar ?' Lat ini sulit larut dalam air tetapi larut dalam

lemak, karenanya mempunyai sifat lip&filik yang sulit diekskresi dan mudah melalui

membran bi&l&gik seperti plasenta dan sa+ar darah &tak' >., 8, 9, 2?

(ilirubin bebas tersebut kemudian bersenya+a dengan albumin dan diba+a ke

hepar' %alam hepar terjadi mekanisme ambilan, sehingga bilirubin terikat &leh resept&r

membran sel hepar dan masuk ke dalam hepar' egera setelah ada dalam sel hepar

terjadi persenya+aan ligandin >pr&tein Y?, pr&tein L dan glutati&n hepar lain yang

memba+anya ke retikulum end&plasma hepar, tempat terjadinya k&njugasi' Pr&ses ini

timbul berkat adanya en im gluk&r&nil transferase yang kemudian menghasilkan

bentuk bilirubin direk' 3enis bilirubin ini dapat larut dalam air dan pada kadar tertentu

dapat diekskresi melalui ginjal' ebagian besar bilirubin yang terk&njugasi ini

diekskresi melalui duktus hepatikus ke dalam saluran pen ernaan dan selanjutnya

menjadi urubilin&gen dan keluar dengan tinja sebagai sterk&bilin' %alam usus,

sebagian di abs&rpsi kembali &leh muk&sa usus dan terbentuklah pr&ses abs&rpsi enter&

hepatik' >., 8, 9, 2?

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IKTERUS KARENA ASI

Pertama, sesaat setelah lahir, usus bayi adalah steril dan fl&ra n&rmal usus

belum tumbuh' 6&ra n&rmal usus >bakteri? akan mengk&nHersi bilirubin

terk&njugasi menjadi sterk&bilin&gen yang akan ter&ksidasi menjadi

sterk&bilin dan diekskresi ke feses' Pada keadaan jumlah bakteri yang

rendah, bilirubin akan di-dek&njugasi &leh en im -glu ur&nidase brush

b&rder dan direabs&rbsi' Pr&ses reabs&rbsi ini disebut siklus enter&hepatik'

Ga"#ar $ . Metabolisme bilirubin pada neonatus. (Dikutip dari Rennie J.M and

Roberton NRC. Neonatal Jaundice In : A Manual of Neonatal Intensive Care 4 t

!d" Arnold" #$$# : 4%4&4'#

"edua, A I pada beberapa +anita mengandung metab&lit pr&gester&n, yaitu

8-alpha-/0-beta pregnanedi&l ' Lat ini menghambat kerja dari en yme

uridine diph&sph&glu ur&ni a id >$%P5A? glu ur&nyl transferase yang

berfungsi mengk&njugasikan bilirubin' Pada hepar ne&natus, aktiHitas en im

8

http://en.wikipedia.org/w/index.php?title=3-alpha-20-beta_pregnanediol&action=edit&redlink=1http://en.wikipedia.org/wiki/Glucuronyl_transferasehttp://en.wikipedia.org/wiki/Glucuronyl_transferasehttp://en.wikipedia.org/w/index.php?title=3-alpha-20-beta_pregnanediol&action=edit&redlink=1

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glu ur&nyl transferase hanya 0, - G dibandingkan pada de+asa, sehingga

k&njugasi bilirubin pada a+alnya memang belum maksimal' Penghambatan

pada kerja en im ini menyebabkan peningkatan kadar bilirubin dalam

darah'

"etiga, terdapat en im pada A I yaitu lip&pr&tein lipase yang menyebabkan

peningkatan k&nsentrasi free fatty a id yang menghambatkerja en im

glu ur&nyl transferase, sehingga kadar bilirubin tak terk&njugasi tinggi'

F. MANIFESTASI KLINIS

Ikterus menyebabkan kulit dan sklera ber+arna kuning'Pengamatan ikterus

paling baik dilakukan dengan ahaya sinar matahari' (ayi baru lahir >((7? tampak

kuning apabila kadar bilirubin serumnya kira-kira 2 mg dl atau 00 mikr& m&l 7 > mg

mg dl tabel ?' >/,8?

)A*!+ %. Dera,at Ikterus Neonatus menurut -ramer%&na Bagian tu#u' (ang

!uning

Rata)rata seru" #i iru#in indire!

* "& + ,%

#

'

4

-epala dan le er

/usat 0 le er

/usat 0 pa a

+en1an 2 tun1kai

)an1an 2 kaki

%$$

% $

#$$

# $

3# $

(Dikutip dari Arfin Behrman K i!man" #e $%n& Da am ' mu Ke$ehatan

Anak" % ume '" edi$i 15" )ener*it Buku Ked%kteran E+C" 1,,," ha

61- 617 " /0 " 2--3 F 77 F 8,

+. DIAGNOSIS

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1. Ana"nesis

Pada breast feeding jaundi e, +arna kuning pada kulit mulai timbul

pada usia /-8 hari, dan mulai berkurang seiring intake A I yang ukup baik

kualitas maupun kuantitas' Pemberian A I yang kurang atau tidak adekuat,

bisa karena pr&duksi A I yang sedikit atau tidak keluar sama sekali, ara

menyusui yang salah, atau bayi menyusu lemah'

edangkan pada breast milk jaundi e, +arna kuning timbul pada usia

8-< hari dan bertahan lebih lama daripada ikterus fisi&l&gis, yaitu 8- /

minggu' (ayi biasanya sehat dan mendapatkan A I se ara reguler dan

ukup, dan dari ri+ayat keluarga terdapat angg&ta keluarga yang mengalami

ikterus ne&nat&rum sebelumnya' %apat ditanyakan apakah +arna kuning

berkurang bila A I dihentikan /O/9 jam' >=?

#i+ayat usia kehamilan kurang bulan dan usia ibu saat mengandung

bayi tersebut perlu ditanyakan, karena merupakan fakt&r resik& terjadinya

breast milk jaundi e' > 0?

a' #i+ayat kehamilan dengan k&mplikasi >&bat-&batan, ibu %M, ga+at

janin, malnutrisi intra uterin, infeksi intranatal?

b' #i+ayat persalinan dengan tindakan k&mplikasi

' #i+ayat ikterus terapi sinar transfusi tukar pada bayi sebelumnya

d' #i+ayat ink&mpatibilitas darah

e' #i+ayat berat badan lahir rendah prematur

f' #i+ayat keluarga yang menderita anemia, pembesaran hepar dan limpa'> /- ;?

2. Pe"eri!saan Fisi!

e ara klinis ikterus pada ne&natus dapat dilihat segera setelah lahir

atau beberapa hari kemudian' Ikterus yang tampak pun sangat tergantung

kepada penyebab ikterus itu sendiri' Pada bayi dengan peninggian bilirubinindirek, kulit tampak ber+arna kuning terang sampai jingga, sedangkan

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pada penderita dengan gangguan &bstruksi empedu +arna kuning kulit

terlihat agak kehijauan' Penilaian akan lebih sulit lagi apabila penderita

sedang mendapatkan terapi sinar' elain kuning, penderita sering hanya

memperlihatkan gejala minimal misalnya tampak lemah dan nafsu minum

berkurang' "eadaan lain yang mungkin menyertai ikterus adalah anemia,

petekie, pembesaran lien dan hepar, perdarahan tertutup, gangguan nafas,

gangguan sirkulasi, atau gangguan syaraf' "eadaan tadi biasanya ditemukan

pada ikterus berat atau hiperbilirubinemia berat'

*)4 dalam panduannya menerangkan ara menentukan ikterus

se ara Hisual, sebagai berikutF

Pemeriksaan dilakukan dengan pen ahayaan yang ukup >di siang hari

dengan ahaya matahari? karena ikterus bisa terlihat lebih parah bila

dilihat dengan pen ahayaan buatan dan bisa tidak terlihat pada

pen ahayaan yang kurang'

Tekan kulit bayi dengan lembut dengan jari untuk mengetahui +arna di

ba+ah kulit dan jaringan subkutan'

Tentukan keparahan ikterus berdasarkan umur bayi dan bagian tubuh

yang tampak kuning' >tabel /?

)A*!+ #. /erkiraan -linis Dera,at IkterusUsia I!terus ter i'at -ada K asi.i!asi

ari %

ari #

ari '

5etiap Ikterus 6an1 terli at

+en1an dan tun1kai7

)an1an dan kaki

Ikterus berat

7 Bi a kunin! ter ihat pada *a!ian tu*uh manapun pada hari pertama dan

ter ihat pada en!an" tun!kai" tan!an dan kaki pada hari kedua" maka

di!% %n!kan $e*a!ai ikteru$ $an!at *erat dan memer ukan terapi $inar$e epatn a. idak per u menun!!u ha$i pemerik$aan kadar *i iru*in $erum

untuk memu ai terapi $inar.

(Dikutip dari )eter C%%per" A. ur %n%" 'ndar$% F" et a . aundi e. 'n

9ana!in! #e:*%rn )r%* em$ a !uide f%r d% t%r" nur$e$ and mid:i e$"

/0 " 2--3 F 77 F 8,

3. Pe"eri!saan Penun/ang

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Pemeriksaan serum bilirubin >bilirubin t&tal dan direk? harus

dilakukan pada ne&natus yang mengalami ikterus' Terutama pada bayi yang

tampak sakit atau bayi-bayi yang terg&l&ng risik& tinggi terkena

hiperbilirubinemia berat' Namun pada bayi yang mengalami ikterus berat,

lakukan terapi sinar sesegera mungkin, jangan menunda terapi sinar dengan

menunggu hasil pemeriksaan kadar serumbilirubin' > /, 8, ;?

Pemeriksaan tambahan yang sering dilakukan untuk eHaluasi

menentukan penyebab ikterus antara lainF

5&l&ngan darah >A(4, #hesus? dan B:&&mbs testC

%arah lengkap dan hapusan darah

)itung retikul&sit, skrining 5 2P%

(ilirubin direk

Pemeriksaan serum bilirubin t&tal harus diulang setiap 9-/9 jam

tergantung usia bayi dan tingginya kadar bilirubin' > /, 8, ;?

0. PENATALAKSANAAN

Tujuan utama dalam penatalaksanaan ikterus karena A I adalah untuk

mengendalikan agar kadar bilirubin serum tidak men apai nilai yang dapat

menbimbulkan kernikterus ensefal&pati bilirubin, serta menjamin bayi mendapat

nutrisi yang adekuat dari A I' > /, 8?

Menyusui tidak perlu dihentikan ke uali kadar bilirubin serum lebih dari 2

mg d7 selama lebih dari /9 jam' >9? (ila kadar bilirubin diba+ah /0 mg d7, biasanya

dilakukan tatalaksana sebagai berikutF

1. Penanganan sendiri di rumah (9)

(erikan A I yang ukup >.- / kali sehari?' Peningkatan asupan A I akan

meningkatkan peristaltik usus yang kemudian akan membantu pengeluaran

bilirubin'

Pemberian A I harus benar, sehingga akan meningkatkan asupan A I'

Penundaan pemberian A I tidak dipertimbangkan, namun

dipertimbangkan pada bayi dengan f&t&terapi' A I diberikan /9 jam

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setelah terapi' "&mbinasi penundaan A I dengan f&t&terapi memberikan

hasil yang ukup memuaskan dalam menurunkan kadar bilirubin serum'

inar matahari dapat membantu meme ah bilirubin sehingga lebih mudah

dipr&ses &leh hepar' Tempatkan bayi dekat dengan jendela terbuka untukmendapat matahari pagi antara jam telanjang? tetapi hati-hati jangan

sampai kedinginan'

01 Tera-i "edis *2,

Terapi sinar > phototherapy ? sesuai dengan peningkatan kadar bilirubin

pada nilai tertentu >tabel 8?' (ayi akan ditempatkan di ba+ah sinar khusus

yang mampu menembus kulit dan mengubah bilirubin menjadi lumirubin

yang lebih mudah diubah &leh tubuh bayi'

3ika terapi sinar yang standar tidak men&l&ng untuk menurunkan kadar

bilirubin, maka bayi akan ditempatkan pada selimut fiber optic atau terapi

sinar ganda triple akan dilakukan > double/triple light therapy ?

Ga"#ar 0 . *a6i sedan1 men,alani fototerapi. (Dikutip dari American

Academ6 of /ediatrics. 5ubcommittee on 6perbilirubinemia.

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Mana1ement of 6perbilirubinemia in t e ne8born infant ' or more

8eeks of 1estation. /ediatrics #$$4 9 %%4 : # 4.

TERAPI SINAR

Pengaruh sinar terhadap ikterus telah diperkenalkan &leh :remer sejak =;.'

(anyak te&ri yang dikemukakan mengenai pengaruh sinar tersebut' Te&ri terbaru

mengemukakan bah+a terapi sinar menyebabkan terjadinya is&merisasi bilirubin'

Energi sinar mengubah senya+a yang berbentuk 9L, ;L-bilirubin menjadi senya+a

berbentuk 9L, ;E-bilirubin yang merupakan bentuk is&mernya' (entuk is&mer ini

mudah larut dalam plasma dan lebih mudah diekskresi &leh hepar ke dalam saluran

empedu' Peningkatan bilirubin is&mer dalam empedu menyebabkan bertambahnya

pengeluaran airan empedu ke dalam usus, sehingga peristaltik usus meningkat dan

bilirubin akan lebih epat meninggalkan usus halus' > ,8.0-9

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(Dikutip dari Ameri an A adem %f )ediatri $. u* %mmittee %n

0 per*i iru*inemia. 9ana!ement %f h per*i iru*inemia in the

ne:*%rn infant 35 %r m%re :eek$ %f !e$tati%n. )ediatri $ 2--4 &

114 2,4

Pada saat penyinaran diusahakan agar bagian tubuh yang terpapar dapat seluas-

luasnya, yaitu dengan membuka pakaian bayi' P&sisi bayi sebaiknya diubah-ubah

setiap 2-. jam agar bagian tubuh yang terkena ahaya dapat menyeluruh' "edua mata

ditutup namun g&nad tidak perlu ditutup lagi, selama penyinaran kadar bilirubin dan

hem&gl&bin bayi di pantau se ara berkala dan terapi dihentikan apabila kadar bilirubin

Q 0 mg d7 >Q < m&l 7?' 7amanya penyinaran biasanya tidak melebihi 00 jam'> , -/ hari

pertama?F refleks isap lemah, hip&t&nia, kejang@ tahap / >pertengahan minggu pertama?F

tangis melengking, hipert&nia, epist&t&nus@ tahap 8 >setelah minggu pertama?F

hipert&ni' (entuk kr&nikF pada tahun pertamaF hip&t&ni, m&t&rik terlambat' edangsetelah tahun pertama didapati gangguan gerakan, kehilangan pendengaran sens&rial'

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. PROGNOSIS

Pada umumnya bayi dengan ikterus terkait A I, baik breast feeding jaundi e

ataupun breast milk jaundi e mempunyai pr&gn&sis baik' )iperbilirubinemia akan

berangsur membaik dengan pemberian A I yang adekuat dan teratur, resp&n yang baik

juga didapatkan dengan pemberian f&t&terapi' Pr&gn&sis adalah baik apabila kadar

bilirubin serum Q /0 mg d7'

)iperbilirubinemia akan berpengaruh buruk atau menimbulkan gejala yang

berat apabila bilirubin indirek telah melalui sa+ar darah &tak' Pada keadaan ini

penderita mungkin menderita kernikterus atau ensefal&pati bilirubin' 5ejala

ensefal&pati bilirubin ini dapat segera terlihat pada masa ne&natus atau baru tampak

setelah beberapa lama kemudian' %engan memperhatikan hal di atas, maka sebaiknya

pada semua penderita hiperbilirubinemia dilakukan pemeriksaan berkala, baik dalam

hal pertumbuhan fisis dan m&t&rik, ataupun perkembangan mental serta ketajaman

pendengarannya' >9?

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BAB III

KESIMPULAN

Ikterus terjadi karena peningkatan bilirubin serum' Pada ne&natus, kadar bilirubin

lebih dari ; mg d7 akan tampak ikterik pada kulit dan sklera' Ikterus fisi&l&gis pada

ne&natus terjadi karena penghan uran sel darah merah yang banyak terjadi pada umur a+al

kehidupan dan karena fungsi k&njugasi hepar ang belumk sempurna'

Ikterus yang terkait A I dibagi menjadi breast feeding jaundi e, yaitu karena

kekurangan asupan A I, dan breast milk jaundi e, yaitu karena ada at tertentu di dalam

A I yang menghambat k&njugasi bilirubin' Ikterus terkait A I umumnya berlangsung

lebih lama daripada ikterus fisi&l&gis'

Tatalaksana ikterus terkait A I yaitu tetap diberikan A I dan dik&mbinasikan

dengan f&t&terapi'

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DAFTAR PUSTAKA

' Ameri an A ademy &f Pediatri s' ub &mmittee &n )yperbilirubinemia' Management

&f hyperbilirubinemia in the ne+b&rn infant 8; &r m&re +eeks &f gestati&n' Pediatri s

/009 @ 9 F /=9'

/' Asil Aminullah@ Ikterus dan )iperbilirubinemia pada Ne&natus dalam A')' Markum

>ed?, (uku Ajar Ilmu "esehatan Anak, 3ilid I, edisi 2, (alai Penerbit 6"$I, 3akarta,

===, hal F 8 8-8

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0' 7a+ren e, #uth A' (reastfeeding F a guide f&r the medi al pr&fessi&n #uth A'

7a+ren e, #&bert M' 7a+ren e' --

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'tt-4++5551cdc1g&6+#reast.eeding+disease+/aundice1't"

S'&u d a "&t'er c&ntinue #reast.eeding i. 'er c'i d 'as /aundice7

Appr&Oimately 20G &f full-term infants deHel&p jaundi e +ithin seHeral days &f birth'3aundi e, &r yell&+ing &f the skin and eyes, & urs +hen a n&rmal substan e, bilirubin,

builds up in the ne+b&rnWs bl&&dstream faster than the liHer an break it d&+n and eO reteit thr&ugh the babyWs st&&l' (y breastfeeding m&re fre uently &r f&r l&nger peri&ds &f time,the infantWs b&dy an usually rid itself &f the bilirubin eO ess' )&+eHer, in s&me ases, theinfant may need additi&nal treatments t& keep the &nditi&n fr&m pr&gressing int& m&reseHere hyperbilirubinemia, bilirubin en ephal&pathy, &r kerni terus'

(reastfeeding jaundi e may & ur in the first +eek &f life in m&re than in 0 breastfedinfants' The ause is th&ught t& be inade uate milk intake, leading t& dehydrati&n &r l&+

al&ri intake' It is a type &f physi&l&gi &r eOaggerated physi&l&gi jaundi e'

(reast milk jaundi e is far less &mm&n and & urs in ab&ut in /00 babies' )ere the jaundi e isnWt usually Hisible until the baby is a +eek &ld' It &ften rea hes its peak during

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the se &nd &r third +eek' (reast milk jaundi e an be aused by substan es in m&mWs milkthat de rease the infantWs liHerWs ability t& deal +ith bilirubin' (reast milk jaundi e rarely

auses any pr&blems, +hether it is treated &r n&t' It is usually n&t a reas&n t& st&p nursing'

In 3uly, /009, the Ameri an A ademy &f Pediatri s >AAP? published guidelines intended

t& redu e the &nset &f these m&re seHere, yet preHentable, &nditi&ns' A &rding t& AAPub &mmittee &n )yperbilirubinemia, f&r eHery ne+b&rn b&rn at 8; &r m&re +eeks &f

gestati&n, health pra titi&ners sh&uld pr&m&te and supp&rt su essful breastfeedingF

X#e &mmendati&n '0F :lini ians sh&uld adHise m&thers t& nurse their infants at least . t&/ times per day f&r the first seHeral days'X

X#e &mmendati&n ' F The AAP re &mmends against r&utine supplementati&n &fn&ndehydrated breastfed infants +ith +ater &r deOtr&se sugarZ +ater'X

HYPERBILIRUBINEMIA AND JAUNDICEJaundice in newborns has become a source of considerable misinformation, confusion, andanxiety. Incidence of jaundice is higher in full-term infants than a decade ago. From1994 to !! 11.9" of newborns were hos#itali$ed for hy#erbilirubinemia% rates rose to

!.!" in !!& to !!'. (he incidence of )ernicterus dro##ed from '.* #er 1!!,!!! li+ebirths to 1. #er 1!!,!!! li+e births as a result of aggressi+e #re+enti+e measures inthese years

according to ur)e et al. && ore #hysicians are

#aying attention to the

de+elo#ment of hy#erbilirubinemia in newborns. (hese two factors ser+e to increase thefre/uency of the /uestion of the role of breastfeeding in the de+elo#ment ofhy#erbilirubinemia. 0ome of the confusion and inconsistencies associated with themanagement can be attributed to indecisi+e terminology. (his discussion attem#ts toclarify the issues and outlines the causes and effects of hy#erbilirubinemia.

Why the Concern About Jaundice?ilirubin is a cell toxin, as can be demonstrated dramatically by adding a little

bilirubin to a tissue culture, which will be /uic)ly destroyed. xcessi+e bilirubincauses concern because when free, unbound, unconjugated bilirubin is in the system, it

can be de#osited in +arious tissues, ultimately causing necrosis of the cells. (he brainand brain cells, if destroyed by bilirubin de#osits, do not regenerate. 2* (he full-blown

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end result is bilirubin ence#halo#athy, or )ernicterus, which is essentially a#athologic diagnosis that de#ends on identifying the yellow #igmentation and necrosis inthe brain, es#ecially in the basal ganglion, hi##ocam#al cortex, and subthalamic nuclei.3t auto#sy, '!" of infants with )ernicterus also ha+e other lesions caused by bilirubintoxicity. ecrosis of renal tubular cells, intestinal mucosa, or #ancreatic cells or

associated 5I hemorrhage may be seen. (he classic clinical manifestations of bilirubin ence#halo#athy are characteri$ed by #rogressi+e lethargy, rigidity, o#isthotonos, high-#itched cry, fe+er, and con+ulsions. (he mortality rate is '!". 0ur+i+ors usually ha+echoreoathetoid cerebral #alsy, asymmetric s#asticity, #aresis of u#ward ga$e, high-fre/uency deafness, and mental retardation. 49 6remature infants are #articularlysusce#tible to bilirubin-related brain damage and may ha+e )ernicterus at auto#sywithout the ty#ical clinical syndrome. 3 significant correlation exists between le+el ofbilirubin and hearing im#airment in newborns when other ris) factors are #resent.7lassic full-blown )ernicterus rarely occurs today, but mild effects on the brain may bemanifested clinically in later life as in coordination, hy#ertonicity, and mental

retardation or learning disabilities, sym#toms sometimes collecti+ely called minimalbrain damage. 2* ilirubin ence#halo#athy is the a##ro#riate term for conditions in whichbilirubin is thought to be the cause of brain toxicity. In res#onse to the continuedconcern about hy#erbilirubinemia, se+eral collaborati+e longrange studies ha+e beendone. 2&,119,1 !,1 & ach one confirms the obser+ation that in normal full-term infants who donot ha+e an incom#atibility, the neurode+elo#mental outcome is normal, as is hearing acuity. 1 9,1 & In a study of ! breastfed infants in whom the maximum bilirubin was 1*.&mg" and the duration was 1 wee)s or more, no late neurode+elo#mental or hearing defectswere seen. (he authors describe a #ea) le+el at 4 to ' days and a second #ea) at thefourteenth to fifteenth day. 3ll ! infants had blood ty#ing, direct and indirect 7oombs8antiglobulin tests, blood count, glucose- -#hos#hate dehydrogenase acti+ity,urinalysis, urine culture, (4 and thyroid-stimulating hormone, total reducing substancesin the urine, and s#ot tests for galactose and aminotransferase to rule out other causesof hy#erbilirubinemia. (he authors also re#orted a 14" incidence of familial jaundice,that is, a #re+ious infant with jaundice 8 of 4& infants who were breastfed who hadsiblings . 19

Mechani ! o" Bi#irubin Productionin the Neonate3 normal full-term infant has a hematocrit in utero of '!" to '". ecause of the lowoxygen tension deli+ered to the fetus +ia the #lacenta, the fetus re/uires morehemoglobin 8:b to carry the oxygen. 3s soon as an infant is born and begins to breatheroom air, the need is gone. (he infant bone marrow does not ma)e more cells, and excesscells are destroyed and not re#laced. (he life s#an of a fetal red blood cell 8; 7 is2! to 9! days instead of an adult

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binding ca#acities that +ary with maturity and other factors, 1' such as #:, infection,and hy#oglycemia. >nconjugated bilirubin is remo+ed from the circulation by thehe#atocyte, which con+erts it by conjugation of each molecule of bilirubin with two molecules of glucuronic acid into direct bilirubin. ?irect bilirubin is water solubleand is excreted +ia the bile to the stools. (he balance between he#atic cell u#ta)e of

bilirubin and the rate of bilirubin #roduction determines the serum unconjugated bilirubin concentration. @aboratory measurements include both bound and unbound indirectbilirubin. (he amount of unconjugated bilirubin that exceeds the binding ca#acity of aninfant

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glucose- -#hos#hate dehydrogenase is the mostcommon genetic defect and urges more fre/uentscreening. Infants with these genetic +ariants whowere not breastfed had hy#erbilirubinemia that wasless res#onsi+e to #hotothera#y% thus it is recommended

that breastfeeding not be discontinued. *2Deter!ination o" Cau e o" JaundiceFollowing the chain of e+ents from the destructionof ; 7s in newborns through the final excretionof conjugated bilirubin in the stools sim#lifiesunderstanding the cause of a s#ecific case of jaundice.111 7auses include 81 increased destruction of; 7s, 8 decreased conjugation in the glucuronidasesystem, 8& decreased albumin binding, and84 increased reabsor#tion from the 5I tract and

decreased excretion. (o be excreted from the body,unconjugated bilirubin has to be conjugated withglucuronic acid in the he#atocyte, which becomeswater- soluble bilirubin glucuronide. (he en$ymein+ol+ed is a s#ecific he#atic en$yme isoform 8131belonging to the uridine di#hos#hoglucuronateglucuronosyltransferase 8>5( family of en$ymes.

uch has been learned about these en$ymes andtheir relationshi# to bilirubin metabolism. 92 >5(scataly$e the conjugation of not only bilirubin butsteroids, bile acids, drugs and other xenobiotics.(he two se#arate families of genes, >5(1 and>5( , ha+e different actions. 5ilbert syndrome,an uncommon genetic anemia associated with #ersistenthy#erbilirubinemia in neonates, is associatedwith a mutation in the coding area of >5(131gene. 0imilar genetic +ariations are #resent in7rigler-

ajjar syndrome. (hese genetic +ariationsare #robably the cause of most #ersistent hy#erbilirubinemia,as suggested by Ba#lan, :ammerman,

and aisels. 9*thnic bac)ground, ris) factors, #re+ious infants

with hy#erbilirubinemia, and family history ofanemia and jaundice are im#ortant to the correctdiagnosis and management, the #reser+ation ofbreastfeeding, and the safety of the infant.Chen albumin binding is altered, the +isibility ofthe jaundice is not affected. (he bilirubin le+el maynot be +ery high, but the substance is not boundto albumin and is a+ailable at lower le+els to #assinto the brain cells. 1'' 6remature infants ha+e muchlower albumin le+els and thus ha+e fewer binding

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sites. ?rugs that also bind to albumin 8e.g., as#irin,sulfadia$ine com#ete for the same binding sites. 3lower le+el of bilirubin #uts infants who ha+e thesemedications in their system at ris) because the bilirubinis unbound and a+ailable to enter tissue cells,

including brain cells.;eabsor#tion of bilirubin from stool in the 5Itract can increase the bilirubin le+el. (his occurswhen the conjugated bilirubin that was excretedinto the colon and the stool is slow to #ass. It is

unconjugated by the action of intestinal bacteriaand reabsorbed, which ha##ens when stools

are decreased or slowed in #assage. 6oor feedings,#yloric stenosis, and other forms of intestinalobstruction are common causes of this ty#e of jaundice.0ome bacteria are more li)ely than others tounconjugate conjugated bilirubin.0e#sis, on the other hand, was not found inmore than &!! infants readmitted for hy#erbilirubinemiawhile healthy and breastfeeding. @owertotal bilirubin and direct bilirubin le+els greaterthan .! mg" in a sic) baby ha+e a high correlationwith se#sis. 9

Sa.e e6e s &. #i iru#in10afe le+els of bilirubinde#end on a number of factors, including acidosis,hy#oxia or anoxia, and se#sis. 3 handy ruleof thumb is the correlation of birth weight in a#remature infant and the indirect bilirubin le+el,using a +alue to & mg lower when an infant hasmulti#le #roblems. (he ris) for ele+ated bilirubinis related to the a+ailability of albumin to bind theindirect bilirubin and #re+ent it from entering thebrain cells. (he amount of albumin is related to the

degree of #rematurity, and thus the rule of thumbis based on birth weight andAor gestational age.Chen an infant is sic), fewer albumin-binding sitesare a+ailable, and the bilirubin le+el of concern ise+en lower.In a well infant weighing less than !!! g,the #ea) tolerated bilirubin le+el abo+e whichaggressi+e thera#y would be initiated corres#ondsroughly to weight as followsD 1*!! g, 1* mgAd@%1'!! g, 1' mgAd@% 1 !! g, 1 mgAd@% and 1!!! g,

1! mgAd@. 6hotothera#y is usually initiated whenthe bilirubin is a##roximately ' mgAd@ lower than

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this le+el. ecause of stri##ing of bilirubin from thebinding sites in the brain ca#illaries in some situations,such as #rematurity, or #resence of a com#etingdrug in the serum, more bilirubin is a+ailableto be de#osited than is measured to be Efree in the

#lasma. 1''3ny +alue of ! mgAd@ or greater warrants considerationof aggressi+e treatment. Jaundice +isiblewhen an infant is younger than 4 hours of age isof s#ecial concern because it is usually associatedwith an incom#atibility or infection. ;a#idly risingbilirubin le+els are also of concern, and a !.' mgAd@rise #er hour is an indication for treatment.(he 3merican 3cademy of 6ediatrics 8336 has#ublished a #ractice #arameter for the management

of hy#erbilirubinemia in healthy term newborns.12' (erm infants who are +isibly jaundiced at orbefore 4 hours of life are not considered healthyand re/uire a diagnostic wor) u# regardless of feedingmethod. (he 336 also addresses jaundice associatedwith breastfeeding in healthy term infants asfollowsDThe AAP discourages the interruption of breastfeedingin healthy term newborns and encourages continued andfrequent breastfeeding at least ! to 1" times e#ery 2$ hours%&'upplementing nursing with water or de(trose water does not

lower the bilirubin le#el in )aundiced* healthy* breastfeedinginfants&12'H(-er#i iru#ine"ia and #reast.eeding1 (womajor clinical conditions exist 8one common, onerare that associate breastfed infants with hy#erbilirubinemia.(able 14-4 &utlines the major clinicalfeatures of these two conditions. (he more commoncondition has been called early breast mil+ )aundice by5artner and @ee & but might be called )aundice while

breastfeeding because the failure to #roduce stool and

the decreased inta)e of calories, #robably not thebreastfeeding, are at fault. 0ome bottle-fed infantsalso are jaundiced, so the a##ro#riate term wouldbe bottle,feeding )aundice for this grou#.Ear ( /aundice 5'i e #reast.eeding1 any studiesof bilirubin le+els in normal newborn nurseries ha+ebeen conducted that loo) at method of feeding.>nfortunately, few ha+e detailed fre/uency of feeds,su##lementation, and stool #attern. 42,119,12! 3 re+iewsummari$ing results in 1& studies co+ering morethan !,!!! infants was re#orted by 0chneider 1 4 toshow a relationshi# between breastfeeding and jaundice.

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3 #ooled analysis of 1 studies showed '14 of

&992 breastfed infants to ha+e total serum bilirubin

le+els of 1 mgAd@ or higher +ersus 12 of 4 '' bottle-fed infants. In a smaller grou# of studies, '4 of

'' breastfed infants had bilirubin le+els of 1' mgAd@ or greater +ersus 1! of &!! bottle-fed infants.

le+en of 1& studies re#orted that breastfed infantshad higher mean bilirubin le+els. In a series of morethan 1 ,!!! infants, the ris) for a breastfed infantbecoming jaundiced was 1D*. (he ris) for becomingjaundiced for a #remature infant was &D % for aninfant of 3sian race, &D' % and with #rolonged ru#ture

of membranes, 1D91. Jaundice is more commonin normal newborns now com#ared with those in the19'!s, when bilirubin was rarely measured becauseit was a com#licated test in normal babies, althoughhos#ital stays a+eraged ' to 2 days. ,12';ates of significant jaundice in 3ustralia rose from!.9" to &.'" from 192' to 19*2. (he associatedfactors most li)ely to be #resent in jaundiced infantswere infre/uent breastfeeding, less fre/uent stooling,and excessi+e weight loss. 1*' It is clear from manystudies that more breastfed than bottle-fed infantsare jaundiced, and the cause re/uires further study. 1Re ati&ns'i- &. #i iru#in e6e t& -assage &. st&& s1(here are 4'! mg of bilirubin in the intestinaltract meconium of an a+erage newborn infant.6assing this meconium is critical to a+oid thedeconjugation and reabsor#tion of unconjugatedbilirubin from the gut into the serum. Failure to #assmeconium is correlated with ele+ated serum bilirubin.(ime of first stool is also correlated with le+elof serum bilirubin. ottle-fed infants were re#orted

by de 7ar+alho et al 4* to excrete more stool 8* gand more bilirubin 8 &.* mg in the first & days thanbreastfed infants, who excreted '* g of stool and1'.2 mg bilirubin. (he serum bilirubin le+els were

.* mgAd@ in bottle-fed and 9.' mgAd@ in breastfedinfants. Furthermore, when the breastfed infantsexcreted more stools and more bilirubin, they hadlower bilirubin le+els. (his relationshi# has beenconfirmed in other studies from days & to 1. 9C#inica# Ri & 'actorin Hy(erbi#irubine!ia7linical examination by +isual assessment of jaundicein newborns is not reliable in a study com#aring

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+isual estimates with laboratory +alues byoyer, 3hn, and 0need. 1&* (hey suggested bilirubin

testing should be based on ris) factors. 7linicalris) factors significantly im#ro+e #redictionof hy#erbilirubinemia com#ared with the use of

early total bilirubin le+els, as re#orted by ewmanet al 141 based on a study of almost '4,!!! infantsolder than & -wee)s< gestational age and at least

!!! g birth weight. From this grou# !2 caseswere found with ele+ated bilirubins drawn before

4*-hour discharge. (he authors found the ris)index was the best #redictor of ele+ated bilirubin8(able 14-' . 7learly, #rematurity carries the greatestris). (he total serum bilirubin before 4* hoursof 9'" or higher the ris) score were accurate #redictorsof reaching a bilirubin of ! mgAd@.Chen the number of feedings at the breast inthe first & days of life was related to bilirubin le+els,de 7ar+alho et al 4* were able to dis#lay a significantrelationshi#. (he greater the number of breastfeedings,the lower the bilirubin. Infants with morethan eight feedings #er day were not significantlyjaundiced. (hese authors also found that water anddextrose su##lements were associated with higherbilirubin le+els. Chen Buhr and 6aneth 1!4 studiedfeeding #ractices in breastfed infants, they notedthat sugar-water inta)e in the first & days negati+elyaffected the +olume of breast mil) a+ailable on thefourth day. (he infants with high glucose inta)ehad higher bilirubin le+els. (hese studies do nota##ear to show a correlation between weight lossand bilirubin le+el, although breastfed infants maylose more weight than bottle-fed infants.Chen 0te+enson 124 measured bilirubin #roductionby calculating #ulmonary carbon monoxide

excretion in both breastfed and bottle-fed infants,he found no difference in the amount of bilirubin#roduced in the two grou#s, suggesting the #roblemwas excretion in the stool.

8a &ric de-ri6ati&n and star6ati&n1 le+atedbilirubin did not im#ede suc)ing ability, as demonstratedin a study by 3lexander and ;oberts.;educed caloric inta)e or star+ation has been associatedwith hy#erbilirubinemia in adult humans andin many animals. (he association between star+ationand early neonatal jaundice has been described. 5artnerand @ee & ha+e #ostulated that star+ation may

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increase bilirubin #roduction, shift bilirubin #ools,

reduce he#atic bilirubin u#ta)e, diminish he#atic

bilirubin conjugation, or increase enteric bilirubinreabsor#tion. 3de/uate caloric inta)e may sim#lydiminish intestinal bilirubin absor#tion. Infants withintestinal obstruction 8#yloric stenosis at birth or inthe early wee)s of life are often jaundiced.

Treat"ent &. ear ( '(-er#i iru#ine"ia1 Chenaisels and 5ifford 1 1 measured serum bilirubin le+els

in newborns and the relationshi# to breastfeeding,they re#orted eight of 1! infants with serumbilirubin greater than 1 .9 mgAd@ were breastfed.

It is the #rocess of altered nourishment that is thecause of relati+e star+ation. (he amount of stress fora mother generated by se#aration from her infant for#hotothera#y was measured by urine cortisol le+elsand com#ared with le+els in mothers who roomedinwith their jaundiced infants during #hotothera#y.(he se#arated mothers were more stressed and weremore li)ely to discontinue breastfeeding than thosewho remained with their infants. 'In a controlled trial of four inter+entions, 14! 1 'of 1 *' infants in the birth cohort whose bilirubinle+els reached 12 mgAd@ 8 91 mmolA@ were randomlyassigned to treatment. (he four inter+entionswere 81 continue breastfeeding and obser+e%8 discontinue breastfeeding and substitute formula%8& discontinue breastfeeding, substituteformula, and use #hotothera#y% and 84 continuebreastfeeding and use #hotothera#y. (he bilirubinreached ! mgAd@ 8&4 mmolA@ in 4" of grou# 1,19" of grou# , &" of grou# &, and 14" of grou#4. 6hotothera#y clearly adds to the decline in bilirubin,

and the authors suggest that the #arents canbe offered the management of their choice. ewmanand aisels 14 recommend that because jaundicedinfants are rarely sic), the only laboratorywor) necessary is a blood ty#e and 7oombs test%only when jaundice is excessi+e should bilirubinle+els be followed closely. Infants with incom#atibilitiesshould be treated aggressi+ely.3n e+aluation of the transcutaneous bilirubinometerdemonstrated that it correlated well with

total serum bilirubins done in the laboratory. 1 1(he correlation in blac) infants was not as close

2,

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but le+els erred on the high side so that underdiagnosingis not a ris). ulti#le chec)s with the meterare easily done to establish trends so that a breastfedinfant can be followed closely without #ainfulstic)s. lood le+els are essential if #hotothera#y is

needed and after it is initiated. 1 &:y#erbilirubinemia results from un#hysiologicmanagement of breastfeeding, ex#ressed largelythrough insufficient fre/uency of breastfeeding. (otreat the actual cause, that is, failed breastfeedingor inade/uate stooling or underfeeding, breastfeedingshould be re+iewed for fre/uency, length ofsuc)ling, and a##arent su##ly of mil), adjusting the

breastfeeding to im#ro+e any deficits. If stooling isthe #roblem, an infant should be stimulated to stool.If star+ation is the #roblem, the infant should recei+eadditional calories 8formula while the mil) su##ly isbeing increased by better breastfeeding techni/ues.(he same would a##ly to bottle-feeding jaundice8i.e., any infant with idio#athic jaundice whois being bottle fed and has a bilirubin le+el greaterthan 1 .9 mgAd@ . 0tooling, fre/uency of feeds, and)ilocalories would be im#ro+ed. ox 14-1 #ro+ides amanagement schema for #re+enting or treating jaundicein the breastfed infant. 3ll infants must ha+e thea##ro#riate laboratory studies #erformed. 15uidelines for the management of hy#erbilirubinemiaof a newborn who is at least &' wee)s< gestationalage ha+e been de+elo#ed by the 0ubcommitteeon :y#erbilirubinemia of the 336 8 ox 14-1 . 12'(he )ey elements of their recommendations a##earin ox 14- . (he nomogram for designation of ris)for jaundice is illustrated in Figure 14-' . 5uidelines

for #hotothera#ies are illustrated in Figure 14- .(he 3cademy of reastfeeding edicine hasbeen de+elo#ing a #rotocol for hy#erbilirubinemiawhich will be on its websiteD htt#DAAwww.3cademyof edicine.com. Jaundice in @GC infantsat less than &' wee)s< gestation also results fromincreased bilirubin #roduction, decreased he#aticconjugation in an immature li+er, and inade/uateexcretion +ia the stool. :y#erbilirubinemia in #reterminfants is more #re+alent, more se+ere, and

more #rotracted. (he ris) for )ernicterus is greateras well. Its management is the #ur+iew of a neonatologist.

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19& In most cases, if human milk is providedit is maintained. In a commentary on the subcommitteeguidelines, Maisels et al 1 ! add the followingrecommendations:Management and follow-up

plans should be based on gestational age, predischargebilirubins, and risk factors for subsequent

hyperbilirubinemia ( o! "#-$%. &hey begin withsuggesting lactation evaluation and support forall breastfeeding mothers. &hey also recommendthat timing of repeat bilirubin measurements afterdischarge depend on age at time of measurementand on degree the level is above the ' th percentile.)ollow-up recommendations can be modifiedaccording to the level of risk. Infants should have apredischarge bilirubin, which has been the recommendationto improve the chances of preventingkernicterus, although this is not an official policybut e!pert opinion. 1 ! *s Maisels et al 1 ! write:-e recommend uni#ersal predischarge bilirubin screeningusing total serum bilirubin T'.% or transcutaneous

bilirubin Tc.% measurements* which help to assess the ris+of subsequent se#ere hyperbilirubinemia& -e also recommenda more structured approach to management and follow,upaccording to the predischarge T'./Tc.* gestational

age* and other ris+ factors for hyperbilirubinemia& Theserecommendations represent a consensus of e(pert opinion basedon the a#ailable e#idence* and they are supported by se#eralindependent re#iewers& 0e#ertheless* their efficacy in pre#enting

+ernicterus and their cost,effecti#eness are un+nown&)ernicteru in Late Preter! In"antCared 'or a *er! Hea#thy In"ant

+ate prematurity ($# 2 to $ 2 weeks gestational age% has not been recogni ed as a riskfactor for ha ardous hyperbilirubinemia by practitioners according to hutani and/ohnson, 9 who report cases of acute and chronic posticteric sequelae. +arge-for- estational-age and late preterm infants are disproportionately represented in the group with kernicterus. 0nsuccessful and suboptimal lactation e!perience was the most frequentassociated factor. &he authors urge attention to early bilirubin values, additional riskfactors, and the success ofbreastfeeding in these infants. &hese infants requireclose monitoring by pediatricians.

Breast "i ! /aundice1 *part from the frequent butlow level (usually less than "1 mg2d+% hyperbilirubinemia,breastfeeding rarely is associated withdelayed but prolonged hyperbilirubinemia, which,

if unchecked, may e!ceed 13 mg2d+. &his syndromehas been called breast milk 4aundice, late-onset

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4aundice, and breast milk 4aundice syndrome. 4 Itoccurs in less than " in 133 births5 the numbers areimprecise because not all mothers breastfeed. &hissyndrome is associated with the milk of a particularmother and will occur with each pregnancy in varying

degrees, depending on each infant s ability tocon4ugate bilirubin (i.e., a premature sibling mightbe more severely affected%. 4 6arly-onset 4aundiceis related to the process of breastfeeding, not themilk itself. It is essential to rule out other causes ofprolonged or e!cessive 4aundice, especially hemolyticdisease, hypothyroidism, glucose- -phosphatedehydrogenase deficiency, inherited hepatic glucuronyltransferase deficiency (7ilbert syndrome,etc.%, and intestinal obstruction.

&he pattern of this 4aundice is distinctly different.8ormally, idiopathic 4aundice peaks onthe third day and then begins to drop. reast milk4aundice, however, becomes apparent or continues

to rise after the third day, and bilirubin levels maypeak any time from the seventh to the tenth day,with untreated cases being reported to peak as lateas the fifteenth day. 9alues have ranged from "3 to1 mg2d+ during this time. 8o correlation e!istswith weight loss or gain, and stools are normal.&he syndrome of breast milk 4aundice wasattributed by *rias et al 14 to a substance in themilk of some mothers that inhibits the hepaticen yme glucuronyl transferase, preventing thecon4ugation of bilirubin. &he substance has beenidentified as ;-pregnane-$

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under investigation. &he role of free fatty acids andthe possibility of abnormal lipases are unresolved.&he undisputed cause of breast milk 4aundice continuesto elude investigators.

*s in early 4aundice associated with breastfeeding,4aundiced infants at $ weeks do not producemore bilirubin than their un4aundiced breastfedpeers or bottle-fed infants.?iagnosis depends on circumstantial evidence,because no easy, rapid laboratory test e!ists. *llother causes, including infection, should be ruledout in the usual manner and a thorough historytaken, including medications and family history andethnic background. If the mother has nursed otherinfants, were they 4aundiced@ 0sually 3= of theprevious children of a given mother whose infanthas breast milk 4aundice have been 4aundiced. &hedifference may be related to the greater maturity ofthe liver of a given infant who then is able to handlethe increased demands on the glucuronyl transferasesystem. 7enetic variations in 07&I*" and A*&B1genes may hold answers. &o establish the diagnosisfirmly, and this is necessary when the bilirubin levelis greater than " mg2d+ for more than 1# hours, abilirubin reading should be obtained 1 hours after abreastfeeding and then breastfeeding discontinuedfor at least "1 hours. 14! &he infant must be fed fluidsand calories. &he infant s mother should be assistedin pumping her breasts to maintain her supply. 6venmore urgent is providing the mother with a sympathetice!planation of the problem and the process.*fter at least "1 hours without mother s milk, the bilirubinlevel should be measured. If a significant dropof more than 1 mg2d+ occurs, it is diagnostic. >henthe level is less than " mg2d+, the infant can be put

to the breast. ilirubin levels should be obtained todetermine if the bilirubin rises again and, if so, howmuch. In most cases, in the time not breastfeeding,the infant s body equilibrates the levels sufficiently,so only a slight increase in bilirubin occurs on returnto breastfeeding followed by a slow but steady drop.If that is the case, breastfeeding can continue. &hebilirubin level should be checked at "3 to "# days tobe certain the bilirubin is truly clearing.If the bilirubin has not dropped significantly after"1 hours without breast milk, the time off the breastshould be e!tended to "C to 1# hours, measuring bilirubin

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levels every hours. If the bilirubin rises whilethe infant is off the breast, the cause of 4aundice isclearly not the breast milk5 breastfeeding should beresumed and other causes for the 4aundice reevaluated.

P'&t&t'era-( and #reast "i ! /aundice1 If the

bilirubin is substantially greater than 13 mg2d+ in afull-term infant (or proportionately lower in a preterminfant%, it is important to lower the bilirubinpromptly5 thus phototherapy should be initiated assoon as the blood work is drawn ( )igure "#- %. &herelationship to breastfeeding can be establishedlater. Aften I9 fluids are also necessary.If one is attempting to establish the diagnosisof breast milk 4aundice, phototherapy should not

be used while breast milk is being discontinued. Ifestablishing the diagnosis is not necessary (perhapsbecause of the same diagnosis in older siblings%,phototherapy can be used to bring the values to amore acceptable range (i.e., less than "1 mg2d+%.>hen phototherapy is discontinued, it is mostimportant to establish that no rebound hyperbilirubinemiaoccurs. In addition, it is important to followthe infant at home after discharge through at

least "# days of life or longer if the values are notless than "1 mg2d+. It should not be assumed thatthe diagnosis is breast milk 4aundice when breastfeedinghas been stopped and phototherapy initiatedsimultaneously.

Late Dia%no i o" Brea t Mi#& Jaundice>ith the frequency of early discharge from the hospital, especially for familiesen4oying the

birthing center concept, breastfed infants are

often discharged before

4aundice for any reason has developed. ecause breast milk 4aundice is likely to bedelayed to the fourth or fifth day, peaking at "3 to "# days of age, most normal infantsare already home. Accasionally, an infant is observed in a pediatrician s office at "3days of age or older with a bilirubin level greater than 13 mg2d+, often 1$ to 1 mg2d+.&his necessitates the admission of the infant to the hospital for a complete bilirubinwork up. It is important to recogni e that other causes of hyperbilirubinemia must beruled out, including blood-type incompatibilities. *t this age it is also necessary torule out biliary obstruction and hepatitis, which might have a high direct or con4ugatedbilirubin level. Bhototherapy is used for # to hours to establish whether this therapywill be effective in dropping the level sufficiently. >hen bilirubin is substantiallygreater than 13 mg2d+ and if a possible association with breast milk e!ists, it isnecessary to stop breastfeeding temporarily and start phototherapy immediately on

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admission while the diagnostic work up is being performed. Atherwise, breastfeeding maycontinue even though I9 fluids may also be necessary. &he *gency for Dealth EareFesearch and Guality through its 6vidence-based Bractice Eenters published a report onmanagement of neonatal hyperbilirubinemia in 133$ after an e!tensive review of more than# 3 abstracts from which 1#" articles were e!amined and "$C included in the report. 9! *

summary of 1C reports spanning $3 years including "1$ cases of kernicterus in term andnear-term infants affirmed the relationship of elevated bilirubin to kernicterus. &heycalculated that si! to "3 4aundiced healthy infants with a &H at or greater than "mg2d+ would need to be treated with phototherapy to prevent &H from rising higher than13 mg2d+ in one infant. &hey concluded that phototherapy combined with the cessation ofbreastfeeding and substitution with formula was the most efficient protocol. ecause this approach has not been tested, more research is needed. In contrast, Ehou et al &*proposed a management of hyperbilirubinemia using a benchmarking model in a $-yearprospective cohort study. &hey found association of high bilirubin with lower gestationalage, older mother, and e!clusive or partial breastfeeding. &he authors recommend

assessing breastfeeding and promoting breastfeeding, supplementing if necessary but never with water, in combination with phototherapy as most efficacious. &* Brolongedbreast milk 4aundice has not been studied in follow-up when the association of thebilirubin elevation has been made with breast milk. * pediatric practice may see only afew in a lifetime. &he safe level for chronic indirect bilirubin has not been established. &he lactation study center recommends greater than or equal to"3 mg2d+.Athers allow a level of "1 mg2d+. &his is accomplished most easily with phototherapy5usually having an infant sleep under phototherapy "1 hours per day, utili ing homedevices such as the bilirubinblanket,J will control the levels. &his is not a casual arrangement. &he eyes must beprotected and the bilirubin monitored. *s the liver matures the problem disappears andphototherapy can be discontinued. &he infant must be under the care of an e!periencedpediatrician. In some cases the bilirubin can be controlled with partial breastfeedingwith the addition of formula in sufficient amounts to maintain the bilirubin at less than "3 mg2d+. Ehildren with 7ilbert syndrome, Erigler-8a44ar syndrome, glucose- -phosphate dehydrogenase, and other genetic variations must be managed individually by agenetic specialist and the pediatrician.