Bilirubin binding in jaundiced newborns: from bench to bedside? Ahlfors Charles E,Bhutani Vinod K,Wong Ronald J,Stevenson David K Pediatric research BACKGROUND:Bilirubin-induced neurologic dysfunction (BIND) is a spectrum of preventable neurological sequelae in jaundiced newborns. Current total plasma bilirubin (B) concentration thresholds for phototherapy and/or exchange transfusion poorly predict BIND. METHODS:The unbound (free) bilirubin (B) measured at these B thresholds provides additional information about the risk for BIND. B can be readily adapted to clinical use by determining B population parameters at current B thresholds. These parameters can be established using a plasma bilirubin binding panel (BBP) consisting of B, B, and two empiric constants, the maximum B (B) and the corresponding equilibrium association bilirubin constant (K). RESULTS:B and K provide the variables needed to accurately estimate B at B < B to obtain B at threshold B in patient samples. Once B population parameters are known, the BBP in a newborn can be used to identify poor bilirubin binding (higher B at the threshold B compared with the population) and increased risk of BIND. CONCLUSION:The BBP can also be used in jaundice screening to better identify the actual B at which intervention would be prudent. The BBP is used with current B thresholds to better identify the risk of BIND and whether and when to intervene. 10.1038/s41390-018-0010-3

Conjunctival Icterus - An Important but Neglected Sign of Clinically Relevant Hyperbilirubinemia in Jaundiced Neonates. Azzuqa Abeer,Watchko Jon F Current pediatric reviews BACKGROUND:Conjunctival icterus is a largely neglected physical sign that may be helpful in identifying neonates with clinically relevant hyperbilirubinemia by practitioners in the hospital and outpatient clinic or parents at home. OBJECTIVE:A recent NICU based study reported that conjunctival icterus is often a sign of significant (TSB ≥ 17 mg/dl) hyperbilirubinemia and TSB levels ≥ 76th-95th percentile on the Bhutani nomogram. In contrast, others report that conjunctival icterus, although frequently present at high TSB levels, may also be detected at lower TSB concentrations; suggesting instead that its absence may help to rule out significant hyperbilirubinemia. RESULT AND CONCLUSION:The current review details the nature of conjunctival icterus and presents new data on its clinical occurrence in relation to TSB levels that re-affirm its correlation with elevated TSB concentrations and use to trigger TSB measurement in the jaundiced neonate. 10.2174/1573396313666170718145535

Neonatal Jaundice. Abbey Pooja,Kandasamy Devasenathipathy,Naranje Priyanka Indian journal of pediatrics Hyperbilirubinemia is a common occurrence in neonates; it may be physiological or pathological. Conjugated hyperbilirubinemia may result from medical or surgical causes, and can result in irreversible liver damage if untreated. The aim of imaging is the timely diagnosis of surgical conditions like biliary atresia and choledochal cysts. Abdominal ultrasound is the first line imaging modality, and Magnetic resonance cholangiopancreatography (MRCP) also has a role, especially in pre-operative assessment of choledochal cysts (CDCs). For biliary atresia, the triangular cord sign and gallbladder abnormalities are the two most useful ultrasound features, with a combined sensitivity of 95%. Liver biopsy has an important role in pre-operative evaluation; however, the gold standard for diagnosis of biliary atresia remains an intra-operative cholangiogram. Choledochal cysts are classified into types according to the number, location, extent and morphology of the areas of cystic dilatation. They are often associated with an abnormal pancreaticobiliary junction, which is best assessed on MRCP. Caroli's disease or type 5 CDC comprises of multiple intrahepatic cysts. CDCs, though benign, require surgery as they may be associated with complications like cholelithiasis, cholangitis and development of malignancy. Severe unconjugated hyperbilirubinemia puts neonates at high risk of developing bilirubin induced brain injury, which may be acute or chronic. Magnetic resonance imaging of the brain is the preferred modality for evaluation, and shows characteristic involvement of the globus pallidi, subthalamic nuclei and cerebellum - in acute cases, these areas show T1 hyperintensity, while chronic cases typically show hyperintensity on T2 weighted images. 10.1007/s12098-019-02856-0

Sixty years of phototherapy for neonatal jaundice - from serendipitous observation to standardized treatment and rescue for millions. Hansen Thor Willy Ruud,Maisels M Jeffrey,Ebbesen Finn,Vreman Hendrik J,Stevenson David K,Wong Ronald J,Bhutani Vinod K Journal of perinatology : official journal of the California Perinatal Association A breakthrough discovery 60 years ago by Cremer et al. has since changed the way we treat infants with hyperbilirubinemia and saved the lives of millions from death and disabilities. "Photobiology" has evolved by inquiry of diverse light sources: fluorescent tubes (wavelength range of 400-520 nm; halogen spotlights that emit circular footprints of light; fiberoptic pads/blankets (mostly, 400-550 nm range) that can be placed in direct contact with skin; and the current narrow-band blue light-emitting diode (LED) light (450-470 nm), which overlaps the peak absorption wavelength (458 nm) for bilirubin photoisomerization. Excessive bombardment with photons has raised concerns for oxidative stress in very low birthweight versus term infants treated aggressively with phototherapy. Increased emphasis on prescribing phototherapy as a "drug" that is dosed cautiously and judiciously is needed. In this historical review, we chronicled the basic to the neurotoxic components of severe neonatal hyperbilirubinemia and the use of standardized interventions. 10.1038/s41372-019-0439-1