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Neonatal Jaundice

Neonatal jaundice

Definition

Neonatal jaundice is the term used when a newborn has an excessive amount of bilirubin in the blood. Bilirubin is a yellowish-red pigment that is formed and released into the bloodstream when red blood cells are broken down. Jaundice comes from the French word jaune, which means yellow; thus a jaundiced baby is one whose skin color appears yellow due to bilirubin.

Description

Normally, small amounts of bilirubin are found in everyone's blood. It is formed and released into the bloodstream when red blood cells are broken down. It is then carried to the liver where it is processed and eventually excreted from the body. When too much bilirubin is made, the excess is discarded into the bloodstream and deposited in tissues for temporary storage. In the neonate, however, there is more bilirubin than can be handled due to immature liver functioning and extra red blood cells that break down. Thus, the extra bilirubin remains in the tissues. Neonatal jaundice affects 60 percent of full-term infants and 80 percent of preterm infants in the first three days after birth.

Demographics

Infants of East Asian and Native American descent have higher levels of bilirubin than white infants, who in turn have higher bilirubin levels than infants of African descent. There is an enzyme, glucose-6-phosphate dehydrogenase (G6PD), deficiency that is more prevalent in infants of East Asian, Greek, and African descent which causes neonatal jaundice to appear at approximately the same time as physiological jaundice. Sickle cell anemia does not predispose newborn infants to jaundice.

Causes and symptoms

Typically, neonatal jaundice occurs in otherwise healthy infants for two reasons. First, infants have too many red blood cells and it is a natural process for the body to break down these excess red blood cells to form a large amount of bilirubin. It is this bilirubin that causes the skin to take on a yellowish color. Second, the newborn's liver is immature and cannot process bilirubin as quickly as the infant will be able to when older. This slow processing of bilirubin has nothing to do with liver disease. It merely means that the baby's liver is not as fully developed as it will be; thus, there is some delay in eliminating the bilirubin.

Breastfeeding is an important risk factor for hyperbilirubinemia in healthy infants and is related to inadequate maternal milk supply in the first few days, decreased caloric intake and delayed passage of meconium. Nonetheless, this is not a reason to give formula or stop breastfeeding. The breastfeeding mother just needs to nurse the baby more frequently and for longer periods of time to enhance the production of breastmilk. Other factors that cause neonatal jaundice are ABO incompatibility and Rh incompatibility. Both of these conditions result in a very fast breakdown of red blood cells. It is also possible for jaundice to appear in infants with physical defects in the organs that work to eliminate bilirubin from the body. An abnormal increase in red blood cells is frequently seen in infants who are large or small for their gestational age, as well as in trisomy syndromes, twin-to-twin transfusion syndrome, maternal-fetal transfusion, use of oxytocin in labor, Asian male babies, presence of bruising and cephalohematoma, and a family history of neonatal jaundice.

As the excess bilirubin builds up in the newborn, jaundice appears first in the face and upper body and progresses downward toward the toes. Most babies with jaundice have physiologic jaundice, which is the type caused by the natural process of breaking down red blood cells. If the baby's jaundice is caused by any other conditions, however, the healthcare giver will provide the parents with additional information for caring for the baby.

When to call the doctor

With short neonatal hospital stays, jaundice will not have peaked or become apparent at the time of hospital discharge. Therefore, infants at risk for severe hyperbilirubinemia should be identified so they can be observed closely both while in the hospital and after discharge. The parents need to be instructed on how to evaluate the infant for jaundice. They should look for it first in the face and upper body and if it progresses downward this means the concentration is getting too high and it is time to call the pediatrician. If there is an area of their living quarters that gets sunlight, it helps to let the baby lie there in only a diaper for a short period of time each day.

Diagnosis

Jaundice can be observed with the naked eye, but it is too difficult to estimate the variation in levels of bilirubin in that manner. Thus, if an infant begins to appear jaundiced, bilirubin levels will be ordered to determine the severity. Jaundice usually becomes apparent when total bilirubin levels exceed 5 mg/dL; however, the clinical significance of bilirubin levels depends on postnatal age in hours. A bilirubin level of 12 mg/dL may be pathologic in an infant younger than 48 hours but is benign in an infant older than 72 hours. In the determination of cause, it is suggested that laboratory testing be reserved for infants with nonphysiologic jaundice. In up to 50 percent of infants with severe jaundice, breastfeeding and lower gestational age were the only causes identified despite extensive workups.

Treatment

The mainstay in treatment of hyperbilirubinemia is phototherapy, which is safe and widely available. Its effectiveness was demonstrated in a study by the National Institute of Child Health and Human Development. Multiple factors can influence the effectiveness of phototherapy, including the type and intensity of the light and the extent of skin surface exposure. Special blue fluorescent light has been shown to be most effective, although many nurseries use a combination of daylight, white, and blue lamps. In the early 2000s, fiberoptic blankets have been developed that emit light in the blue-green spectrum, which is light at a wavelength of 425475 nm. Light at this wavelength converts bilirubin to a water-soluble form that can be excreted in the bile or urine. The intensity of light delivered is inversely related to the distance between the light source and the skin surface. Since phototherapy acts by altering the bilirubin that is deposited in the tissue, the area of the skin exposed to phototherapy should be maximized. This has been made more practical with the development of fiberoptic phototherapy blankets that can be wrapped around an infant.

Home-based care for neonatal jaundice has become more prevalent than hospital care, and the availability of fiberoptic blankets has made it possible. Infants receiving home phototherapy need daily visits by a nurse, who performs a physical examination and measures the total serum bilirubin level. If bilirubin levels continue to rise, hospital readmission should be considered. Discontinuation of home phototherapy is safe once the total serum bilirubin level has decreased to less than 15 mg/dL in healthy full-term infants older than four days. Office evaluation within two to three days of discontinuing home phototherapy is recommended.

Potential side effects of phototherapy used for elevated bilirubin levels, include watery diarrhea , increased water loss, skin rash, and transient bronzing of the skin. Many infants who are readmitted to the hospital because of hyperbilirubinemia are mildly to moderately dehydrated. Breastfeeding should be increased to every two to two and a half hours. Increased feedings can increase peristalsis and meconium passage, decreasing bilirubin resorption into circulation.

Full-term infants rarely require an exchange transfusion if intense phototherapy is initiated in a timely manner. It should be considered if the total serum bilirubin level is approaching 20 mg/dL and continues to rise despite intense in-hospital phototherapy. Exchange transfusion corrects anemia associated with the destruction of red blood cells and is effective in removing sensitized red blood cells before they are destroyed. It also removes about 60 percent of bilirubin from the plasma, resulting in a clearance of about 30 percent to 40 percent of the total bilirubin. If a transfusion is not performed and bilirubin levels get higher, the infant progresses through three phases. In the first two to three days the infant is lethargic, has muscle weakness, and sucks weakly. Progression is marked by a tensing of the muscles, arching, fever , seizures, and high-pitched crying. In the final phase, the patient is hypotonic for several years.

Prognosis

The prognosis for physiological neonatal jaundice is generally very good. Very few infants ever have bilirubin levels greater than 20 mg/dL, which is the level that is correlated with kernicterus (an abnormal accumulation of bile pigment in the brain and other nerve tissue that causes yellow staining and tissue damage). It rarely occurs with bilirubin levels lower than 20 mg/dL but typically occurs when levels exceed 30 mg/dL. Levels between 20 and 30 mg/dL associated with prematurity and hemolytic disease may increase the risk of kernicterus. There are long-term neurological problems when this occurs. Affected children have marked developmental and motor delays in the form of cerebral palsy and mental retardation may also be present.

Prevention

Elevated bilirubin in the neonate is the most common reason for hospital readmission in the first two weeks of life. Kernicterus is still relatively uncommon but has been on the rise with the mandated early postnatal discharge policies. Bilirubin-induced complications can be prevented by introducing a neonatal jaundice protocol to identify infants at risk for significant bilirubin increases, by ensuring adequate parental education and providing for follow-up care.

Parental concerns

Parents of a newborn need to be vigilant in monitoring changes in their infant. If the mother is breastfeeding, she should nurse the baby at least once every three hours to ensure the onset of milk production and to maintain hydration, which can also be evaluated by the number of wet diapers. Many pediatricians recommend seeing the infant at two weeks but if the parents feel it should be sooner due to alterations in the newborn's physical status, they should take the infant in for a visit.

KEY TERMS

ABO incompatability The reaction that occurs with blood groups that are of a different type.

Cephalohematoma A benign swelling of the scalp in a newborn due to an effusion of blood beneath the connective tissue that surrounds the skull, often resulting from birth trauma.

Kernicterus A potentially lethal disease of newborns caused by excessive accumulation of the bile pigment bilirubin in tissues of the central nervous system.

Meconium A greenish fecal material that forms the first bowel movement of an infant.

Oxytocin A hormone that stimulates the uterus to contract during child birth and the breasts to release milk.

Peristalsis Slow, rhythmic contractions of the muscles in a tubular organ, such as the intestines, that move the contents along.

Rh incompatability A factor of blood classified as negative or positive and related to the reaction that occurs between different types.

Trisomy An abnormal condition where three copies of one chromosome are present in the cells of an individual's body instead of two, the normal number.

Resources

BOOKS

Klaus, M. H., and A. A. Fanaroff. Care of the High-Risk Neonate, 5th ed. Philadelphia, PA: Saunders Company, 2001.

Olds, Sally, et al. Maternal-Newborn Nursing and Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

Seidel, H. M., et al. Primary Care of the Newborn. St. Louis, MO: Mosby, 2001.

PERIODICALS

Morantz, C., and B. Torrey. "AHRQ report on neonatal jaundice: Agency for Healthcare Research and Quality." American Family Physician (June 1, 2003).

ORGANIZATIONS

Association of Women's Health, Obstetric and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site: <www.awhonn.org>.

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL, 60007. Web site: <www.aap.org>.

American College of Obstetricians and Gynecologists. 409 12th Street, SW, PO Box 96920, Washington, DC 20090. Web site: <www.acog.org>.

Linda K. Bennington, MSN, CNS

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Neonatal Jaundice

Neonatal Jaundice

Definition

Neonatal jaundice (or hyperbilirubinemia) is a higher-than-normal level of bilirubin in the blood. Bilirubin is a by-product of the breakdown of red blood cells. This condition can cause a yellow discoloration of the skin and the whites of the eyes called jaundice.

Description

Bilirubin, a by-product of the breakdown of hemoglobin (the oxygen-carrying substance in red blood cells), is produced when the body breaks down old red blood cells. Normally, the liver processes the bilirubin and excretes it in the stool. Hyperbilirubinemia means there is a high level of bilirubin in the blood. This condition is particularly common in newborn infants. Before birth, an infant gets rid of bilirubin through the mother's blood and liver systems. After birth, the baby's liver has to take over processing bilirubin on its own. Almost all newborns have higher than normal levels of bilirubin. In most cases, the baby's systems continue to develop and can soon process bilirubin. However, some infants may need medical treatment to prevent serious complications which can occur due to the accumulation of bilirubin.

Causes and symptoms

In newborn infants, the liver and intestinal systems are immature and cannot excrete bilirubin as fast as the body produces it. This type of hyperbilirubinemia can cause jaundice to develop within a few days after birth. About one-half of all newborns develop jaundice, while premature infants are much more likely to develop it. Hyperbilirubinemia is also more common in some populations, such as Native American and Asian. All infants with jaundice should be evaluated by a health care provider to rule out more serious problems.

Hyperbilirubinemia and jaundice can also be the result of other diseases or conditions. Hepatitis, cirrhosis of the liver, and mononucleosis are diseases that can affect the liver. Gallstones, a blocked bile duct, or the use of drugs or alcohol can also cause jaundice.

Extremely high levels of bilirubin in infants may cause kernicterus, a form of brain damage. Signs of severe hyperbilirubinemia include listlessness, high-pitched crying, apnea (periods of not breathing), arching of the back, and seizures. If severe hyperbilirubinemia is not treated, it can cause mental retardation, hearing loss, behavior disorders, cerebral palsy, or death.

Diagnosis

The initial diagnosis of hyperbilirubinemia is based on the appearance of jaundice at physical examination. The child is often placed by an open window so he/she may be checked in natural light. Blood samples may be taken to determine the bilirubin level in the blood.

Treatment

Most cases of newborn jaundice resolve without medical treatment within two to three weeks, but should be checked by the health care provider. It is important that the infant is feeding regularly and having normal bowel movements. If bilirubin levels are extremely high, the infant may be treated with phototherapyexposure of the baby's skin to fluorescent light. The bilirubin in the baby's skin absorbs the light and is changed to a substance that can be excreted in the urine. This treatment can be done in the hospital and is often done at home with special lights which parents can rent for the treatment. Treatment may be needed for several days before bilirubin levels in the blood return to normal. The baby's eyes are shielded to prevent the optic nerves from absorbing too much light. Another type of treatment uses a special fiberoptic blanket. There is no need to shield the baby's eyes with this treatment, and it can be done at home. In rare cases, where bilirubin levels are extremely high, the baby may need to receive a blood transfusion.

Prognosis

Most infants with hyperbilirubinemia and associated jaundice recover without medical treatment. Phototherapy is very effective in reducing bilirubin levels in the majority of infants who need it. There are usually no long-term effects on the child from the hyperbilirubinemia or the phototherapy. It is very rare that a baby may need a blood transfusion for treatment of this condition.

Prevention

There is no way to predict which infants will be affected by hyperbilirubinemia. Newborns should be breastfed or given formula frequently, and feedings should begin as soon as possible after delivery to increase activity of the baby's digestive system.

Resources

OTHER

D'Alessandro, Hellen Anne. Biliary Atresia. The Virtual Hospital Page. University of Iowa. http://www.vh.org/Providers/Textbooks/ElectricGiNucs/Text/BiliaryAtresia.html.

"Jaundice/Hyperbilirubinemia." http://www2.medsch.wisc.edu/childrenshosp/Parents_of_Preemies/jaundice.html

"Jaundice in Newborn (Hyperbilirubinemia)." http://www.ivillage.com.

"Neonatal Jaundice." http://www.gi.vghtc.gov.tw/Teaching/Biliary/Jaundice/s13.htm.

"Neonatology on the Web." http://www.neonatology.org.

KEY TERMS

Bilirubin A yellowish-brown substance in the blood that forms as old red blood cells are broken down.

Hemoglobin A protein, an oxygen-carrying pigment of the erythrocyte (red blood cell) formed in the bone marrow.

Jaundice A yellow discoloration of the skin and whites of the eyes.

Kernicterus A serious condition where high bilirubin levels cause brain damage in infants.

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Ritter's disease

Ritter's disease (rit-erz) n. see staphylococcal scalded skin syndrome. [ G. Ritter von Rittershain (1820–83), German physician]

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Neonatal Jaundice

Neonatal Jaundice

Definition

Neonatal jaundice and hyperbilirubinemia are terms used when a newborn has a higher-than-normal level of bilirubin in the blood. Bilirubin is an endproduct of the breakdown of the hemoglobin present in the red blood cells at the end of their life cycle. Hemoglobin carries oxygen to tissues and cells. Before birth the placenta is not as efficient in providing oxygen as the baby's lungs will be after birth. Because of this, infants in utero have more red blood cells than they will need after birth to provide enough oxygen. Therefore, newborns have an excess of red blood cells that they need to process, and an immature liver with which to complete the job. Jaundice refers to the yellow discoloration of the skin and sclera (whites) of the eyes, which results as the breakdown of bilirubin goes faster than the rate at which it can leave the body, causing its level to rise in the blood.

Description

When the fetus is in utero, bilirubin is processed through the placenta and the maternal-fetal circulation. After birth, the infant's often-immature liver must take over this task. Clinical jaundice (serum bilirubin levels of 5-7 mg/dL and above) occurs in about 60-70% of term newborns and about 80% of premature infants. Ever since hospital stays after delivery decreased to 2448 hours postpartum, hyperbilirubinemia has become the leading cause of hospital readmissions in the first two weeks of life. The greatest concern with hyperbilirubinemia is that the unexcreted bilirubin will begin to deposit in the brain of the neonate, resulting in a serious, potentially life-threatening condition called kernicterus. Another term used for kernicterus is brain encephalopathy.

Causes and symptoms

An elevated bilirubin level may be due to its increased production, a decreased rate of conjugation, or abnormalities of the liver. In order for the bilirubin to be excreted in the urine and stool, it must be converted, or conjugated, from a fat- or lipid-soluble form to a water-soluble form. Bilirubin that has not been excreted can be reabsorbed and contributes to increased blood levels.

Initial symptoms of a rising bilirubin level can be subtle, and usually include increased drowsiness, which leads to poor feeding, and the subsequent decreased urine and stool output. The diaper may contain orange spots, an indication of the presence of uric acid crystals, a sign of dehydration. A change in the infant's cry to a high-pitched tone may indicate early neurological damage.

There are several types of jaundice. The most common form of neonatal jaundice appears between the first 24-72 hours after birth and is usually considered a benign form. It is often referred to as early-onset breast milk jaundice, and is related to insufficient breastfeeding, which results in decreased nutritional intake and decreased stooling. With decreased stooling the bilirubin in the stool is not being excreted, and is also available for reabsorption. Increasing the feedings from six to 12 times a day, and checking for latching-on and a good suck and swallow pattern, can lead to a decreasing bilirubin level to within normal limits. To encourage adequate maternal milk production, supplementation with water or glucose is discouraged.

Late-onset breast milk jaundice may occur in 10-30% of breast-fed infants and appears in the second to sixth weeks of life. This form of jaundice is believed to be related to a substance present in the mother's milk that affects the infant's absorption of bilirubin.

Jaundice that sets in within the first 24 hours after birth is usually due to an Rh factor or ABO blood incompatibility between the mother and infant.

Risk factors for the development of hyperbilirubinemia include:

  • premature birth
  • Asian and Native American descent—including more rapid rise and higher peak levels of bilirubin
  • maternal diabetes
  • hemolytic disease in the neonate
  • sepsis
  • family history of jaundice
  • presence of excessive bruising due to traumatic birth, and cephalhematoma
  • oxytocin-induced delivery
  • mother's use of sulfa medications during pregnancy
  • history of familial liver disease
  • delayed cord clamping
  • thyroid gland abnormalities
  • G6PD (glucose-6-hosphate dehydrogenase) deficiency

Diagnosis

Diagnosis of hyperbilirubinemia usually begins with the observation of jaundice at the time of physical examination. However, a delay in recognition of jaundice may occur since many infants have already gone home prior to its onset. Pediatric practices vary as to times of follow-up after hospital discharge. Parents may call their pediatric care provider's office because of jaundice, or because of a decreased ability of the infant to feed. Examination of the infant is best done next to a window so that the jaundice can be assessed in natural light. Blood tests to check the bilirubin level, blood type, and for signs of dehydration will usually be ordered.

Treatment

Treatment is primarily focused on decreasing the bilirubin level to prevent the progression of the condition to kernicterus. In kernicterus, the bilirubin deposits in the brain. This extreme condition leads to central nervous system damage and can progress to hearing loss, seizures, and death.

Phototherapy

For many infants, increasing breastfeeding will be sufficient to bring about adequate hydration and an increase in gastric motility and stooling, so that the bilirubin is effectively excreted from the body. Some infants may need the additional assistance of phototherapy. The light source most effective in treating hyperbilirubinemia occurs in the blue-green spectrum. Phototherapy may be provided in the hospital. In the hospital the infant is usually placed in a special bassinet, with an overhead light source. The skin is uncovered, exposing as much surface area to the light. The infant's eyes and genitals are usually shielded from direct light and heat, depending on the intensity of the light. If the bilirubin level is under about 15-20 mg/dL, phototherapy may be administered via a fiberoptic source referred to as a blanket or belt in the home. The home unit is designed to encourage parent-infant bonding. The blanket/belt wraps around the infant's bare middle so that the cool light source is next to the skin. There is no need to shield the eyes from the light, and parents can hold, feed and interact with the infant as usual. Most insurance companies cover the cost of the home rental for the phototherapy equipment and the accompanying daily home nursing visits.

In 1994 the American Academy of Pediatrics (AAP) developed guidelines for care and management of neonatal jaundice. These guidelines were reviewed and updated in 2004. In studies where experienced pediatric practitioners evaluated the same infants for jaundice, considerable discrepancies existed. Despite all the research done in this area, there are no consistent predictors of which infants will continue from benign jaundice to kernicterus. Research studies express concern over finding a balance between treating those that need treatment, without treating well infants unnecessarily.

Prognosis

Jaundice addressed in its early stages rarely progresses to kernicterus, and therefore the prognosis for complete resolution of the problem is excellent. Phototherapy is extremely effective in bringing down the bilirubin levels. Some extreme cases may require a blood transfusion, but those situations are relatively rare. Infants who do develop kernicterus may continue to have long-term neurological effects present if the kernicterus was well established at the time of initiation of treatment.

KEY TERMS

Bilirubin— A yellowish-brown substance in the blood that forms as old red blood cells are broken down.

Jaundice— The yellow discoloration of the skin and sclera of the eyes as a result of poor liver function.

Kernicterus— A serious condition in which bilirubin deposits in the brain leading to permanent neurological damage and potentially death.

Health care team roles

The nurse may participate in the care of the infant in the hospital nursery, where he or she may be the first to notice the jaundice. The nurse may also be the one to take the parent's call about the jaundice in the pediatric care provider's office. In the home setting, the nurse's role involves daily visits to the home for infant assessment and blood draws via a heel stick for bilirubin evaluation, parent teaching on bottle or breastfeeding and neonatal and postpartum issues. The nurse should inform the parents that phototherapy increases the baby's metabolism, resulting in increased output to clear the bilirubin. This means that the infant will require more feedings to compensate for the fluids lost. The nurse should also inform the parents that the stool containing bilirubin may be more loose than usual and of a greenish color. Some pediatric practices may have the parents bring the infant into the laboratory where the technician would be the one to draw the infant's blood for bilirubin evaluation. Heel sticks on an infant can be difficult when the infant is dehydrated. Ways to facilitate a more successful blood draw include:

  • Use of a heel warmer to increase circulation to the foot.
  • Having a parent hold the infant in a seated position so that the foot is below the level of the heart.
  • Having the parent feed the infant prior to the lab visit.

Prevention

Primary prevention begins with addressing the risk factors mentioned above. Prevention of kernicterus requires early detection, monitoring and potential treatment of jaundice with rising bilirubin levels. Frequent feedings of ten or more per day help to ensure adequate hydration, nutrition, gastric motility, and stool and urine output.

Resources

BOOKS

Behrman, Richard E., Robert M. Kliegman, and Hal B. Jenson. Nelson Textbook of Pediatrics, 16th ed. Philadelphia: W. B. Saunders Company, 2000.

Burns, Catherine E., Margaret A. Brady, Ardys M. Dunn, and Nancy Barber Starr. Pediatric Primary Care A Handbook for Nurse Practitioners, 2nd ed. Philadelphia: W. B. Saunders Company, 2000.

Pasquariello, Patrick S. The Children's Hospital of Philadelphia: Book of Pregnancy and Child Care. New York: John Wiley & Sons, 1999.

Taeusch, H. William, and Roberta A. Ballard. Avery's Diseases of the Newborn, 7th ed. Philadelphia: W. B. Saunders Company, 1998.

PERIODICALS

Moyer, Virginia A., Chul Ahn, and Stephanie Sneed."Accuracy of Clinical Judgement in Neonatal Jaundice." Archives of Pediatric and Adolescent Medicine 154 (2000): 391-394.

Newman, Thomas B. and M. Jeffrey Maisels. "Less Aggressive Treatment of Neonatal Jaundice and Reports of Kernicterus: Lessons About Practice Guidelines." Pediatrics 105, no. 1 Pt 3 (2000): 242-245.

Wiley, Catherine C., Naline Lai, Christopher Hill, and Georgine Burke. "Nursery Practices and Detection of Jaundice After Newborn Discharge." Archives of Pediatric and Adolescent Medicine 152 (1998): 972-975.

ORGANIZATIONS

Archives of Pediatric and Adolescent Medicine; Journal of the American Medical Association. 〈http://www.archpedi.ama-assn.org〉.

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Neonatal Jaundice

Neonatal jaundice

Definition

Neonatal jaundice and hyperbilirubinemia are terms used when a newborn has a higher-than-normal level of bilirubin in the blood . Bilirubin is an end-product of the breakdown of the hemoglobin present in the red blood cells at the end of their life cycle. Hemoglobin carries oxygen to tissues and cells. Before birth the placenta is not as efficient in providing oxygen as the baby's lungs will be after birth. Because of this, infants in utero have more red blood cells than they will need after birth to provide enough oxygen. Therefore, newborns have an excess of red blood cells that they need to process, and an immature liver with which to complete the job. Jaundice refers to the yellow discoloration of the skin and sclera (whites) of the eyes, which results as the breakdown of bilirubin goes faster than the rate at which it can leave the body, causing its level to rise in the blood.

Description

When the fetus is in utero, bilirubin is processed through the placenta and the maternal-fetal circulation. After birth, the infant's often-immature liver must take over this task. Clinical jaundice (serum bilirubin levels of 5-7 mg/dL and above) occurs in about 60-70% of term newborns, and about 80% of premature infants . Ever since hospital stays after delivery decreased to 24-48 hours postpartum, hyperbilirubinemia has become the leading cause of hospital readmissions in the first two weeks of life. The greatest concern with hyperbilirubinemia is that the unexcreted bilirubin will begin to deposit in the brain of the neonate, resulting in a serious, potentially life-threatening condition called kernicterus. Another term used for kernicterus is brain encephalopathy.

Causes and symptoms

An elevated bilirubin level may be due to its increased production, a decreased rate of conjugation, or abnormalities of the liver. In order for the bilirubin to be excreted in the urine and stool, it must be converted, or conjugated from a fat- or lipid-soluble form to a water-soluble form. Bilirubin that has not been excreted can be reabsorbed and contributes to increased blood levels.

Initial symptoms of a rising bilirubin level can be subtle, and usually include increased drowsiness, which leads to poor feeding, and the subsequent decreased urine and stool output. The diaper may contain orange spots, an indication of the presence of uric acid crystals, a sign of dehydration . A change in the infant's cry to a high-pitched tone may indicate early neurological damage.

There are several types of jaundice. The most common form of neonatal jaundice appears between the first 24-72 hours after birth and is usually considered a benign form. It is often referred to as early-onset breast milk jaundice, and is related to insufficient breastfeeding, which results in decreased nutritional intake and decreased stooling. With decreased stooling the bilirubin in the stool is not being excreted, and is also available for reabsorption. Increasing the feedings from six to 12 times a day, and checking for latching-on and a good suck and swallow pattern, can lead to a decreasing bilirubin level to within normal limits. To encourage adequate maternal milk production, supplementation with water or glucose is discouraged.

Late-onset breast milk jaundice may occur in 10-30% of breast-fed infants and appears in the second to sixth weeks of life. This form of jaundice is believed to be related to a substance present in the mother's milk that affects the infant's absorption of bilirubin.

Jaundice that sets in within the first 24 hours after birth is usually due to an Rh factor or ABO blood incompatibility between the mother and infant.

Risk factors for the development of hyperbilirubinemia include:

  • premature birth
  • Asian and Native American descent—including more rapid rise and higher peak levels of bilirubin
  • maternal diabetes
  • hemolytic disease in the neonate
  • sepsis
  • family history of jaundice
  • presence of excessive bruising due to traumatic birth, and cephalhematoma
  • oxytocin-induced delivery
  • mother's use of sulfa medications during pregnancy
  • history of familial liver disease
  • delayed cord clamping
  • thyroid gland abnormalities
  • G6PD (glucose-6-phosphate dehydrogenase) deficiency

Diagnosis

Diagnosis of hyperbilirubinemia usually begins with the observation of jaundice at the time of physical examination . However, a delay in recognition of jaundice may occur since many infants have already gone home prior to its onset. Pediatric practices vary as to times of follow-up after hospital discharge. Parents may call their pediatric care provider's office because of jaundice, or because of a decreased ability of the infant to feed. Examination of the infant is best done next to a window so that the jaundice can be assessed in natural light. Blood tests to check the bilirubin level, blood type, and for signs of dehydration will usually be ordered.

Treatment

Treatment is primarily focused on decreasing the bilirubin level to prevent the progression of the condition to kernicterus. In kernicterus, the bilirubin deposits in the brain. This leads to central nervous system damage, and can progress to hearing loss , seizures, and death.

Phototherapy

For many infants, increasing breastfeeding will be sufficient to bring about adequate hydration and an increase in gastric motility and stooling, so that the bilirubin is effectively excreted from the body. Some infants may need the additional assistance of phototherapy . The light source most effective in treating hyperbilirubinemia occurs in the blue-green spectrum. Phototherapy may be provided in the hospital. In the hospital the infant is usually placed in a special bassinet, with an overhead light source. The skin is uncovered, exposing as much surface area to the light. The infant's eyes and genitals are usually shielded from direct light and heat, depending on the intensity of the light. If the bilirubin level is under about 15–20 mg/dL, phototherapy may be administered via a fiberoptic source referred to as a blanket or belt in the home. The home unit is designed to encourage parent-infant bonding. The blanket/belt wraps around the infant's bare middle so that the cool light source is next to the skin. There is no need to shield the eyes from the light, and parents can hold, feed and interact with the infant as usual. Most insurance companies cover the cost of the home rental for the phototherapy equipment and the accompanying daily home nursing visits.

In 1994 the American Academy of Pediatrics (AAP) developed guidelines for care and management of neonatal jaundice. As of March 2001 these guidelines were being reviewed, but the 1994 guidelines remain in effect. In studies where experienced pediatric practitioners evaluated the same infants for jaundice, considerable discrepancies existed. Despite all the research done in this area, there are no consistent predictors of which infants will continue from benign jaundice to kernicterus. Research studies express concern over finding a balance between treating those that need treatment, without treating well infants unnecessarily.


KEY TERMS


Bilirubin —A yellowish-brown substance in the blood that forms as old red blood cells are broken down.

Jaundice —The yellow discoloration of the skin and sclera of the eyes as a result of poor liver function.

Kernicterus —A serious condition in which bilirubin deposits in the brain leading to permanent neurological damage and potentially death.


Prognosis

Jaundice addressed in its early stages rarely progresses to kernicterus, and therefore the prognosis for complete resolution of the problem is excellent. Phototherapy is extremely effective in bringing down the bilirubin levels. Some extreme cases may require a blood transfusion, but those situations are relatively rare. Infants who do develop kernicterus may continue to have long-term neurological effects present if the kernicterus was well established at the time of initiation of treatment.

Health care team roles

The nurse may participate in the care of the infant in the hospital nursery, where he or she may be the first to notice the jaundice. The nurse may also be the one to take the parent's call about the jaundice in the pediatric care provider's office. In the home setting, the nurse's role involves daily visits to the home for infant assessment and blood draws via a heel stick for bilirubin evaluation, parent teaching on bottle or breastfeeding and neonatal and postpartum issues. The nurse should inform the parents that phototherapy increases the baby's metabolism , resulting in increased output to clear the bilirubin. This means that the infant will require more feedings to compensate for the fluids lost. The nurse should also inform the parents that the stool containing bilirubin may be more loose than usual and of a greenish color. Some pediatric practices may have the parents bring the infant into the laboratory where the technician would be the one to draw the infant's blood for bilirubin evaluation. Heel sticks on an infant can be difficult when the infant is dehydrated. Ways to facilitate a more successful blood draw include:

  • Use of a heel warmer to increase circulation to the foot.
  • Having a parent hold the infant in a seated position so that the foot is below the level of the heart.
  • Having the parent feed the infant prior to the lab visit.

Prevention

Primary prevention begins with addressing the risk factors mentioned above. Prevention of kernicterus requires early detection, monitoring and potential treatment of jaundice with rising bilirubin levels. Frequent feedings of ten or more per day help to ensure adequate hydration, nutrition , gastric motility, and stool and urine output.

Resources

BOOKS

Behrman, Richard E., Robert M. Kliegman, and Hal B. Jenson. Nelson Textbook of Pediatrics, 16th Edition. Philadelphia: W. B. Saunders Company, 2000.

Burns, Catherine E., Margaret A. Brady, Ardys M. Dunn and Nancy Barber Starr. Pediatric Primary Care A Handbook for Nurse Practitioners, 2nd Edition. Philadelphia: W. B. Saunders Company, 2000.

Pasquariello, Patrick S. The Children's Hospital of Philadelphia: Book of Pregnancy and Child Care. New York: John Wiley & Sons, 1999.

Taeusch, H. William, and Roberta A. Ballard. Avery's Diseases of the Newborn, 7th Edition. Philadelphia: W. B. Saunders Company, 1998.

PERIODICALS

Moyer, Virginia A., Chul Ahn, and Stephanie Sneed. "Accuracy of Clinical Judgement in Neonatal Jaundice." Archives of Pediatric and Adolescent Medicine 154(2000): 391-394.

Newman, Thomas B. and M. Jeffrey Maisels. "Less Aggressive Treatment of Neonatal Jaundice and Reports of Kernicterus: Lessons About Practice Guidelines." Pediatrics 105, no. 1 Pt 3 (2000): 242-245.

Wiley, Catherine C., Naline Lai, Christopher Hill, and Georgine Burke. "Nursery Practices and Detection of Jaundice After Newborn Discharge." Archives of Pediatric and Adolescent Medicine 152 (1998): 972-975.

ORGANIZATIONS

Archives of Pediatric and Adolescent Medicine; Journal of the American Medical Association. <http://www.archpedi.ama-assn.org>.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.

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"Neonatal Jaundice." Gale Encyclopedia of Nursing and Allied Health. . Retrieved September 18, 2018 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/neonatal-jaundice-1

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