Neonatal Jaundice Islamic University Nursing College Neonatal Jaundice

Neonatal Jaundice Islamic University Nursing College

Neonatal Jaundice (Hyperbilirubinemia) • Definition: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails. • Unconjugated bilirubin = Indirect bilirubin. • Conjugated bilirubin = Direct bilirubin.

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Neonatal Jaundice • Visible form of bilirubinemia – Newborn skin >5 mg / dl • Occurs in 50 -60% of term and 80% of preterm neonates • However, significant jaundice occurs in 6 % of term babies. • Immature liver to conjugate bilirubin from the destroyed RBCs

Hb → globin + haem 1 g Hb = 34 mg bilirubin Non – heme source 1 mg / kg Bilirubin Ligandin (Y - acceptor) Bilirubin glucuronidase Intestine Bil glucuronide β glucuronidase bacteria Bilirubin metabolism Stercobilin

Clinical assessment of jaundice Area of body Bilirubin levels mg/dl (*17=umol) 1 - Face 4 -8 2 - Upper trunk 5 -12 3 - Lower trunk & thighs 8 -16 4 - Arms and lower legs 11 -18 5 - Palms & soles > 15

Physiological jaundice Characteristics • Appears after 24 hours of birth. • Maximum intensity by 4 th-5 th day in term & 7 th day in preterm. • Serum level less than 15 mg/dl. • Clinically not detectable after 14 days. • Disappears without any treatment Note: Baby should, however, be watched for worsening jaundice.

Why does physiological jaundice develop? • Increased bilirubin load. • Defective uptake from plasma. • Defective conjugation. • Decreased excretion. • Increased entero-hepatic circulation.

Pathological jaundice Appears within 24 hours of age. Increase of bilirubin > 5 mg/dl/day. Serum bilirubin > 15 mg/dl. Jaundice persisting after 14 days. Stool clay/white colored and urine staining clothes yellow. • Direct bilirubin > 2 mg/dl. • • •

Causes of jaundice Appearing within 24 hours of age • Hemolytic disease of NB: Rh, ABO • Infections: TORCH, malaria, bacterial • G 6 PD deficiency. • • • T – Toxoplasmosis / Toxoplasma gondii O – Other infections R – Rubella C – Cytomegalovirus H – Herpes simplex virus or neonatal herpes simplex

Causes of jaundice Appearing between 24 -72 hours of life • Physiological • Sepsis • Polycythemia • Intraventricular hemorrhage • Increased entero-hepatic circulation

Causes of jaundice After 72 hours of age • Sepsis • Cephalhaematoma • Neonatal hepatitis • Extra-hepatic biliary atresia • Breast milk jaundice • Metabolic disorders (G 6 PD).

Risk factors for jaundice JAUNDICE • J - jaundice within first 24 hrs of life • A - a sibling who was jaundiced as neonate • U - unrecognized hemolysis • N – non-optimal sucking/nursing • D - deficiency of G 6 PD • I - infection • C – cephalhematoma /bruising • E - East Asian/North Indian

Altered physiology RBCs destruction Bilirubin into circulation In the Liver converted into Direct or conjugated water soluble bilirubin Combines with Albumin Unconjugated or Indirect bilirubin Enzymes of bile in the intestine Reabsorbed to liver Hydrolyzed to unconjugated Or Execrated in stool

Diagnostic evaluation: • Normal values of unconjugated B. are 0. 2 to 1. 4 mg/d. L. • Investigate the cause of jaundice. • Mother blood Rh.

Therapeutic Management • Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity • Prevention of hyperbilirubinemia: early feeds, adequate hydration • Reduction of bilirubin levels: phototherapy, exchange transfusion, • Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.

Babies under phototherapy Baby under conventional phototherapy Baby under triple unit intense phototherapy

Prognosis • Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.

Nursing considerations of Hyperbilirubinemia • Assessment: v observing for evidence of jaundice at regular intervals. v Jaundice is common in the first week of life and may be missed in dark skinned babies Blanching the tip of the nose

Approach to jaundiced baby Ascertain birth weight, gestation and postnatal age Ask when jaundice was first noticed Assess clinical condition (well or ill) Decide whether jaundice is physiological or pathological • Look for evidence of kernicterus* in deeply jaundiced NB • • *Lethargy and poor feeding, poor or absent Moro's, or convulsions

Nursing diagnosis • See the high risk infant plan of care. Plus: Ø Body Temp. , risk for imbalanced Temp. related to use of phototherapy. Ø Fluid volume, risk for deficient related to phototherapy. Ø Interrupted family process related to situational crisis, re hospitalization for therapy.

The goals of planning • Infant will receive appropriate therapy if needed to reduce serum bilirubin levels. o Infant will experience no complications from therapy. o Family will receive emotional support. o Family will be prepared for home phototherapy (if prescribed).

Nursing intervention • • • Distance of light should be 45 -60 cm. Cover eyes. Turning infant every 2 h. Avoid hyperthermia. Monitor temp every 2 -4 h. Adequate fluid orally or IV. NJ - 23

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