Home > Encyclopedia of Nursing & Allied Health > 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.

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KEY TERMS

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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.

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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.

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