Understanding Neonatal Jaundice
Newborn Jaundice is a yellow tint to a newborn’s skin and the white part of the eyes. It is a sign that there’s too much bilirubin in the baby’s blood. The word for having too much bilirubin in the blood is hyperbilirubinemia. Jaundice usually appears in the first 5 days of life.
Causes:
Jaundice is caused by too much bilirubin in the blood. Bilirubin is a yellow substance produced when red blood cells, which carry oxygen around the body, are broken down. The bilirubin travels in the bloodstream to the liver.
Signs of Jaundice:
Yellowing of the skin and the whites of the eyes is a sign of infant jaundice that usually appears between the second and fourth day after birth. To check for infant jaundice, press gently on your baby’s forehead or nose. If the skin looks yellow where you pressed, it’s likely your baby has mild jaundice.
Types of Jaundice:
Breast milk jaundice is a type of neonatal jaundice associated with breastfeeding. It is characterized by indirect hyperbilirubinemia in a breastfed newborn that develops after the first 4-7 days of life, persists longer than physiologic jaundice, and has no other identifiable cause.
Pathologic Jaundice all etiologies of jaundice beyond physiologic and breastfeeding or breast milk jaundice are considered pathologic. Features of pathologic jaundice include the appearance of jaundice within 24 hours after birth, a rapidly rising total serum bilirubin concentration (increase of more than 5 mg/dl/day), and a total serum bilirubin level higher than 17 mg/dl in a full-term newborn.Other features of concern include prolonged jaundice, evidence of underlying illness, and elevation of the serum conjugated bilirubin level to greater than 2 mg/dl or more than 20 percent of the total serum bilirubin concentration. Pathologic causes include disorders such as sepsis, rubella, toxoplasmosis, occult hemorrhage, and erythroblastosis fetalis.
Causes of pathologic jaundice include sepsis, rubella, toxoplasmosis, occult hemorrhage and erthroblastosis fetalis (Porter & Dennis, 2002).
Investigation:
Serum Blood Test
Normal values of total bilirubin are from 0.3 to 1.0 mg/dl. In a newborn, higher bilirubin is normal due to the stress of birth. Normal bilirubin in a newborn would be under 5 mg/dl, but many newborns have some kind of jaundice and bilirubin levels above 5 mg/dl
In general, a total bilirubin level above 1.9 mg/dl is considered elevated. The normal range for total bilirubin level in the blood is 0.3 to 1.9 mg/dl. Direct, or conjugated, bilirubin normally ranges from 0 to 0.3 milligrams per deciliter.
Management:
Before treatment is initiated, the minimum evaluation should include the infant’s age and postnatal course, a maternal and gestational history, physical examination of the infant, and determination of the total serum bilirubin level and the rate at which it is rising.
Mild infant jaundice often disappears on its own within two or three weeks. For moderate or severe jaundice, your baby may need to stay longer in the newborn nursery or be readmitted to the hospital. Treatments to lower the level of bilirubin in your baby’s blood may include: Light therapy (phototherapy).
Phototherapy should be instituted when the total serum bilirubin level is at or above 15 mg/dl (257 mol/l) in infants 25 to 48 hours old, 18 mg/dl (308 mol/l) in infants 49 to 72 hours old, and 20 mg/dl (342 mol/l) in infants older than 72 hours.
Light treatment is the process of using light to eliminate bilirubin in the blood. Your baby’s skin and blood absorb these light waves. These light waves are absorbed by your baby’s skin and blood and change bilirubin into products, which can pass through their system.
Phototherapy employs blue wavelengths of light to alter unconjugated bilirubin in the skin. The bilirubin is converted to less toxic water-soluble photo-isomers that are excreted in the bile and urine without conjugation. The decision to initiate phototherapy is based on the newborn’s age and total serum bilirubin level.
Another bilirubin level will be checked 12–18 hours later to make sure it hasn’t risen again. Babies usually need to be under phototherapy lights for around 48 hours and often longer.
The efficacy of phototherapy depends on several important factors. The ideal configuration is four special blue bulbs (F20T12/BB) placed centrally, with two daylight fluorescent tubes on either side. The power output of the lights (irradiance) is directly related to the distance between the lights and the newborn. Ideally, all lights should be 15 to 20 cm from the infant. To expose the greatest surface area, the newborn should be naked except for eye shields. For double phototherapy, a fiber-optic pad can be placed under the newborn. This method is twice as effective as standard phototherapy.
Physiological jaundice normally clears by the time your baby is two week’s old.
Phototherapy will be stopped when the bilirubin level falls to a safe level, which usually takes a day or two. Phototherapy is generally very effective for newborn jaundice and has very few side effects, although your baby may develop a temporary rash or tan as a result of the treatment.
Potential problems that may occur with phototherapy include burns, retinal damage, thermoregulatory instability, loose stools, dehydration, skin rash, and tanning of the skin. Because phototherapy is continuous, treatment also involves significant separation of the infant and parents.
The only contraindication to the use of phototherapy is conjugated hyperbilirubinemia, as occurs in patients with cholestasis and hepatic disease. In this setting, phototherapy may cause a dark grayish-brown discoloration of the skin (bronze baby syndrome).
Evaluation:
With intensive phototherapy, the total serum bilirubin level should decline by 1 to 2 mg/dl (17 to 34 μ mol/l) within four to six hours. The bilirubin level may decline more slowly in breastfed infants (rate of 2 to 3 mg/dl/day) than in formula-fed infants. Phototherapy usually can be discontinued when the total serum bilirubin level is below 15 mg/dL.1 The average rebound bilirubin level after phototherapy is below 1 mg/dl. Therefore, hospital discharge of most infants does not have to be delayed to monitor for rebound elevation.
If the total serum bilirubin level remains elevated after intensive phototherapy or if the initial bilirubin level is meets defined critical levels based on the infant’s age, preparations should be made for exchange transfusion.
Exchange Transfusion:
Exchange transfusion is the most rapid method for lowering serum bilirubin concentrations. This treatment is rarely needed when intensive phototherapy is effective. The procedure removes partially hemolyzed and antibody-coated erythrocytes and replaces them with uncoated donor red blood cells that lack the sensitizing antigen.
In the presence of hemolytic disease, severe anemia, or a rapid rise in the total serum bilirubin level (greater than 1 mg/ dl per hour in less than six hours), exchange transfusion is the recommended treatment. Exchange transfusion should be considered in a newborn with non-hemolytic jaundice if intensive phototherapy fails to lower the bilirubin level.
Complications of exchange transfusion can include air embolism, vasospasm, infarction, infection, and even death. Because of the potential seriousness of these complications, intensive phototherapy efforts should be exhausted before exchange transfusion is initiated.
Nursing Management:
The AAP (2004) recommends that an assessment of jaundice take place in a well-lit room, or preferably, in daylight at a window, whenever the infant’s vital signs are measured, but no less than every 8 to 12 hours.
For Breastmilk Jaundice, treatment includes a 48-hour formula substitution to determine if bilirubin levels decline. However, the mother should continue to express breastmilk to maintain production (Porter & Dennis, 2002).
To offset this risk, the American Academy of Pediatrics [AAP] (2004) recommends for every newborn at 35 weeks or more gestation, health practitioners are to promote and support successful breastfeeding, and advise mother to nurse 8 – 12 times per day.
Most importantly, when phototherapy is use, the baby’s eye should be protected with an eye shield to prevent retina damage and the male child’s genital should be covered with the eye.
Where Biliblanket is not used, the baby’s position should be changed every 1-2 hours for maximum exposure and effective treatment.