2 Neonatal Jaundice Learning Objectives: Define hyperbilirubinemia. Differentiate between physiological and pathological jaundice.State causes of hyperbilirubinemia.Discuss the pathophysiology of hyperbilirubinemia.Describe the most dangerous complication of hyperbilirubinemia.List the three elements of therapeutic management.Design plan of care for baby has hyperbilirubinemia.
3 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.
5 Neonatal Jaundice Newborn skin >5 mg / dl Visible form of bilirubinemiaNewborn skin >5 mg / dlOccurs in 60% of term and 80% of preterm neonatesHowever, significant jaundice occurs in % of term babies
8 Clinical assessment of jaundice Area of body Bilirubin levels mg/dl (*17=umol)FaceUpper trunkLower trunk & thighsArms and lower legsPalms & soles > 15
9 Physiological jaundice CharacteristicsAppears after 24 hoursMaximum intensity by 4th-5th day in term & 7th day in pretermSerum level less than 15 mg / dlClinically not detectable after 14 daysDisappears without any treatmentNote: Baby should, however, be watched for worsening jaundice.
10 Why does physiological jaundice develop? Increased bilirubin load.Defective uptake from plasma.Defective conjugation.Decreased excretion.Increased entero-hepatic circulation.
11 Course of physiological jaundice Age in DaysTermPreterm15105Bilirubin levelmg/dl
12 Pathological jaundice Appears within 24 hours of ageIncrease of bilirubin > 5 mg / dl / daySerum bilirubin > 15 mg / dlJaundice persisting after 14 daysStool clay / white colored and urine staining clothes yellowDirect bilirubin> 2 mg / dl
13 Causes of jaundice Appearing within 24 hours of age Hemolytic disease of NB : Rh, ABOInfections: TORCH, malaria, bacterialG6PD deficiency
14 Causes of jaundice Appearing between 24-72 hours of life Physiological SepsisPolycythemiaIntraventricular hemorrhageIncreased entero-hepatic circulation
15 Causes of jaundice After 72 hours of age Sepsis Cephalhaematoma Neonatal hepatitisExtra-hepatic biliary atresiaBreast milk jaundiceMetabolic disorders (G6PD).
16 Risk factors for jaundice J - jaundice within first 24 hrs of lifeA - a sibling who was jaundiced as neonateU - unrecognized hemolysisN – non-optimal sucking/nursingD - deficiency of G6PDI - infectionC – cephalhematoma /bruisingE - East Asian/North Indian
17 Diagnostic evaluation: Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.Investigate the cause of jaundice.
18 Therapeutic Management Purposes: reduce level of serum bilirubin and prevent bilirubin toxicityPrevention of hyperbilirubinemia: early feeds, adequate hydrationReduction of bilirubin levels: phototherapy, exchange transfusion,Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.
19 Babies under phototherapy Baby under conventional phototherapyBaby under triple unit intense phototherapy
20 Phototherapy if hemolysis Maisel’s chartSr Bilirubin (mg/dl)Birth weightAge in hrs< 2424 – 4849 – 72>72<5All5-9Phototherapy if hemolysis10-14< 2500gPHOTOTHERAPY> 2500gInvestigate if bilirubin> 12mg%15-19EXCHANGEConsider ExchangePhototherapy> 20
21 PrognosisEarly recognition and treatment of hyperbilirubinemia prevents severe brain damage.
22 Nursing considerations of Hyperbilirubinemia Assessment:observing for evidence ofjaundice at regular intervals.Jaundice is common inthe first week of life andmay be missed in dark skinnedbabiesBlanching the tipof the nose
23 Approach to jaundiced baby Ascertain birth weight, gestation and postnatal ageAsk when jaundice was first noticedAssess clinical condition (well or ill)Decide whether jaundice is physiological or pathologicalLook for evidence of kernicterus* in deeply jaundiced NB*Lethargy and poor feeding, poor or absent Moro's, or convulsions
24 Nursing diagnosis See the high risk infant plan of care. Plus: Body T., risk for imbalanced T. related to use of phototherapy.Fluid volume, risk for deficient related to phototherapy.Interrupted family process related to situational crisis, re hospitalization for the therapy.
25 The goals of planningInfant will receive appropriate therapy if needed to reduce serum bilirubin levels.Infant will experience no complications from therapy.Family will receive emotional support.Family will be prepared for home phototherapy (if prescribed).