NEONATAL JAUNDICE MANAGEMENT

 NEONATAL JAUNDICE

Introduction

Jaundice is the most common condition that requires medical attention in newborns. Yellowish coloration of the skin and sclera in newborns with jaundice is as a result of accumulation of unconjugated bilirubin. In most infants, unconjugated hyperbilirubinaemia reflects a normal transitional phenomenon. However, in some infants, serum bilirubin levels may excessively rise, which can cause for concern because unconjugated bilirubin is neurotoxic and lead to death in newborns and lifelong neurologic disorders in infants who survive kernictrus. Therefore, it is for these reasons that we need to study and understand neonatal jaundice for us to offer proper Nursing care.

Definition

1. Neonatal jaundice is a yellowish discoloration of the skin and other tissues of a newborn infant. A bilirubin level of more than 85 umol/l (5 mg/dl) manifests clinical jaundice in neonates (Leifer, 2003).

2. Neonatal jaundice is a condition that results from deposits of bilirubin in the skin and sclera. In term neonates it appears when serum bilirubin concentrations reach 85-120µmol/l (5-7mg/dl) with a cephalo caudal progression as levels increase (Fraser and Cooper, 2005).

In newborns jaundice is marked on the underlying skin and subcutaneous tissue, sclera and the face extending down onto the chest. This condition is common and affects more than 70% of newborns.

Classifications

(A) Physiological jaundice

Physiological jaundice appears on the second or third day of life and never before 24 hours and fades by one week of age. Bilirubin levels never exceed 200- 215umol/l (12- 13mg/dl). Physiologic jaundice is a normal transitional state and may also be seen in term and health babies.

Causes

Increased red cell breakdown (haemolysis) - In the newborn, bilirubin production is more than twice that of normal adults per kg body weight and the neonate shades off the excess hemoglobin after birth in order for the baby to adapt to external environment.

Decreased albumen binding capacity- the transportation of bilirubin from the spleen to the liver is due to lower albumin concentration usually common in preterm babies. Reduced albumin binding capacity will result in acidotic babies.

Decreased activity of UDP Glucuronyl -transferase that correlates with gestational age leading to decreased conjugation and excretion of bilirubin.

The enzyme is present at birth but in low levels, and these Levels normally increase after the first 24 hours.

Enterohepatic reabsorption of bilirubin from the gut- this process is increased in the new born bowel as neonate lack normal enteric bacteria which break down bilirubin to urobilinogen. They also have increased beta glucuronidase which hydrolyses conjugated bilirubin back into unconjugated state.

Other causes include;

Breast-feeding can increase the chances of an infant developing Neonatal Jaundice. In a poorly feeding baby, bowel movements are infrequent and this prevents the bilirubin from being excreted in the stools. Mothers should, therefore, increase the frequency of breast-feeding in order to facilitate passage of stools. However, sometimes, high levels of a hormone present in the breast milk can interfere with the processing of bilirubin. In such cases breast-feeding may need to be interrupted till the bilirubin levels come down to normal.

B. Pathological jaundice

This type of jaundice appears within 24hrs of birth and is characterized by increase in serum bilirubin of 85umol/l or 5mg/day. It does not exceed 200umol/l(12.9mg/dl). This type of jaundice may persist for 7-10 days in term babies while in pre term may even last for 2weeks.

Causes

The underlying cause of pathological jaundice is in interference with bilirubin production, transport, conjugation and excretion. Any disease or disorder that increases bilirubin production or that alters the transport or metabolism of bilirubin interferes with the normal process of physiological jaundice.

Excess production of bilirubin

Blood type ABO incompatibility.

Rh incompatibility.

Infection (Hepatitis B) or other defects in the liver that impede the elimination of bilirubin.

Haemoglobinopathies such as. Sickle cell disease, thalassaemia.

Enzyme deficiency e.g. G6PD maintains the integrity of the cell membrane of the red blood cells is linked to genetic disorder carried by females that affect male infants especially of the African, Asians and Mediterranean races.

Spherocytosis – this is the fragile Red blood cell membrane.

Extraverted blood such as in Cephalo hematoma and bruising.

Sepsis – leading to breakdown of red blood cells.

Polycythaemia – blood contains too many Red blood cells in maternal /fetal or twin to twin transfusion.

2. Transportation –

Factors that reduce the albumin plasma levels or reduce albumin binding capacity such as hypothermia, acidosis or hypoxia can interfere with albumin transporting capacity.

Drugs that compete with bilirubin for binding such as Aspirin, Sulphonamide and Ampicilin decreases bilirubin clearance.

3. Conjugation time – these factors may interfere with conjugation in the liver and they include

Dehydration, starvation, hypoxia and sepsis (glucose and oxygen are required for conjugation).

4. Infections like toxoplasmosis, others, rubella, cytomegalovirus, herpes (TORCH)

5. Other viral infections like hepatitis

Other bacterial infections particularly caused by E – coli.

5. Excretion – factors that can interfere and bilirubin excretion such as:

Hepatic obstruction caused by congenital abnormalities e.g. extra hepatic bilirary atresia.

Obstruction of bile plugs from increase bile plugs from increased viscosity such as in systemic fibrosis, hemolytic disorders, dehydration and total parenteral nutrition

Saturation of protein carriers needed to excrete conjugated bilirubin into the biliary system.

Infection and other congenial disorders that are idiopathic neonatal hepatic and can cause excess of the conjugated bilirubin (Myles, 2005).

Pathophysiology

Following the cause of neonatal jaundice such as excessive breakdown of RBCs which may result from factors like infections, there will be increased levels of bilirubin in blood. Aging, immature or malformed RBCs are removed from the circulation and broken down in the reticuloendothelial system of the liver, spleen, macrophages and heamoglobin is broken down to heam, globin and iron. Heam is converted to biliverdin and then to unconjugated bilirubin. Bilirubin is a waste product from the breakdown of haem, most of which is found in RBCs. Globin is further broken down into amino acids which are reused by the body to make proteins. Iron is also stored in the body or used for new RBCs. In general, there is conjugated and unconjugated bilirubin. Unconjugated bilirubin is fat soluble and cannot be excreted easily in the bile or urine. It can be neurotoxic and has a high affinity for extra vascular tissue and the brain. Once it crosses the blood brain barrier, and it can damage cells of the CNS and produce kernictrus or bilirubin encephalopathy.kernictrusis is the yellowish staining of the brain due to deposition of unconjugated bilirubin in the basal ganglia of brain. While conjugated bilirubin is water soluble in the liver and can be excreted either in faeces or urine. Once in the liver, bilirubin is detached from albumin and transported by intracellular carrier proteins Y and Z to the smooth endoplasmic reticulum of the liver. Bilirubin is then combined with Glucose and glucuronic acid and conjugation occurs in the presence of oxygen. In the liver of the fetus and newborn, the activity of UDP-GT is limited because of the immaturity of the liver enzyme system. At birth, the UDP-GT activity level is only 0.1 percent to 1 percent that of the adult. Activity increases overtime but does not reach adult levels until 6-14 weeks after birth. As a result of this, bilirubin accumulates in the blood stream of all the newborns.

Signs and symptom of neonatal jaundice

The signs and symptoms of Neonatal Jaundice largely depend on the underlying causes

In physiological Jaundice, the baby usually feeds well.

On examination the liver is usually normal.

The urine is dark, while the stool appears normal.

High levels of bilirubin can cause high-pitched crying.

Apnoea (temporary stoppage of breathing).

Restlessness.

Seizures and arched backs in the infants.

Extremely high levels of bilirubin (Hyperbilirubinemia) lead to Kernicterus, a condition where the brain is severely damaged.

Diagnosis for neonatal jaundice

The initial diagnosis of neonatal jaundice is based on a physical examination, which is done by placing the infant on sunlight and checking for signs of jaundice. The Jaundice usually starts from the head region and can be first detected from the face. It then slowly spreads down the body and reaches the feet. At this stage the baby must be in the care of a health professional. Blood tests can also be carried out to confirm Hyperbilirubinemia.

Laboratory investigations

Serum bilirubin - to determine levels and check if the bilirubin is conjugated or unconjugated.

Direct coomb’s test – this is done to detect the presence of maternal antibodies in serum.

Haemoglobin estimation to rule out anaemia.

Peripheral blood smears to assess structure of the red blood cell and rule out any abnormality.

WBC counts to detect infection.

G6PD assay.

Medical management

The purpose of treating neonatal jaundice is to avoid complications such as neurotoxicity (kernicterus).

Phototherapy, intravenous immune globulin (IVIG), and exchange transfusion are the most widely used therapeutic modalities in infants with neonatal jaundice.

Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia. This therapeutic principle was discovered in England in the 1950s and is now the most widely used in the newborns. Bilirubin is excreted in bile and, to some extent, in the urine. The half-life of bilirubin in serum is much shorter than that in E isomers. Phototherapy lowers the total serum bilirubin concentration which is the therapeutic benefit. Bilirubin by virtue of their water-soluble nature makes it to cross the blood-brain barrier. Phototherapy may reduce the risk of bilirubin-induced neurotoxicity as soon as the lights are turned on

Indications for phototherapy

Serum bilirubin levels of;

For premature babies of <1.5kg, levels 5-8mg/dl.

Premature babies above 1.5kg, sick infants and those with haemolysis levels of 8-10mg/dl

Term infants who are healthy with jaundice after 48hrs bilirubin levels of 17-22mg/dl.

Phototherapy can be administered using various approaches and basic principles these include;

1. Wavelength must be considered- Bilirubin absorbs light primarily around 450-460 nm. However, the ability of light to penetrate skin is also important; longer wavelengths penetrate better. Thus, lamps with output predominantly in the blue region of the spectrum (460-490 nm) are probably most effective. In practice the light which is used phototherapy is white, blue, turquoise, and green wavelengths.

2. The amount of irradiation and reduction in serum bilirubin- A dose-response relationship may be observed between the amount of irradiation and reduction in serum bilirubin up to an irradiation level of 30-40 µW/cm2/nm. Many older phototherapy units deliver much less energy, some at or near the minimally effective level, which appears to be approximately 6µW/cm2/nm. On the other hand, newer phototherapy units, when properly configured and with the use of reflecting blanket and curtains may deliver light energy above the 40 µW/cm2/nm suggested to be the saturation level.

3. Distance- the energy delivered to the infant's skin decreases with increasing distance between the infant and the light source. This distance should be between 50 cm and 60 cm when providing phototherapy to infant's with jaundice.

4. Effectiveness- the efficiency of phototherapy depends on the amount of bilirubin that is irradiated. Irradiating a large skin surface area is more efficient than irradiating a small area.

5. The nature and character of the light source-The nature and character of the light source may affect energy delivery. Irradiation levels using quartz halide spotlights are maximal at the center of the circle of light and decrease sharply towards the perimeter of the circle. Large infants and infants who can move away from the circle's center may receive less efficient phototherapy.

Types of light administered in phototherapy

Although green light theoretically penetrates the skin better, it has not been shown plainly to be more efficient in clinical use than blue or white light, makes babies look sick. Green light has not gained widespread acceptance yet.

Blue fluorescent tubes are widely used for phototherapy. Narrow-spectrum blue lamps (special blue) appear to work best, while ordinary blue fluorescent lamps are probably equivalent to standard white daylight lamps. Blue lights may cause discomfort in hospital staff members, which can be improved by mixing blue and white tubes in the phototherapy unit.

White (daylight) fluorescent tubes- are less efficient than special blue lamps; however, decreasing the distance between infants and lamps can compensate for the lower efficiency. Use of reflecting materials also helps. Thus, in developing countries where the cost of special blue lamps may be prohibitive, efficient phototherapy is accomplished with white lamps.

Fiberoptic light - This unit deliver high energy levels, but to a limited surface area. Efficiency may be comparable to that of conventional low-output overhead phototherapy units but not to that of overhead units used with maximal output.

Advantages include the following of fiberoptic light;

Low risk of overheating the infant.

No need for eye shields.

Ability to deliver phototherapy with the infant in a bassinet next to the mother's bed.

Simple deployment for home phototherapy.

The possibility of irradiating a large surface area when combined with conventional. Overhead phototherapy units (double/triple phototherapy).

Nursing care during phototherapy

Clean skin with warm water and observe for any rashes or excoriation.

Expose baby ,s body to the light

Baby is turned regularly to allow distribution of light to all body parts

The eyes are covered to prevent retina damage

When the baby is breastfeeding, switch off the lights and remove the eye pads so that the baby and mother can communicate to promote bonding.

For the male infant, gonads are covered to avoid damages.

Temperature control is very important as the baby may become to cold or too hot as a result of radiant heat from the light.

Nurse the baby in the incubator in order to control the temperature.

Observe of side effects of phototherapy such as diarrhea, dehydration due to soluble water loss, skin, rush, browning of the skin.

The light has to range between 50-60cm above the baby.

Observation to be done 4 hourly TPR, activity to be done to check for irritation of mental, irritated skin colour , type of cry, elimination of stool colour, amount, odor, consistency, frequency, dextrose test. General condition should be observed to see whether improving or not,

If the fontanelle is depressed, it is an indication of dehydration.

Hydration

Monitor intake and output.

Give extra fluid to prevent dehydration through Intravenously

If baby cannot be cannulated give the fluids through the NG tube.

Feeding increases peristalsis and passage of meconium , provide extra fluids such as 5% dextrose between feedings to prevent volume deficit which may result from insensible fluid loss due to heat from phototherapy.

Behavior

Monitor the sleeping pattern and the wake stress of the baby.

Check Dextrostix test to rule out hypoglycemia.

Observe the feeding behavior.

Phototherapy is discontinued during feeding so that the baby can interact with the mother.

Encourage the mother to touch and speak to the baby in order to promote bonding.

Skin

Skin is cleaned with warm water. Observe skin rush, excoriation and dryness. Apply some baby lotion.

Prevention of infection

Maintain aseptic technique when doing cold care.

Wash hands before and after handling the baby.

Exchange blood Transfusion (EBT)

Exchange transfusion becomes the second-line treatment when phototherapy fails to control serum bilirubin levels. However, data has shown that treatment with IVIG in infants with Rh or ABO immunization can significantly reduce the need for exchange transfusions. This is the transfusion where the baby’s blood is gradually removed and replaced to fresh, rhesus positive, AO B compatible blood and it has the effect of washing out excess bilirubin and unwanted antibodies also increases hemoglobin levels. Amounts equal to twice the baby’s blood volume need to be used. Rhesus negative blood is used so that there is no rhesus antigen to attract antibodies. It does not alter the baby’s blood group therefore the neonate will continue to produce rhesus positive blood cells. Exchange blood transfusion can reduce bilirubin levels to ≥25g/dl.

Indications for exchange blood transfusion

Anaemic babies –If Hb is <10/dl.

If jaundice appears within 2hours of birth.

Hyperbilirubinaemia –Serum levels are 100-135 µmol at birth.

Babies with serum bilirubin of 300-400 µmol within seven days in preterm babies..

In conditions where there is Kernictrus.( An encephalopathy caused by deposits of unconjugated bilirubin in the basal nuclei of the brain)

.

Management of infant on exchange blood transfusion

It’s carried out in neonates and is only used after phototherapy has failed or where there is evidence of kernictrus.

The Blood Transfusion is given via the umbilical vein. At least 10mls of blood is withdrawn to determine levels of serum – bilirubin, hemoglobin level and glucose before transfusion.

The blood transfusion is accompanied by removing and discarding 5 – 10ml of blood and immediately replacing it with a similar amount of fresh blood. This procedure is repeated until the calculated volume has been exchanged.

A double volume results in about 90% of the babies’ blood.

A continuous slow infusion of calcium is given constantly in order to correct hypocalcaemia which is due to the citrate stored in the blood. The procedure takes 2 hours.

Monitor the vital signs.

Monitor the heart rate with cardiorator or ECG.

Report any changes and note the skin colour for cyanosis and pallor which may be an indicator for heart failure or collapse.

Abnormalities such as gitterness or twitching should be monitored as it may be the result of hypoglycemia or hypocalcaemia.

Post blood transfusion care

The baby should be nursed in the incubator and it should be warm, observe the behavior, the umbilical for bleeding every ½ hourly, estimate blood capillary glucose. Estimate calcium levels for a while after the exchange of blood transfusion.

Side effects of exchange transfusion

Blood reactions.

Necrotizing enterocolitis

Acidosis

Hypocalcaemia

Hypoglycemia

Increased risk of infections

Air embolism

Complications of neonatal jaundice

Kernictrus- At an extreme levels bilirubin causes brain damage. The high levels of unconjugated bilirubin on the brain cells.

Increased risk of infection

Thrombocytopenia

Encephalopathy results from deposits of unconjugated bilirubin in the basal ganglia.

To sum up on Jaundice we can say that it is is the most common condition that requires medical attention in newborns. The yellow coloration of the skin and sclera in newborns with jaundice is as a result of accumulation of unconjugated bilirubin. Phototherapy and exchange blood transfusion are the major treatment regimen of neonatal jaundice and prevention of complications such as kernictrus.

NURSING CARE OF NEONATAL CONDITIONS

Common problems affecting the neonates with neonatal conditions include:

Difficulties in breathing.

Risk of developing hypothermia.

Risk of acquiring infections.

Risk of developing nutritional imbalance.

Disturbed sleep patterns.