Neonatal jaundice

1. Neonatal Jaundice
Islamic University
Nursing College

2. 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.

3. NJ - 3

4. 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

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

6. 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

7. Physiological jaundice
Characteristics
• Appears after 24 hours of birth.
• Maximum intensity by 4th-5th day in term &
7th 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.

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

9. 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.

10. Causes of jaundice
Appearing within 24 hours of age
• Hemolytic disease of NB: Rh, ABO
• Infections: TORCH, malaria, bacterial
• G6PD deficiency.
• T – Toxoplasmosis / Toxoplasma gondii
• O – Other infections
• R – Rubella
• C – Cytomegalovirus
• H – Herpes simplex virus or neonatal herpes simplex

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

12. Causes of jaundice
After 72 hours of age
• Sepsis
• Cephalhaematoma
• Neonatal hepatitis
• Extra-hepatic biliary atresia
• Breast milk jaundice
• Metabolic disorders (G6PD).

13. 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 G6PD
• I - infection
• C – cephalhematoma /bruising
• E - East Asian/North Indian

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

15. Diagnostic evaluation:
• Normal values of unconjugated B. are 0.2 to
1.4 mg/dL.
• Investigate the cause of jaundice.
• Mother blood Rh.

16. 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.

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

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

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

20. 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

21. Nursing diagnosis
• See the high risk infant plan of care. Plus:
 Body Temp., risk for imbalanced Temp.
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.

22. 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).

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

24. QUESTIONS?