Overview Of Jaundice In Newborn

Typically, red blood cells circulate the body for approximately 120 days until they inevitably grow old or become damaged and new cells must replace them. In a healthy adult with a mature liver, these red blood cells are broken down by macrophages in the liver, thus being metabolized and then eventually excreted from the body. From this process of breakdown, a biproduct called bilirubin is created. This biproduct more specifically is produced by the breakdown of hemoglobin, which is a protein in red blood cells that circulate oxygen to the body’s tissues and collects carbon dioxide to be removed. The liver then conjugates the bilirubin, which is where the bilirubin is converted from fat-soluble to a water-soluble component and can thus be sent out into the bile ducts, and inevitably excreted through the small intestine and feces.

Conversely, a newborn’s liver is immature and unable to maintain the body’s cycle of recycling and excreting red blood cells in a manner of efficiency and effectiveness as the mature liver can accomplish. In addition, the fetus has many circulating red blood cells to meet the oxygen demands of the body as it’s in a low oxygen environment. Once born, the lungs can begin to fulfill the oxygen needs, consequently decreasing the need for the excess red blood cells in circulation, which introduces the necessity as these extra red blood cells that are now dying, they must be sent to the liver to be broken down. As the liver is still immature in the newborn, it can become overwhelmed by the demand of the body to break down these red blood cells and in turn conjugate the biproduct of bilirubin, so it can be excreted from the body. Newborns essentially have a higher level of red blood cells as well as a higher turnover rate with a shorter life span, plus the limited ability to conjugate bilirubin.

As a result, the bilirubin remains unconjugated, where it remains fat soluble and is bound to the protein albumin in the blood. Due to this, bilirubin in the blood stream increases above normal amounts, also known as hyperbilirubinemia. As this excess bilirubin circulates the body, it can cross into cells and stain them yellow, which in turn can present the baby as jaundiced, which is having a yellow tinge to the skin. Jaundice can be physiological, where it appears after the first 24 hours of life, consequently from the newborn going through extra-uterine hepatic adaptation. This usually lasts only a few days, permitting the levels of bilirubin don’t continue to increase and remain outside the levels of being dangerously high, and eventually resolves. When jaundice presents within the first 24 hours of life this condition is deemed pathological in nature. In this case, the jaundice is caused by an underlying disease or complication in the newborn, such as a blood type incompatibility between the mother and baby. This condition is serious and must be treated and investigated promptly, for without treatment, the newborn may suffer devastating complications.

Consequences of Untreated Hyperbilirubinemia

If the excess bilirubin in the bloodstream continues to increase and is left untreated at high numbers it can be detrimental to the baby’s health, specifically to their central nervous system. High bilirubin levels can lead to a condition called kernicterus. This is a disorder where the excess bilirubin can stain neurons in the brain and spinal cord and can result in irreversible defects, injury, or death. If significant brain damage occurs as a result of high serum bilirubin before proper treatment is provided, the baby can suffer from convulsions, intellectual disabilities, hearing loss and cerebral palsy. Parents of the jaundiced baby need to be aware of these consequences as treatment is essential to prevent such, in cases deemed necessary. Education on the process of phototherapy should be discussed thoroughly to clear up any fears or misconceptions.

Blood Test to Confirm Initiation of Phototherapy

Hyperbilirubinemia can be determined by testing blood for its total serum bilirubin (TSB). If the values present as higher than referenced for how many hours the newborn has been alive, phototherapy will be initiated.

How Phototherapy works and Necessary Nursing Care

Bilirubin that is unconjugated is bound to albumin in the blood and is unable to be excreted while in this form. In order for that bilirubin to leave the bloodstream and be excreted into the bile, it must go through a process of conjugation in the liver where it’s converted to being water-soluble. Phototherapy works by exposing the baby to special lights, which work to convert the fat-soluble unconjugated bilirubin into water-soluble conjugated bilirubin, which then in turn allows it to be excreted through the gastrointestinal tract thus, lowering serum bilirubin levels. Important considerations for this therapy include position of the lights, as the baby can receive burns if the lights are too close and ineffective therapy will be the result of the lights being too far away. The infant should be nude, as this exposes the most skin to the therapeutic lights, besides the exception of a diaper. The nurse should ensure the infant is wearing protective eyewear to prevent ultra-violet rays from damaging the retinas, as well as placing the eyewear snug enough so it doesn’t slip and occlude the nares. These protective eye patches should be removed by the nurse every 4 hours to cleanse the eyes and observe for irritation, inflammation or dryness. The nurse must turn the newborn every 3-4 hours so there is not prolonged exposure of the lights to a specific spot. The nurse is not to shut off the lights unless the infant needs to be fed, needs a diaper change or for maternal bonding such as skin-to-skin care. Serum bilirubin levels must be monitored routinely, however the lights will need to be turned off while doing a blood draw as the lights may influence a false low. Monitor the baby’s hydration status as he/she will require more fluids due to increased evaporative water loss. The nurse must monitor vital signs, paying attention to temperature (as overheating can occur), at least every 4 hours. Observe the baby’s level of consciousness routinely and perform neuro checks as deemed necessary. Also, the nurse should be monitoring the baby’s elimination for loose, greenish stools and ensure to keep him/her clean and dry. The nurse should be communicating with the parents and give opportunities for them to express their feelings, as they may be having a mixture of emotions including sadness, fear, and anxiety. As a nurse, it’s important to try assist the parents in validating and coping with their emotions at this time.

Encouraging bonding and positive attachment during jaundice therapy

The nurse should encourage parents to participate in kangaroo care for the newborn as this can strengthen the emotional bond between parents and the baby. It may provide some relief of the feelings of anxiety they may be having at this time, and in addition, it can cause the release of oxytocin in the mother which in turn will reduce stress levels. The baby also greatly benefits from the skin-to-skin contact as it can increase the baby’s feelings of safety and happiness, assist in the baby’s thermoregulation, as well as participate in stabilizing the baby’s heart rate and respiratory rate. The nurse should point out the positive features of the baby to the parents and allow the family to have privacy with the baby in the short times he/she is not under the bili lights to influence attachment. Also, the nurse should encourage the parents to take part in the care for their newborn while he/she is receiving treatment, and always make them feel comfortable during their visits if treatment is occurring in the hospital.

Discharge information for parents who have a newborn with jaundice

The nurse should advise the parents to perform routine assessments of the baby’s skin to observe the current condition of jaundice. Jaundice first is evident in the face and head, and as bilirubin levels keeps rising, it expands to the trunk then furthers to the extremities. Therefore, parents can be aware of how effective the treatment has been or if the jaundice is worsening. Parents should press their finger gently into the infant’s skin and observe the colour of where they pressed. If the colour appears slightly lighter than the newborn’s skin rather than having a yellow tint, that is an indicator their skin colour is returning to normal. Also, the bilirubin’s main path of excretion is through the digestive tract, so providing the phototherapy has been successful in converting fat-soluble bilirubin into water-soluble, it should be able to exit the body naturally through the baby’s stool. The mother should make efforts to establish a regular breast-feeding pattern, such as every 2-4 hours. Mother’s should take note of how the infant is feeding and if their ability to latch on is effective as baby’s who are jaundiced typically feed poorly, thus, if the mom notices the infant is nursing better, this is a sign of improvement. In conjunction with such, the parents must make note of the quantity and characteristics of the baby’s stools and amount of urine output. Advise the parents to do this as loose stools and increased urine output provide insight into how much bilirubin is being excreted. The baby’s alertness and energy levels often increase once the jaundice begins to disappear. Total serum bilirubin levels should be in the low risk percentile of below according to how many hours the infant has been alive, which will indicate bilirubin levels have stabilized.

B. Postpartum Teaching

Discharge teaching for mom and normal newbornParents should be advised that newborns eat approximately every 2-4 hours and a feeding pattern will most likely develop by 2 weeks postpartum. Babies occasionally spit-up and this is very common but be wary that frequent vomiting can result in dehydration and should be reported to the pediatrician. It’s normal for a newborn to sleep around 16-20 hours per day, so it may be helpful for the parent providing care to rest when the baby rests. Babies should be placed on their backs to sleep and parents should avoid putting pillows in the crib with the baby or using a plastic covering on the mattress as these may be hazardous. For the first 3-4 months of life infants have trouble falling asleep by themselves, therefore it’s helpful to rock and cradle the baby while he/she is trying to fall asleep. Recommend the mom to breast feed the child up until the infant is 4-6 months old as the immature digestive system cannot handle large protein molecules until about 4 months. When the baby is crying, educate parents to check if the baby needs something such as he/she needing a diaper change or being hungry, as crying is the baby’s way of communication. Some techniques that may comfort a baby when fussy is to rock or cradle baby, take the baby for a ride in the car, turn on external noise such as a vacuum cleaner, washing machine or the air conditioner. Stimulate the baby through the five senses as it’s necessary for development of the brain.

This includes talking, singing, making faces with the baby, holding and cuddling, and allowing him/her to feel different textures and shapes. Demonstrate to parents how to use the bulb syringe to suction the airways if there are excess secretions and teach that yellow or green nasal discharge is a sign of illness and should be assessed by the health care provider. Provide thermoregulation by dressing the baby in clothes that would keep parents comfortable in the environment then wrap in a light blanket. Normal temperature range is 36. 5 C to 37. 5 C, any temperature outside of normal range should be reported to the health care provider. Educate parents to make note of the voiding and stool patterns of the newborn. It is normal for the baby to void 6-7 times a day, any absence of voiding within 12 hours should be promptly reported. Stools should be soft, have a sweetish odor and typically aren’t formed when it comes to breast-fed infants. Well-formed stools with a darker colour and more unpleasant odour are usually evident in formula-fed infants. It is normal for the baby to turn red while straining to pass a stool and this does not indicate constipation.

Constipation in infants manifests in infrequent, hard, dry stools. If the baby has more than two episodes of diarrhea in one day, the health care provider should be notified as this can dehydrate the baby. When bathing the newborn, it’s important to be cautious with the water temperature as the baby needs protection from chilling and scalding alike as their skin is tender and they have not developed the shivering mechanism to regulate body temperature. The nurse should educate the parents that daily tub baths aren’t necessary and they may even dry out the infant’s skin, and inform parents to also pay attention to the cord site by cleansing it once a day with plain water. As for the baby’s safety, parents must be aware that newborns quickly learn to roll over and move around, therefore should never be left unattended on high surfaces as unintentional rolling or movements cannot be anticipated. Educate the parents on normal newborn appearance and that yellow and blue tints to the skin are abnormal, and possibly require immediate assessment and intervention by a health care professional.

The nurse should assess the parent’s knowledge on proper use of car seats as improper use can be devastating to the infant in the event of an accident. The newborn’s car seat should be positioned in the middle of the backseat of the care facing the rear and should be designed to fit the weight of the baby. Parents must be informed never to place car seats in the front unless the airbags are disabled as airbags can cause significant injury or even death in the event that they are deployed with a newborn in the front seat. Finally, ensure parents are aware to make a follow up appointment with the pediatrician within the recommended time frame, and educate on follow up screenings and immunizations for the infant.