Understanding Neonatal Jaundice
By Jennifer Turney, MSN, RN, CNS, CPN, contributor
Neonatal jaundice (or hyperbilirubinemia) is observed during the first week of life in approximately 80% of newborns in the United States (Balasundaram & Bhutani, 2016). Jaundice is the yellow discoloration in a newborn baby’s skin and eyes, and is one of the most common problems encountered in term newborns. Jaundice occurs due to the inability of the infant’s immature liver to rid the unconjugated bilirubin from the bloodstream (AAP, 2004 & CDC 2015).
If left unmonitored and untreated, jaundice can progress into severe hyperbilirubinemia, bilirubin encephalopathy or kernicterus (AAP, 2004).
Prenatal factors that increase the risk for elevated serum bilirubin levels include fetal-maternal blood group incompatibility, prematurity, previously affected sibling, cephalohematomas, bruising, trauma from instrumented delivery and delayed meconium passage (Porter & Dennis, 2002).
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Physiological jaundice in healthy term newborns follows a typical pattern. The average total serum bilirubin level usually peaks at 5 to 6 mg/dL on the third to fourth day of life and then declines over the first week after birth (Porter & Dennis, 2002).
One type of physiologic, or exaggerated physiologic jaundice, is known as early onset breastfeeding jaundice. Early onset breastfeeding jaundice usually occurs in the first week of life with an incidence of 1 in 10 breastfed babies (CDC, 2015). The cause is usually related to inadequate milk intake resulting in dehydration and low caloric intake (CDC, 2015 & 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.
Late onset breastmilk jaundice occurs in about 1 in 200 babies and occurs later in the newborn period, with bilirubin levels peaking around the sixth to fourteenth day of life (CDC, 2015 & Porter & Dennis, 2002). In this case, the cause of jaundice is due to a substance in the mother’s milk that decreases the ability of the infant’s liver to metabolize bilirubin (CDC 2015 & Porter & Dennis, 2002). 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).
Jaundice is pathologic if it occurs in the first 24 hours and requires immediate intervention; if the total serum bilirubin level rises by more than 5mg/dL per day, or, is higher than 17 mg per dL, in a full-term newborn (Porter & Dennis, 2002). Causes of pathologic jaundice include sepsis, rubella, toxoplasmosis, occult hemorrhage and erthroblastosis fetalis (Porter & Dennis, 2002).
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. Jaundice is most commonly seen first in the face and progresses caudally to the trunk and extremities (AAP, 2004). A visual estimation of bilirubin levels is discouraged because it can lead to errors, especially in darkly pigmented infants (AAP, 2004).
Laboratory evaluation of a total serum bilirubin (TSB), or transcutaneous bilirubin (TcB), is recommended on every infant that: 1) appears jaundice in the first 24 hours after birth; 2) jaundice appears excessive for age; and 3) prior to discharge to determine level of risk (AAP, 2004).
TcB devices provide a noninvasive way to assess bilirubin levels and have reduced invasive blood sampling (Balasundaram & Bhutani, 2016). However, TcB measurements are not reliable in infants undergoing phototherapy. For example, it may overestimate TSB levels in infants who have increased skin pigmentation, and may likely underestimate TSB levels in light-skinned patients. Therefore if a TcB level is exceeding the 75th percentile, a confirmatory TSB level is to be obtained (Balasundaram & Bhutani, 2016).
The most reliable method for assessing risk of hyperbilirubinemia and threshold for intervention is to plot the TSB/ TcB level upon the hour-specific nomogram (AAP, 2004 & Balasundaram & Bhutani, 2016).
The most common treatment for hyperbilirubemia is phototherapy. The absorption of light through the skin converts unconjugated bilirubin and promotes the excretion in the stool and urine (Muchowski, 2014). The AAP (2004) has published guidelines for phototherapy in hospitalized term and near-term newborns.
When phototherapy is ineffective, an exchange transfusion is occasionally indicated. In 2004, guidelines for exchange transfusion were published by the AAP, and should be performed on infants with TSB levels in the range indicated by the nomogram, with TSB levels of 25 mg/ dL or greater, and with jaundice and signs of acute bilirubin encephalopathy (lethargy, altered mental state, apnea, irritability, muscle tone abnormalities and/or altered cry patterns [Muchowski, 2014]).
Through the development and adoption of standardized guidelines on assessment and monitoring, risk assessment and early treatment for hyperbilirubinemia, adverse outcomes such as bilirubin encephalopathy and kernicterus have become rare and unusual in the United States (Balasundaram & Bhutani, 2016).
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American Academy of Pediatrics [AAP] (2004). Management of Hyperbilirubinemia in Newborn Infant 35 or More Weeks Gestation. Pediatrics 114 (1) 297-316.
Balasundraram, M. & Bhutani, V. (2016) Severe Hyperbilirubinemia Prevention (SHP Toolkit). Retrieved from: https://www.cpqcc.org/qi-tool-kits/severe-hyperbilirubinemia-prevention-shp
Centers for Disease Control & Prevention [CDC] (2015). Jaundice. Retrieved from https://www.cdc.gov/breastfeeding/disease/jaundice.htm
Porter, M.L, Dennis, B.L. (2002) Hyperbilirubinemia in the term newborn. American Family Physician 65 (4) 599-606.
Muchowski, K.E. (2014) Evaluation and treatment of neonatal hyperbilirubinemia. American Academy of Family Physicians 89 (11). 873-878.
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