Jaundice in the full-term newborn.
In most healthy full-term newborns, jaundice is noticed during the first week of life and becomes noticeable at a bilirubin level of 5 mg/dl. Although uncommon, bilirubin toxicity occurs at bilirubin levels greater than 17 with possible long-term effects on brain cells (AAP, 2004; Harris, Bernbaum, Polin, Zimmerman, & Polin, 2001). With a greater understanding of jaundice and its treatment, nurses are able to closely monitor this common but potentially devastating condition, encourage breastfeeding, and provide optimal care and support for parents.
Pathophysiology of Jaundice
Bilirubin is formed from the breakdown of hemoglobin in red blood cells. Red blood cells (RBC) only live for 70-90 days in the newborn period, unlike the older child whose cells live 120 days (Berkowitz, 2000). Increased RBC destruction, decreased hepatic blood flow, and immature systems for breakdown of bilirubin causes jaundice in the newborn (Augustine, 1999; Berkowitz, 2000). The gastrointestinal tract (GI) in the newborn lacks the necessary bacteria to break down waste, increasing the reuptake of bilirubin (Berkowitz, 2000). Jaundice results from liver immaturity, obstruction of bile ducts, and excessive hemolysis.
Physiologic jaundice refers to jaundice in the immediate newborn period without signs of illness (Parks et al., 2000). In most newborns, total serum bilirubin levels peak between the second to fourth day of life. Early discharge from the hospital of infants less than 48 hours of age, without appropriate and timely follow up, has significantly increased the numbers of newborn re-admissions for management of hyperbilirubinemia (Harris et al., 2001). In addition, incidence of acute bilirubin encephalopathy and kernicterus have increased among otherwise healthy breastfed infants with poor feeding and delayed follow up visits (AAP, 2004; Harris et al., 2001).
Kernicterus is a pathologist's term describing the yellow deposits and brain cell death from extremely high levels of bilirubin, generally >25-30 mg/dl. The term is often used interchangeably with bilirubin encephalopathy. Kernicterus denotes chronicity of this condition and can be seen with magnetic resonance imaging. It is frequently associated with G6PD Dehydrogenase Deficiency (AAP, 2004; Hayes, 2000; Schwoebel & Sakraida, 1997). Acute bilirubin encephalopathy is used to describe the clinical disorder with signs of stupor, hypotonia/extensor hypertonia, poor feeding, and fever. Sequelae include cerebral palsy with athetosis (involuntary writhing movements), oculomotor damage, and high frequency hearing loss (Hayes, 2000). One study concluded that although infrequent, kernicterus has at least 10% mortality and over 70% long-term morbidity (Stanley et al., 2004). Of interest, bilirubin is thought to have some beneficial antioxidant effects at normal levels and has sparked new interest in jaundice research (Greenberg, 2002; Schwoebel & Sakraida, 1997). Laboratory studies in rats are ongoing to determine the significance of bilirubin in oxidative injury with potential benefit in stroke and Alzheimer's disease prevention.
Newborns who are breastfed are three times more likely to have total bilirubin levels >12 mg/dl than bottle-fed infants as there may be considerable delay before breastfeeding is well established (Augustine, 1999). Bilirubin is primarily excreted through the bowel. Colostrum aids in the evacuation of meconium, the infant's first stools, thereby reducing the enterohepatic circulation of bilirubin (Hayes, 2000). Inadequate caloric intake and subsequent weight loss, delayed passage of stool, and bruising from delivery place the infant at high risk for jaundice (Hayes, 2000). In addition to physiologic jaundice, many conditions are associated with hyperbilirubinemia such as sepsis, twin-to-twin transfusion, hemolysis from Rh incompatibility, and slowed excretion of bilirubin seen with hypothyroidism and cystic fibrosis (Augustine 1999; Berkowitz 2000).
The nurse obtains a thorough pregnancy and birth history. The history includes family history of congenital disorders such as cystic fibrosis and family history of blood disorders or jaundice. Documentation includes maternal disease such as diabetes, presence or exposure to infection, and maternal hepatitis vaccination. Pregnancy history includes gestational age, maternal blood type, and Rh and isoimmune antibody titers. It is important to note the presence of newborn trauma such as cephalohematoma, adequacy and number of feedings, infant output including the color of stools, presence of temperature instability, and the time of onset of jaundice as well as associated symptoms such as vomiting or delayed stooling.
Black infants tend to have lower levels of bilirubin than whites with an average peak for both on the third day of life. Asian and Native American infants tend to have higher levels, which peak on the fourth to fifth day with a longer duration (Hayes, 2000). Persistent early high levels of bilirubin should prompt investigation for G6PD deficiency found in individuals from the Mediterranean and Middle East, Arabian peninsula, Southeast Asia, and Africa.
The family of an infant with significant jaundice often reports a sleepy infant who does not take well to the breast. A gradual increase in jaundice may go unnoticed. Jaundice appears in a cephalocaudal manner, first seen on the newborn face and sclera and progressing to the trunk, arms, and lower extremities. Visual examination of the infant is not a reliable measure of jaundice and should be verified with transcutaneous bilirubinometry (TCB) and/or serum bilirubin testing (AAP, 2004; Moyer, Ahn, & Snead, 2000). The AAP (2004) recommends term infants with TCB greater than 19 measured on the sternum have a serum bilirubin level checked as well. TCB is a screening tool with some question of its reliability and should not be used in preterm infants, infants receiving phototherapy, or in non-Caucasian infants (AAP, 2004).
End-tidal carbon monoxide (ETCOc) level is new technology used in some neonatal intensive care units to confirm the presence of hemolysis. The measurement of ETCOc is the only clinical test that provides a direct measurement of the rate of heme catabolism and the rate of bilirubin production. It is too early to tell how this test, which currently is not widely available, will affect management (AAP, 2004).
Physical assessment of the infant with jaundice includes observing for signs of sepsis, which may contribute to jaundice, such as poor feeding, apnea, hypothermia, bruising, petechiae, and cephalohematoma. The nurse notes the presence of lethargy, vomiting, tenderness in the right upper quadrant, excessive weight loss, hepatosplenomegaly, dark urine or pale white stools (acholic stools suggest biliary atresia), and rashes. Ocular anomalies, hearing deficits, unusual facial features, and cardiac defects suggest a genetic syndrome (Berkowitz, 2000).
The onset of significant jaundice in the first 24 hours of life is not considered a normal finding and deserves careful monitoring. Table 1 describes risk factors for jaundice and factors suggesting a pathologic cause of jaundice.
There are many causes of jaundice other than physiologic jaundice, which the health care provider needs to be familiar. Table 2 gives a brief summary of the differential diagnosis of jaundice.
The AAP (2004) suggests measurement of total, direct, and indirect bilirubin levels as appropriate, and if direct bilirubin is less than 1.5, then one may follow total bilirubin. Indirect bilirubin levels measure "free" or unconjugated bilirubin and direct bilirubin levels measure conjugated bilirubin (Pagana & Pagana, 2002). Conjugation refers to the pairing of bilirubin with intracellular proteins in the liver. Conjugated bilirubin is water-soluble and eliminated by the kidneys and GI tract (Berkowitz, 2000). Free floating or unconjugated bilirubin has a greater chance of being reabsorbed and thus raising blood levels as well as potentially crossing the blood brain barrier causing damage (Schwoebel & Sakraida, 1997).
Laboratory studies for the newborn with jaundice include a total and direct bilirubin level, newborn cord blood type, Rh and screen (indirect Coomb's) and direct Coomb's test if not done previously by the facility (AAP, 2004; Alexander & Robin, 2000). The direct and indirect Coomb's tests detect antibodies against RBC seen in ABO/Rh incompatibility that may cause cellular damage and hemolytic anemia (AAP, 2004; Pagana & Pagana, 2002). Complete blood count with differential, platelet count, albumin (to aid in assessment of unbound bilirubin), blood culture, urinalysis, and peripheral smear to rule out infection and hemolysis may be warranted. A reticulocyte count may be useful if the infant is anemic to measure red blood cell production by the bone marrow. Family history of G6PD deficiency or hemolytic disease requires further evaluation. All blood work including chromosomal studies must be completed before exchange transfusion (Alexander & Robin, 2000). Parks et al. (2000) summarizes laboratory findings for hyperbilirubinemia:
* Elevated serum indirect bilirubin with normal reticulocyte count and negative Coomb's test is associated with physiologic, breast milk jaundice, or familial nonhemolytic jaundice.
* Elevated serum indirect bilirubin with increased reticulocyte count is indicative of increased hemolysis seen with ABO/Rh incompatibility and red blood cell abnormalities.
* Elevation of both direct and indirect bilirubin with a negative Coomb's test and normal reticulocyte count is indicative of hepatitis, metabolic or obstructive disorders, or sepsis.
In addition to phenylketonuria, many metabolic diseases including hypothyroidism are tested in the nursery prior to discharge. Testing urine for reducing substances offers a quick evaluation method for galactosemia (AAP, 2004; Berkowitz, 2000). Another rapid test for conjugated hyperbilirubinemia is noting a yellow color to the foam of a shaken tube of urine; the challenge, of course, is in obtaining the sample (Berkowitz, 2000). Liver function studies are appropriate when the direct bilirubin is >2 mg/dl, if the provider suspects hepatitis or if hepatomegaly is present.
Several new methods of evaluating jaundice are available but not widely used. Noninvasive transcutaneous bilirubinometry offers a more objective measure of jaundice than visual estimates, which are not recommended (AAP, 2004; Hayes, 2000). Expired carbon monoxide levels, a byproduct of bilirubin breakdown, also are being used in some facilities to evaluate the presence of hemolysis (AAP, 2004; Schwoebel & Sakraida, 1997).
Table 3 helps delineate the causes of conjugated and unconjugated hyperbilirubinemia.
Treatment of jaundice includes encouraging frequent breastfeeding, phototherapy using overhead and/or fiberoptic pads, medication, and exchange transfusion.
Non-pharmacologic treatment. Non-
pharmacologic treatment includes frequent breastfeeding and phototherapy when warranted. It is recommended that mothers breastfeed their newborns 8-12 times per day during the first 3 days of life to prevent significant jaundice (AAP, 2004; Hayes, 2000). The AAP supports breastfeeding with the addition of expressed breast milk or formula supplementation only when the milk supply is inadequate, or the infant experiences excessive weight loss (< 7%) or shows signs of dehydration. Intravenous fluids and water supplementation do not lower the bilirubin level significantly and are unnecessary in the infant who is adequately hydrated (AAP, 2004; Augustine, 1999; Hayes, 2000). The AAP recommends formal evaluation of breastfeeding at 24-48 hours of life with follow up 48-72 hours after discharge. Early evaluation affords the provider the opportunity to correct problems and help mothers establish and maintain breastfeeding.
Adequate milk intake for the newborn is evidenced by six urine saturated diapers and three stools per day (AAP, 2004; Hayes, 2000). After the infant returns to birth weight, one would expect a gain of approximately one-half to one ounce per day. Occasionally breastfeeding must be temporarily halted for 24-48 hours when jaundice is prolonged due to substances in the breast milk. Breastmilk jaundice has a later onset, as late as the fifth day, and may last several weeks. Some authorities advocate temporary cessation of breastfeeding, which causes a rapid decline in bilirubin levels. However, this action is usually unnecessary and is not used as a diagnostic maneuver. Bilirubin levels tend to rise slightly after breastfeeding is resumed but do not return to the same high level (Hayes, 2000).
The first line of treatment after increasing number of feeds is phototherapy, which uses a special artificial blue light to alter bilirubin so it may be excreted in the urine and stool (AAP, 2004; Augustine, 1999). A low serum albumin level of less than 3.0 g/dL is considered a factor in deciding when to initiate phototherapy (AAP, 2004). Regular sunlight does not lower bilirubin as rapidly, exposes the infant to potential sunburn, and is not recommended. Fiberoptic pads may be used alone for the infant with mild jaundice or in addition to overhead phototherapy for the infants with higher bilirubin levels. These pads allow the infant to be held and fed more readily without interruption of therapy and with less risk of temperature instability. Fiberoptic pads may be used in home management of an infant with a mild degree of jaundice with in-home nursing visits and serum bilirubin monitoring.
Traditional overhead phototherapy placed within 15-20 cm of infant has been found to decrease the bilirubin level 1-2 mg/dl in the first 4-6 hours with continued decreases (AAP, 2004; Hayes, 2000) (see Table 4 for guidelines). When bilirubin levels are steadily decreasing, < 14 mg/dl, and feeding is well established, phototherapy may be discontinued.
With both types of phototherapy, the nurse monitors temperature stability, skin integrity, and fluid and weight loss. The newborn's eyes and genitals are protected from the light. Specially designed eye patches are made just for this purpose. As of this writing, no research studies address coverage of infant genitalia, but it has long been standard practice to cover the genitals with a modified diaper or mask. Staff monitor for signs of eye irritation. Infants with severe cholestatic jaundice are monitored for purpura and bullous eruptions while receiving phototherapy (AAP, 2004).
Pharmacologic treatment. Medication for jaundice is rarely used. Phenobarbital has been shown to decrease bilirubin levels by increasing excretion by the liver (Hayes, 2000). This therapy is not routinely used for newborns with direct hyperbilirubinemia as it must be administered over as many as 6 days; however, it is useful in children with Crigler-Najjar syndrome type II (Berkowtiz, 1996; Hayes, 2000).
The use of agar, tin protoporphyrin, zinc or tin mesoporphyrin and herbal products continues to be researched. Tin mesoporphyrin, inhibits the production of heme oxygenase and, when approved by the U.S. Food and Drug Administration, could prevent the need for exchange transfusion in infants who are not responding to phototherapy (AAP, 2004).
Infants with isoimmune hemolytic disease may benefit from intravenous-globulin (0.5-1 g/kg over 2 hours) if the total serum bilirubin is rising despite intensive phototherapy or approaching the need for exchange transfusion (AAP, 2004). Intravenous-globulin has been shown to reduce the need for exchange transfusions in Rh and ABO hemolytic disease. Monitoring and treatment of sepsis is essential to resolving hyperbilirubinemia as quickly as possible.
Exchange transfusion. Exchange transfusion is seldom used but is indicated when bilirubin levels reach 25-30 mg/dl and to correct anemia in infants severely affected by hemolytic process. Exchange transfusion is considered at lower levels in infants with hemolytic disease, sepsis, prior hypoxia, hypoglycemia, prematurity, and infants who do not respond to intensive phototherapy or have a rapid rise in bilirubin (AAP, 2004; Hayes, 2000). Immediate exchange transfusion is recommended in any infant who is jaundiced with signs of the acute bilirubin encephalopathy including hypertonia, arching, retrocollis and opisthotonos (head and heels drawn back), fever, and high-pitched cry--even if the bilirubin is decreasing (AAP, 2004) (see Table 4).
Exchange transfusion lowers bilirubin by nearly 50% but also has risks. Infants receiving exchange transfusion are given fresh blood that is irradiated to lower the risk of graft versus host reaction (signs: maculopapular rash, eosinophilia, leukopenia, thrombocytopenia), and hyperkalemia. Citrate in the blood may cause disturbance in calcium and magnesium levels and acidosis. Rebound hypoglycemia is also a risk that occurs 1-2 hours post transfusion. Lastly, hypothermia, hemodynamic instability, sepsis, thrombosis, necrotizing enterocolitis, bleeding, and HIV are risks of exchange transfusion (AAP, 2004).
Nurses are aware that confirmation of capillary bilirubin by venous sampling is not necessary and should not delay treatment of jaundice (AAP, 2004). The first line of treatment for most infants with jaundice requiring intervention is phototherapy. The infant receiving phototherapy requires extra attention and care to the placement of lights to be therapeutic yet prevent chilling or burning the infant. Some infants may also benefit from a fiberoptic pad underneath them, especially in the breastfed infant who is encouraged to feed 8-12 times in 24 hours. Supplements are not normally needed and are discouraged as they interfere with breastfeeding. Infants in incubators may not receive the full benefit of phototherapy. Light irradiance should be measured and maintained according to hospital policy and an average reading from several areas above the infant recorded.
Nurses carefully document intake and output. Diapers of preterm or high-risk infants are weighed. All infants should be weighed unclothed daily, preferably on the same scale. Infants may develop skin breakdown when diapers are not used and become chilled if left on wet sheets. Therefore, linens should be changed frequently, ideally with each void.
Nursing assessment includes evidence of birth trauma, head size and presence of cephalohematoma, tachypnea, dyspnea, enlarged liver, lethargy, irritability, feeding and stooling, sleep patterns, and interaction with family. These observations are communicated with the nurse practitioners and physicians caring for these infants, as well as other nursing staff, to improve quality and continuity of care.
Serum bilirubin levels above 25 mg/dL or higher at any time is a medical emergency and the infant should be evaluated immediately for exchange transfusion (AAP, 2004) (see Table 4). Infants receiving exchange transfusions receive individualized care in neonatal intensive care as the procedure is very time consuming and the infant needs close monitoring. Infants returning to the hospital after discharge with jaundice should not be detained in the emergency department as treatment may be delayed (AAP, 2004).
Patient Education and Counseling
Families of newborns with jaundice need to be included in and well informed of the plan of care. They may feel inadequate and guilty especially if the infant requires prolonged hospitalization. Frequent breastfeeding 8-12 times or more in 24 hours is encouraged and supported by the nurse and through the use of staff trained in lactation. Families are taught that additional supplementation with water or formula is not necessary for the healthy infant and may interfere with breastfeeding. Parent education includes use of a breast pump and milk storage if the mother is discharged before her infant, which is helpful for mothers anticipating return to work after the postpartum period. A contact person for lactation information and evaluation is made readily available.
Home health services that feature extensive education and daily visits may be used for home phototherapy for low risk selected infants. Parents should be discouraged from placing their infant in sunlight as it may cause chilling and unnecessary eye and skin exposure. Lastly, parents should be instructed to avoid using herbal remedies for their newborn infant (see Table 5 for a parent-information handout, which is available in English, Spanish, Chinese, and Italian at www.aap.org/family/jaundice faq.htm).
Newborns with hyperbilirubinemia need close observation and follow up. Hospital readmission may be necessary to manage complications and for closer observation of newborns that are poor feeders, have lost significant weight, or have signs of dehydration or bilirubin encephalopathy. Infants with serum bilirubin levels >5 mg/dl in the first 24 hours of life and older infants with levels >12-14 mg/dl need close lab monitoring and thorough evaluation (AAP, 2004; Hayes, 2000).
Recommendations for follow up vary according to length of hospital stay and presence/severity of jaundice. Clinical evaluation of all newborn infants 48-120 hours after discharge and again at 2-4 weeks after birth is recommended. Infants who received phototherapy in the hospital or are receiving home phototherapy should be followed 24 hours after discharge (AAP, 2004; Hayes, 2000; Maisels & Kring, 2002). Direct bilirubin levels are checked daily in newborns with significant jaundice; the frequency of laboratory studies is left to the discretion of the provider.
Alexander, D.C., & Robin, B. (2000). Neonatology: Unconjugated hyperbilirubinemia in the newborn. In G.K. Sieberry, & R. Iannone (Eds.), The Harriet Lane handbook (15th ed.). St. Louis: Mosby, Inc.
American Academy of Pediatrics (AAP). (2004). Practice Parameter: Management of hyperbilirubinemia in the healthy term newborn. Pediatrics, 94(4), 558-565. Retrieved March 16, 2006, from http://aappolicy.aappub lications.org/cgi/reprint/pedi atrics;94/4/558.pdf
Augustine, M.C. (1999). Hyperbilirubinemia in the healthy term newborn. The Nurse Practitioner, 24(4), 24-41.
Berkowitz, C.D. (2000). Pediatrics: A primary care approach (2nd ed.). Philadelphia: W.B. Saunders Company.
Gomella, T.L., Cunningham, M.D., Eyal, F.G., & Zenk, K.E. (1999). Neonatology (4th ed.). New York: Lange Medical Books/McGraw Hill.
Greenberg, D.A. (2002). The jaundice of the cell. Proceedings of the National Academy of Sciences, 99(5), 15837-15839.
Harris, M.C., Bernbaum, J.C., Polin, J.R., Zimmerman, R., & Polin, R.A. (2001). Developmental follow-up of breastfed term and near term infants with marked hyperbilirubinemia. Pediatrics, 107(5), 1075-87.
Hayes, G. (2000). The jaundiced newborn: Minimizing the risks. Patient Care, 34(2), 45-56.
Maisels, M.J., & Kring, E. (2002). Rebound in serum bilirubin levels following intensive phototherapy. Archives of Pediatric Adolescent Medicine, 156, 669-672.
Moyer, V.A., Ahn, C., & Snead, S. (2000). Accuracy in clinical judgment in neonatal jaundice. Archives of Pediatric Adolescent Medicine, 154, 391-394.
Pagana, K.D., & Pagana, T.J. (2002). Mosby's diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby-Year Book, Inc.
Parks, D.K., Montgomery, D., & Yetman, R.J. (2000). Perinatal conditions: Jaundice. In C.E. Burns, M.A. Brady, A.M. Dunn, & N.B. Starr (Eds.), Pediatric primary care. (2nd ed.) (pp. 1172-1216). Philadelphia: W.B. Saunders Company.
Schwoebel, A., & Sakraida, S. (1997). Hyperbilirubinemia: New approaches to an old problem. Journal of Perinatal and Neonatal Nursing, 11(3), 78-102.
Stanley, I.P., Chung, M., Kulig, J., O'Brien, R., Sage, R., Glicken, S., et al. (2004). An evidence based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics, 114(1), 130-153.
Shannon Munro Cohen, MSN, APRN, BC, FNP-C, is Family Nurse Practitioner, Department of Veterans Affairs Medical Center, Salem, VA.
Table 1. Assessment of Risk Factors of Jaundice and Non-Physiologic Causes of Jaundice Factors suggesting pathologic Risk factors for jaundice cause of jaundice * Jaundice in first 24 hours * Sibling with jaundice in of life newborn period * Total serum bilirubin * Prematurity, perinatal rising more than 5 mg/dl/24h depression-decreased Apgar score at 5 minutes * Total serum bilirubin >15 * Inadequate or ineffective mg/dl in full-term infant breast-feeding * Jaundice persisting after * Significant weight loss first week of life after birth * Direct reacting bilirubin * Maternal diabetes >1 mg/dl at any time * Family history of hemolytic * Race (Asian, Native disease American) * Pallor, hepatomegaly, * Drug exposure-oxytocin, splenomegaly sulfonamides, aspirin * Failure of phototherapy to * Altitude lower bilirubin * Polycythemia * Excessive weight loss * Blood group incompatibility, known hemolytic disease G6PD deficiency * Male gender * Bruising, cephalohematoma * Delayed stooling * Trisomy 21 * Early discharge with inadequate follow up and poor feeding * Jaundice observed within first 24 hours of life Note: Adapted from American Academy of Pediatrics. (2004); Augustine, M.C. (1999); Hayes, G. (2000); Parks, D.K., Montgomery, D., & Yetman, R.J. (2000). Table 2. Differential Diagnosis Jaundice appearing at birth or within 24 hours: sepsis, Erythroblastosis retails, concealed hemorrhage, cytomegalic inclusion disease, rubella, congenital toxoplasmosis. Jaundice appearing on the 2nd or 3rd day: physiologic, Hyperbilirubinemia of the newborn (severe form of jaundice), Crigler-Najjar syndrome (familial nonhemolytic icterus). Jaundice appearing after the 3rd day, within the 1st week: septicemia, syphilis, toxoplasmosis, cytomegalic inclusion disease. Other causes of early jaundice: intrauterine transfusions, extensive ecchymosis or hematomas, polycythemia. Jaundice appearing after the 1st week: breast milk jaundice, septicemia, congenital atresia of the bile ducts, hepatitis, rubella, herpetic hepatitis, galactosemia, hypothyroidism, spherocytosis (congenital hemolytic anemia), other hemolytic anemias (G6PD deficiency, glutathione synthetase, reductase, peroxidase, pyruvate kinase deficiencies). Jaundice persisting during the 1st month: inspissated bile syndrome, hyperalimentation associated cholestasis, hepatitis, cytomegalic inclusion disease, syphilis, toxoplasmosis, familial nonhemolytic icterus, congenital atresia of bile ducts, galactosemia, rarely physiologic jaundice, pyloric stenosis, hypothyroidism. Note: Adapted from the American Academy of Pediatrics (2004); Parks, Montgomery, & Yetman (2000). Table 3. Conjugated Versus Unconjugated Hyperbilirubinemia "Free" or Unconjugated Conjugated Hyerbilirubinemia Hyperbilirubinemia (elevated indirect level) (elevated direct level) * Physiologic jaundice * Sepsis * Polycythemia from delayed cord * Hepatitis clamping, cord stripping toward * Syphilis infant, twin to twin transfusion * TORCH * Rh or ABO incompatibility * Coxsackie B virus * Congenital hypothyroidism * Inborn errors of metabolism * High intestinal obstruction * Hyperalimentation * Pyloric stenosis * Cystic fibrosis * Duodenal atresia * Meconium ileus * Breast milk jaundice * Biliary atresia * G6PD * Rifampin, erythromycin, * Alpha thalassemia tetracycline * Excessive bruising from birth trauma, or cephalohematoma * Starvation/poor feeding Note: Adapted from the American Academy of Pediatrics (2004); Augustine (1999); Hayes (2000); Parks, Montgomery, & Yetman (2000). Table 4. Management of Hyperbilirubinemia in the Healthy Term Newborn Age, hours Total serum bilirubin (TSB) Level Phototherapy <=24hours Low risk >7 Moderate risk >5 25-48 Low risk>12 Moderate risk>10 49-72 Low risk>15 Moderate risk >12 >72 Low risk>18 Moderate risk >15 Exchange Transfusion if Intensive Phototherapy Fails <=24hours 19 25-48 [greater than or equal to] 20 49-72 [greater than or equal to] 22 >72 [greater than or equal to] 24 Low risk defined as 38 weeks gestation and well Moderate risk 38 weeks plus risk factor or 35-37 6/7 week and well * Intensive phototherapy should produce a decline of TSB of 1 to 2 mg/dL with-in 4 to 6 hours and the TSB level should continue to fall and remain below the threshold level for exchange transfusion. If this does not occur, it is considered a failure of phototherapy. * Term infants who are clinically jaundiced at <=24 hours old are not considered healthy and require further evaluation. * Preterm infants should receive exchange transfusion when level reaches infant's weight ie: 11 mg/dl in 1100-g infant (Berkowitz, 2000). Note: Adapted from the American Academy of Pediatrics (2004). Table 5. Question and Answers: Jaundice and Your Newborn (Posted: June 25, 2004) The following Frequently Asked Questions (FAQs) are from the American Academy of Pediatrics (AAP). Feel free to excerpt these FAQs or use them in their entirety for distribution to your families. Please attribute these FAQs to the American Academy of Pediatrics. Congratulations on the birth of your new baby! To make sure your baby's first week is safe and healthy, it is important that: 1. Your baby is checked for jaundice in the hospital. 2. If you are breastfeeding, you get the help you need to make sure it is going well. 3. Your baby is seen by a doctor or nurse at 3 to 5 days of age. Q: What is jaundice? A: Jaundice is the yellow color seen in the skin of many newborns. It happens when a chemical called bilirubin builds up in the baby's blood. Jaundice can occur in babies of any race or color. Q: Why is jaundice common in newborns? A: Everyone's blood contains bilirubin, which is removed by the liver. Before birth, the mother's liver does this for the baby. Most babies develop jaundice in the first few days after birth because it takes a few days for the baby's liver to get better at removing bilirubin. Q: How can I tell if my baby is jaundiced? A: The skin of a baby with jaundice usually appears yellow. The best way to see jaundice is in good light, such as daylight or under fluorescent lights. Jaundice usually appears first in the face and then moves to the chest, abdomen, arms, and legs as the bilirubin level increases. The whites of the eyes may also be yellow. Jaundice may be harder to see in babies with darker skin color. Q: Can jaundice hurt my baby? A: Most infants have mild jaundice that is harmless, but in unusual situations the bilirubin level can get very high and might cause brain damage. This is why newborns should be checked carefully for jaundice and treated to prevent a high bilirubin level. Q: How should my baby be checked for jaundice? A: If your baby looks jaundiced in the first few days after birth, your baby's doctor or nurse may use a skin test or blood test to check your baby's bilirubin level. A bilirubin level is always needed if jaundice develops before the baby is 24 hours old. Whether a test is needed after that depends on the baby's age, the amount of jaundice, and whether the baby has other factors that make jaundice more likely or harder to see. Q: Does breastfeeding affect jaundice? A: Jaundice is more common in babies who are breastfed than babies who are formula-fed, but this occurs mainly in infants who are not nursing well. If you are breastfeeding, you should nurse your baby at least 8 to 12 times a day for the first few days. This will help you produce enough milk and will help to keep the baby's bilirubin level down. If you are having trouble breastfeeding, ask your baby's doctor or nurse or a lactation specialist for help. Breast milk is the ideal food for your baby. Q: When should my newborn get checked after leaving the hospital? A: It is important for your baby to be seen by a nurse or doctor when the baby is between 3 and 5 days old, because this is usually when a baby's bilirubin level is highest. The timing of this visit may vary depending on your baby's age when released from the hospital and other factors. Q: Which babies require more attention for jaundice? A: Some babies have a greater risk for high levels of bilirubin and may need to be seen sooner after discharge from the hospital. Ask your doctor about an early follow-up visit if your baby has any of the following: * A high bilirubin level before leaving the hospital * Early birth (more than 2 weeks before the due date) * Jaundice in the first 24 hours after birth * Breastfeeding that is not going well * A lot of bruising or bleeding under the scalp related to labor and delivery * A parent or brother or sister who had high bilirubin and received light therapy Q: When should I call my baby's doctor? A: Call your baby's doctor if: * Your baby's skin turns more yellow. * Your baby's abdomen, arms, or legs are yellow. * The whites of your baby's eyes are yellow. * Your baby is jaundiced and is hard to wake, fussy, or not nursing or taking formula well. Q: How is harmful jaundice prevented? A: Most jaundice requires no treatment. When treatment is necessary, placing your baby under special lights while he or she is undressed will lower the bilirubin level. Depending on your baby's bilirubin level, this can be done in the hospital or at home. Jaundice is treated at levels that are much lower than those at which brain damage is a concern. Treatment can prevent the harmful effects of jaundice. Putting your baby in sunlight is not recommended as a safe way of treating jaundice. Exposing your baby to sunlight might help lower the bilirubin level, but this will only work if the baby is completely undressed. This cannot be done safely inside your home because your baby will get cold, and newborns should never be put in direct sunlight outside because they might get sunburned. Q: When does jaundice go away? A: In breastfed infants, jaundice often lasts for more than 2 to 3 weeks. In formula-fed infants, most jaundice goes away by 2 weeks. If your baby is jaundiced for more than 3 weeks, see your baby's doctor. Note: Available in English, Spanish, Chinese, and Italian at www.aap.org/family/jaundicefaq.htm
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|Author:||Cohen, Shannon Munro|
|Date:||May 1, 2006|
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