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Neonatal Jaundice

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Melissa RL

on 5 June 2014

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Transcript of Neonatal Jaundice

Types
Nonpathologic:
- Physiologic
- Breastfeeding
- Human Milk (aka breast milk)
- Prematurity
Food for thought
- A new therapy currently under development consists of inhibition of bilirubin production through blockage of heme oxygenase

- Bilirubin has more antioxidant capability than vitamin E (role as a free radical quencher!)

- The future may hold some different assessments and interventions with the increasing understanding of gene polymorphisms and higher prevalence of genetic screening

- There is currently some debate on long term use/effect of phototherapy (skin cancer)

- Phototherapy at home is now done at CSSS Pierre-Boucher since 2009 is going well (OIIQ)
Treatments
Risk &
Epidemiology
Causes
Neonatal Jaundice
Pathophysiology
Nursing Process:
Assessment & Evaluation
Look at:
- skin color, conjunctiva and buccal mucosa - not very reliable!
- transcutaneous bilirubinometry (TcB)
- blood test to evaluate TSB


If jaundice persists:
Fam Hx
- Previous sibling w jaund, ESP if required Tx
- Other family members with jaundice
- Known family history of Gilbert syndrome
- Anemia, splenectomy, or bile stones in family
- Known heredity for hemolytic disorders
- Liver disease

Hx of pregnancy and delivery
- Maternal illness (viral or other infection)
- Maternal drug intake
- Delayed cord clamping
- Birth trauma with bruising and/or fractures

Postnatal Hx
- Loss of stool color
- Breastfeeding
- Greater than average weight loss
- Hypothyroidism Sx
- Metabolic disease Sx (e.g. galactosemia)
-infant's weight curve evaluation

*
Red Flags
(in a significantly jaundiced infant)
- changes in muscle tone
- seizures
- altered cry characteristics
- decreased activity
- lethargy
- irritability
*
require immediate attention to prevent kernicterus
*

- hepatosplenomegaly
- petechiae
- microcephaly
Nursing Process:
Diagnosis
Nursing Process:
Plan & Implement
- discuss collaboratively with parents suggested interventions
- encourage & help with breastfeeding
- phototherapy
- increase feedings (peristalsis & bacteria)
- breast milk jaundice: supplement feeds of breast milk with 5 mL of a breast milk substitute reduces level and duration
- explain exchange transfusion
- administer phenobarbital
- assess risk before discharge!
- teach neurotoxicity signs
References
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316.
Bhutani, V. K., Johnson, L., & Sivieri, E. M. (1999). Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics, 103(1), 6-14.
Carpenito-Moyet, Lynda Juall. (2013). Handbook of nursing diagnosis (14th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Casey, G. (2013). Jaundice: an excess of bilirubin. Nurs N Z, 19(1), 20-24.
Ford, K. L. (2010). Detecting neonatal jaundice. Community Pract, 83(8), 40-42.
Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks' gestation) - Summary. (2007). Paediatr Child Health, 12(5), 401-418.
Hansen, T. U. (2014). Neonatal Jaundice. Medscape. New York: WebMD. Retrieved from http://emedicine.medscape.com/article/974786-overview.
Hervé Puy, M. D., Laurent Gouya, M. D., & Jean-Charles Deybach, M. D. Lancet Seminar: Porphyrias.
Lauer, B. J., & Spector, N. D. (2011). Hyperbilirubinemia in the newborn. Pediatr Rev, 32(8), 341-349. doi: 10.1542/pir.32-8-341
Linn, S., Schoenbaum, S. C., Monson, R. R., Rosner, B., Stubblefield, P. G., & Ryan, K. J. (1985). Epidemiology of neonatal hyperbilirubinemia. Pediatrics,75(4), 770-774.
Lomax, A. (2011). Examination of the Newborn: An Evidence Based Guide. John Wiley and Sons.
Newman, T. B., Easterling, M. J., Goldman, E. S., & Stevenson, D. K. (1990). Laboratory Evaluation of Jaundice in NewbornsFrequency, Cost, and Yield.American Journal of Diseases of Children, 144(3), 364-368.
Ottinger, D. (2013). Bronze baby syndrome. Neonatal Netw, 32(3), 200-202. doi: 10.1891/0730-0832.32.3.200
Perry, Shannon E, Hockenberry, Marilyn J, Lowdermilk, Deitra Leonard, & Wilson, David. (2013). Maternal child nursing care: Elsevier Health Sciences.
Preer, G. L., & Philipp, B. L. (2011). Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed, 96(6), F461-466. doi: 10.1136/adc.2010.184416
Stevenson, D., Maisels, M. J., & Watchko, J. (2012). Care of the Jaundiced Neonate. McGraw Hill Professional.
Watson, R. L. (2009). Hyperbilirubinemia. Crit Care Nurs Clin North Am, 21(1), 97-120, vii. doi: 10.1016/j.ccell.2008.11.001
http://www.oiiq.org/lordre/dossiers-strategiques/ordonnances-collectives/ictere-chez-le-nouveau-ne

Images
http://www.wallsave.com/wallpaper/1024x768/wwe-divas-maggie-simpson-v-41282.html
http://www.soliris.com.au/images/ThreeRBCs.jpg
http://www.ebi.ac.uk/biomodels-main/static-pages.do?page=ModelMonth%2F2012-10
http://misc.medscape.com/pi/iphone/medscapeapp/html/A178841-business.html
http://upload.wikimedia.org/wikipedia/commons/d/d9/Heme_Breakdown.png
http://intranet.tdmu.edu.ua/data/kafedra/internal/patologanatom/classes_stud/en/med/lik/ptn/Pathomorphology/3/15_Prenatal%20and%20perinatal%20pathology.htm
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/22694.jpg
http://upload.wikimedia.org/wikipedia/en/c/cd/Jaundice-types.png
http://www.flaticon.com/png/256/43223.png
http://gaby.fachrul.com/img/pregnacytreatment/pregnancy-fitness/free-stock-photo-illustration-of-a-pregnant-woman-silhouette400-x-702-27-kb-png-x.jpg
http://www.clker.com/cliparts/x/q/F/j/z/y/family-tree-3-generation-hi.png

75% of bilirubin is derived from hemoglobin (25% myoglobin, cytochromes, and catalase)
Jaundice is the most common condition in newborn that requires medical intervention.

At the international level, the incidence is higher in East Asians, American Indians, Greeks islanders, higher altitude areas and developing countries, and is lower in Africans (lower TSB levels).

Newborns with certain genetic polymorphisms are at 3-22 times more likely to get jaundiced (e.g. UGT1A1 and OATP2)

Mortality/Morbidity: Death from kernicterus may occur, esp. in countries with less developed medical care systems. Nigeria with many babies with G-6-PD deficiency = 11% died vs 1/100 000 in Europe & North America

Sex: risk is higher in male infants

Age: risk is inversely proportional to gestational age
jaundice = hyperbilirubinemia = icterus
American Academy of Pediatrics 2004
* Provide information and written guidelines about jaundice to all parents
* Provide information and written guidelines about jaundice to all parents
Differential Diagnoses:
Biliary Atresia (blockage or absence of common bile duct between liver and small intestine)
Cholestasis (bile cannot flow from liver to duodenum)
Cytomegalovirus Infection (viral infection)
Dubin-Johnson Syndrome (defect in the ability of hepatocytes to secrete conjugated bilirubin into the bile)
Duodenal Atresia (first part of the small bowel cannot allow the passage of stomach contents)
Galactose-1-Phosphate Uridyltransferase Deficiency (Galactosemia; body is unable to metabolize galactose)
Hemolytic Disease of Newborn (ABO or Rh incompatibility)
Hepatitis B (liver inflammation due to HBV infection)
Hypothyroidism (underactive thyroid)
Pathological jaundice = bili levels that can lead to:
- hearing loss
- mild cognitive delays
- kernicterus (brain bilirubin deposits)
- cerebral palsy
- ADHD
- ataxia
- athetosis
- behavioral problems
Contraindications & Complications

Phototherapy:

- hepatocellular disease + elevated conjugated bili = potential
bronze infant syndrome

(dark, grayish-brown skin, serum, and urine)
-
congenital porphyria
(or family Hx): severe blistering and photosensitivity

Exchange transfusion:
complication rate = 12%
- infection
- portal venous thrombosis
- thrombocytopenia (decreased platelet levels)
- necrotizing enterocolitis (bowel necrosis)
- electrolyte imbalances
- graft versus host disease
- death
ibuprofen too!
Pathologic:
- Unconjugated Hyperblirubinemia
increased bili production
deficient hepatic uptake
impaired bili conjugation
increased enterohepatic circulation
- Conjugated Hyperbilirubinemia
>10-20 % of TSB is conjugated bili
UTI
sepsis
cholestasis
biliary atresia
thyroid abnormalities
galactosemia
- Kernicterus
BBB crossing of bili
Key points in
phototherapy
:
-
naked
except for diapers
-
eyes
covered to reduce retinal damage
- distance between the infant's
skin
and the light source
- cover inside of the bassinet with
reflecting
material
- hang a
white curtain
around the phototherapy unit and bassinet
- when using spotlights, infant
placed at center
of circle of light
-
observe
the infant
movements
closely (especially for preterm)
- monitor
temperature
(fluid)
- monitor for
weight
loss, urine
- adjust
fluid intake
accordingly: preferred fluid is
milk
- timing of
follow-up
serum bilirubin testing must be individualized
-
extreme
serum bilirubin values (
>500 µmol/L
) = monitoring
every hour
-
moderate
TSB = monitoring every
6-12 hours
-
discontinue
phototherapy TSB
< 25-50 µmol/L phototherapy level

Key points in
exchange transfusion
:
- replace infant’s blood volume
twice
-
albumin

infusion
1-4 hours before procedure can help
- IV
gamma globulin
can be done at the same time
+ CO
+ CO ------------------> eliminated
by lungs
Infant with acute advanced bilirubin encephalopathy (post-exchange transfusion). Note the classic facies, hypertonia with retrocollis, opisthotonus, and cephalohematoma.
48h in Canada
Full transcript