Case presentation

(hyperbilirubinemia) WMCC NICCU

C.I : Jo-ann Tubog R.N Student : Bonn Eljay F.Paas

What is hyperbilirubinemia?
Neonatal hyperbilirubinemia is the diagnosis given to newborns that have too much bilirubin in their systems. Bilirubin is produced in the body when red blood cells break down. Neonates are not easilyable to get rid of bilirubin and it can build up in the blood and other tissues and fluids of the babys body before birth the placenta ( the organ that nourishes the developing baby ) removes the bilirubin from the infant so that it can be processed by the mothers liver. The common sign of neonatal hyperbilirubinemia is yellowing of the skin and eyes. This yellowing is called jaundice. The term "jaundice" is used broadly by many outside of the medical community for the condition neonatal hyperbilirubinemia. A degree of jaundice is normal to newborn babies. This condition is fairly common in preterm babies.

Causes
Neonatal hyperbilirubinemia is often a direct result of a newborn's body not being able to excrete, or get rid of, the bilirubin as fast as needed after birth. Some newborns develop what is called breast milk jaundice. This is also hyperbilirubinemia, yet it appears after a baby is over a week old. It can occur when an infant isn't consuming enough calories or is dehydrated. A baby that is born with an infection and/or liver problems may also have or develop hyperbilirubinemia. Main cause of physiologic jaundice according to research is the trauma during labor and delivery.

Signs and symptoms

Signs and symptoms of infant jaundice usually appears between the second or fourth day of life and includes yellowing of the eyes, yellowing of the skin. Skin yellowing usually begins on a newborn's face and then travels to the chest, belly area, legs and soles of the feet. The yellow color is best seen right after gently pressing a finger onto the skin. They are too sleepy and they are difficult to arouse- either they dont wake up from sleepy easily like normal baby, or they dont wake up fully, or they cant be kept awake. They have a high pitched cry, and decreased muscle tone, becoming hypotonic or floppy. With episodes of increased muscle tone, develop fever, may arch their heads back into very controlled position known as OPISTHOTONUS or RETROCOLLIS. Babies who have neonatal hyperbilirubinemia may also seem sluggish, projectile vomiting, increase moro startle reflex(CNS), term 5-10ml/dl preterm 10-15ml/dl. They may also have trouble eating regardless if they are bottle- or breastfed.

Diagnostic exams
Your doctor will likely diagnose infant jaundice on the basis of your baby's appearance. However, it's not possible to judge the severity of jaundice based on appearance alone. Your doctor will need to measure the level of bilirubin in your baby's blood. The level of bilirubin (severity of jaundice) will determine the course of treatment.

Tests to determine jaundice include: A physical exam A laboratory test of a sample of your baby's blood :complete blood count :coombs test :reticulocyte count A skin test with a device called a transcutaneous bilirubinometer, which measures the reflection of a special light shone through the skin

Concerns
If large amounts of bilirubin go to the brain, it can lead to seizures and/or brain damage. This is called kernicterus. Identifying neonatal hyperbilirubinemia is vital. While most cases of neonatal hyperbilirubinemia are identified in a hospital setting, women who have their babies at home should have their newborns checked by a pediatrician the day of birth.

Unconjugated bilirubin
bilirubin that has not been conjugated in the liver. It gives an indirect reaction to the van den bergh test. A high level of it in the blood is indicative of hemolysis or a lack of bilirubin clearance by the liver. Called also free bilirubin. (indirect reacting) binds to albumin in the blood for transport to the liver, where it is taken up by hepatocytes and conjugated with glucuronic acid by the enzyme uridine diphosphogluconurate glucuronosyltransferase (to convert id db..UGT) to make it water soluble . the conjugated bilirubin(direct reacting) is excreted in bile into the duodenum. Neonates have sterile digestive tracts. They do have the enzyme B-glucuronidase (an enzyme that will deconjugate that is found in the intestine of the newborn) which deconjugates the conjugated bilirubin. Which is thne reabsorbed by the intestines and recycled into the circulation. This is called enterohepatic circulation of bilirubin.

Physiologic jaundice
Physiologic jaundice affects nearly all newborns to some degree. It is more prevalent in certain ethnic groups, such as Chinese, Japanese, Korean, Hispanic, and Native Americans. If you define jaundice as bilirubin levels of greater than 10mg/dl, one study found that Japanese newborns were more than three times as likely to be jaundiced as white newborns. Babies who are premature or are low birth weight are more likely to become jaundiced. Babies who dont feed often enough during the early days, and who dont stool often, are also more likely to become jaundiced. This underscores the importance of early, frequent feedings. Colostrum (the sticky yellow fluid produced before the milk comes in) acts as a laxative. Bilirubin accumulates in the babys stools, and if it isnt excreted, it re-circulates in his system. Frequent stooling helps lower bilirubin levels.

In the baby with physiologic jaundice, bilirubin levels will usually peak between the third and fifth days of life and are usually less than 12mg/dl. Occasionally they will go higher than 15mg/dl. Most doctors will monitor levels closely during this time, checking the babys levels with a blood test, pricking his heel, toe, or finger. If the levels are rapidly rising, or are 20mg/dl or higher (lower levels are used with premature infants), phototherapy is often suggested. This is a treatment which involves exposing skin to blue range light which breaks down the bilirubin and makes it more easy for the baby to excrete. Years ago, nurses noticed that babies who were in cribs near sunny windows had lower bilirubin levels than other babies in the nursery. Researchers then found that phototherapy can make bilirubin levels drop quickly. Until the past few years, babies with high bilirubin levels had to be in the hospital for phototherapy treatments now, with new technology, babies can receive phototherapy at home using bili-blankets, provided by home health care providers. In most cases, bilirubin levels drop rapidly after phototherapy is initiated, and once the levels begin to go down, they almost always continue to decline. Usually only a day or two or therapy is needed.

Breastfeeding jaundice
Is a type of exaggerated physiological jaundice seen in breastfed infants in the 1st week of life, especially in those that are not nursing often enough. Breast feeding increase enterohepatic hepatic circulation of bilirubin in some infants who have decreased milk intake and who also have dehydration or low caloric intake. The increased enterohepatic circulation also may result from reduced intestinal bacteria that convert bilirubin non resorbed matabolities

Breastmilk jaundice
Breast milk jaundice is long-term jaundice in an otherwise healthy, breast-fed baby. It develops after the first week of life and continues up to the sixth week of life. Bilirubin is a yellow pigment that is created as the body gets rid of old red blood cells. The liver helps break down bilirubin so that it can be removed from the body in the stool. If jaundice occurs or lasts past the first week of life in an otherwise healthy and thriving breast-fed infant, the condition may be called "breast milk jaundice." It is probably caused by factors in the breast milk that block certain proteins in the liver that break down bilirubin, and it is thought to be caused by an increased concentration of B-glucuronidase in breastmilk. Causing an increase in the decinjugation and reabsorption of bilirubin in the intestines. Breast milk jaundice tends to run in families. It occurs equally often in males and females and affects 0.5% to 2.4% of all newborns. Change to formula milk .theres a pregnanediol In mothers milk.

Pathologic hyperbilirubinemia
In order to understand jaundice, it is useful to know about the role of the liver in producing bile. The most important function of the liver is the processing of chemical waste products like cholesterol and excreting them into the intestines as bile. The liver is the premier chemical factory in the bodymost incoming and outgoing chemicals

pass through it. It is the first stop for all nutrients, toxins, and drugs absorbed by the digestive tract. The liver also collects chemicals from the blood for processing. Many of these outward-bound chemicals are excreted into the bile. One particular substance, bilirubin, is yellow. Bilirubin is a product of the breakdown of hemoglobin, which is the protein inside red blood cells. If bilirubin cannot leave the body, it accumulates and discolors other tissues. The normal total level of bilirubin in blood serum is between 0.2 mg/dL and 1.2 mg/dL. When it rises to 3 mg/dL or higher, the person's skin and the whites of the eyes become noticeably yellow. Bile is formed in the liver. It then passes into the network of hepatic bile ducts, which join to form a single tube. A branch of this tube carries bile to the gallbladder, where it is stored, concentrated, and released on a signal from the stomach. Food entering the stomach is the signal that stimulates the gallbladder to release the bile. The tube, which is called the common bile duct, continues to the intestines. Before the common bile duct reaches the intestines, it is joined by another duct from the pancreas. The bile and the pancreatic juice enter the intestine through a valve called the ampulla of Vater. After entering the intestine, the bile and pancreatic secretions together help in the process of digestion.

Treatment
Treatment will depend on: Your baby's bilirubin level, which naturally rises during the first week of life How fast the bilirubin level has been going up Whether your baby was born early How old your baby is now Often, the bilirubin level is low (20 mg/dL is the usual normal limit for babies who are over a week old). Sometimes no treatment is needed, other than close follow-up. Sometimes jaundice is caused by not enough breastfeeding (instead of from the milk itself). Extra fluids are helpful for babies who have not been getting enough breast milk. Nursing more often (up to 12 times a day) will increase the baby's fluid levels and can cause the bilirubin level to drop. Ask your doctor before giving your newborn formula. It is still best to keep breastfeeding. At times, fluids given through a vein can help increase the baby's fluid level and lower bilirubin levels. To help break down the bilirubin, your child may be placed under special blue lights (phototherapy). If the bilirubin level is not too high or is not rising quickly, you can do phototherapy at home. You can use either a fiberoptic blanket that has tiny bright lights in it, or a bed that shines light up from the mattress. A nurse will come to your home to teach you how to use the blanket or bed, and to check on your child.

You must keep the light therapy on your child's skin and feed your child every 2 to 3 hours (10 to 12 times a day). Feeding prevents dehydration and helps bilirubin leave the body. Therapy will continue until your baby's bilirubin level is low enough to be safe. If the bilirubin level is above the usual limit and other causes have already been ruled out, the mother can stop nursing for 24 hours to see if the baby's bilirubin level goes down. Giving the baby formula will cause the bilirubin level to drop quickly in babies with breast milk jaundice. During that time the mother can express the milk or pump her breasts (to stay comfortable and maintain the flow of milk) while feeding the baby formula. In most cases, when nursing is restarted the bilirubin will not return to its previous levels.

Nursing diagnosis
Risk for ineffective airway clearance related o presence of oropharyngeal secretions Things to be done: Monitor vital signs Note for presence of secretions Keep infants mouth and nose clear from any obstruction Provide oxygen when needed as ordered by the doctor Perform suctioning when needed

y y y y y

Nursing diagnosis
Risk for aspiration related to immature cardiac esophageal sphincter y y y y y y y Assist infants breathing and feeding pattern Monitor vital signs, especially respiratory rate every 4hours report any deviations Check the mouth and nose for secretions Auscultate lungs for irregular breath sounds Slowly feed infants Asses infants skin color and activity Burp the infant between feedings

Nursing diagnosis
Risk for injury related to properties of phototherapy and effects on body regulatory mechanism y y y y Turn the baby every two hours to avoid burning Cover eyes and the genitals Always watch the baby Always check the babys condition.

Nursing Interventions
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.