Jaundice in the NICU

Sally Gibson

Purpose

To understand the physiological process which causes jaundice in the new-born

To enable staff to identify signs & symptoms of jaundice

To ensure staff understand the treatment/s for neonatal jaundice & risks of failing to treat it adequately

To enable staff to support parents of infants receiving treatment

What is Jaundice ?

One of most common conditions needing medical/nursing attention

in new-borns.

Yellow colouration of the skin & white

of the eyes

Caused by excess bilirubin in the blood.

Approx. 60% of term & 80% of preterm babies develop

jaundice in 1st week of life.

Approx. 10% of breastfed babies

remain jaundice at one month of age

Clinical recognition can be difficult in

babies with darker skin tones

High risk if jaundiced before 24 hrs of age

Physiology (the science bit)

Breakdown of

(foetal) red blood cells

Unconjugated bilirubin is a by-

product (binds to fat)

Bilirubin transported to

the liver

Bilirubin conjugated to make it water

soluble

Conjugated bilirubin excreted

into bile

Transferred to the intestines for

excretion

At Risk Infants

Low birth weight Preterm

Exclusively breast fed

Previous sibling with jaundice

Visible within first 24hrs

Mothers with rhesus negative

blood

Infection Excessive bruising

Combination of factors

increases the risk

Signs of Jaundice

Yellow shade to skin Yellow shade to

eyes & gums

Sleepy baby

Poor feeding

Seizures

Altered muscle tone

Dark urine

Fever

Why Does it Matter?

Kernicterus

At high levels

bilirubin passes

from the blood

into the brain

and causes

damage which

can cause

death or long

term problems

Treatment

Can we prevent jaundice?

Do we treat every jaundiced baby?

How do we decide what (if any) treatment is necessary?

Treatment

Low

• Ensure adequate hydration

• Frequent feeds – assess effectiveness of BF

• Exclude or treat other causes e.g. infection

Raised

• Commence phototherapy

• May be single or multiple depending on serum bilirubin level

High

• Exchange transfusion

• Consider immunoglobulin if haemolytic disease

How Does Phototherapy

Work?

Skin is exposed to blue/green light source

The light makes bilirubin soluble in water

It can then be excreted in urine

And is more easily dealt with by the liver

Phototherapy Devices

Fluorescent

Biliblanket

Bilibed

LED

Which

device?

Depends

on the

needs of

the baby &

level of

jaundice

Care of a Baby Receiving Phototherapy

Expose skin & protect eyes

Monitor bilirubin level

Ensure hydration

Maintain temperature

Side Effects of Phototherapy

Diarrhoea Skin rash/risk of

burn

Dehydration ‘Bronzing’ of

skin

Supporting Parents

Reassure

Encourage to touch

baby

Short cuddles

Why can’t I hold my

baby

http://bestpractice.bmj.com/best-

practice/pdf/patient-summaries/neonatal-

jaundice-standard.pdf

Prolonged Jaundice

‘Normal’ neonatal jaundice resolves within the first 2 weeks of life (term) or 3 weeks for preterm babies

Any baby remaining jaundiced after this time will require further investigations

Needs split bilirubin level to determine ratio of conjugated to unconjugated bilirubin

Phototherapy does not work on conjugated bilirubin

May need supportive treatment – vitamins & urso

Any questions?

References Dent J (2000) Hematological Problems In: Boxwell G. ED. Neonatal Intensive

Care. Cambridge, Cambridge University Press

Jones C (2014) Separating Fact from Fiction in the Not-So-Normal Newborn

Nursery: Newborn Jaundice. Online:

https://richarddawkins.net/2014/05/separating-fact-from-fiction-in-the-not-so-

normal-newborn-nursery-newborn-jaundice/ [accessed 22.6.17]

Juretschke LJ (2005) Kernicterus: still a concern. Neonatal Netw 24 (2): 7-19

Metherall J (2003) Phototherapy for neonatal hyperbilirubinaemia: delivering an

adequate dose. Journal of Neonatal Nursing 9(6): 182-186

National Institute for Clinical Excellence (NICE) (2010) Neonatal jaundice

www.nice.org.uk/guidance/CG98 (updated Oct 2016)

Shaw NM (2003) Assessment and management of hematologic dysfunction

Comparative Neonatal Nursing: a physiologic perspective (3rd edition) WB

Saunders. Philadelphia

Weiss EM & Zimmerman SS (2013) A Tale of Two Hospitals: The Evolution of

Phototherapy Treatment for Neonatal Jaundice. Pediatrics 131 (6): 1032-1034

Wentworth SDP (2005) Neonatal Phototherapy – Today’s Lights, Lamps and

Devices. Infant Vol 1 (1): 14-19