Which conditions are risk factors that may place infants at a higher risk for developing jaundice select all that apply?

Q: Which conditions are risk factors that may place infants at a higher risk for developing jaundice select all that apply one some or all responses may be correct quizlet?

Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes.

Q: What causes high levels of jaundice in newborns?

Jaundice can happen if your babys liver doesnt work well. This may be because of an infection or other factors. The liver is the part of the body most responsible for getting rid of bilirubin. A problem with the liver can cause higher levels of bilirubin.

Q: What are common risk factors for developing newborn jaundice quizlet?

Risk factors for the development of severe hyperbilirubinemia include cephalhematoma or significant bruising, early gestational age, exclusive breastfeeding (especially unsuccessful breastfeeding and/ or weight loss of 8% to 10%), isoimmune or other hemolytic anemia, and a sibling with a history of neonatal jaundice.

Q: Which infant is at highest risk for pathologic jaundice?

Breast-fed newborns may be at increased risk for early-onset exaggerated physiologic jaundice because of relative caloric deprivation in the first few days of life.

Note: This guideline is currently under review.

Inhaltsverzeichnis Show

Introduction
Definition of Terms
Investigations
Risk Factors
Phototherapy
Potential Complications
Discharge planning and community-based management
Family Centered Care
Special Considerations
Companion Documents
Evidence Table
Which conditions are risk factors that may place infants at a higher risk for developing jaundice select all that apply one some or all responses may be correct quizlet?
What causes high levels of jaundice in newborns?
What are common risk factors for developing newborn jaundice quizlet?
Which infant is at highest risk for pathologic jaundice?

Introduction

Aim

Definition of Terms

Assessment

Managment

Potiential Complications

Discharge Planning

Family Centered Care

Special Considerations

Companion Documents

Links

Evidence Table

References

Introduction

This guideline applies to neonates within the first two weeks of life.

Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. Approximately 60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which classically becomes visible on day 3, peaks days 5-7 and resolves by 14 days of age in a term infant and by 21 days in the preterm infant. Treatment with phototherapy is implemented in order to prevent the neurotoxic effects of high serum unconjugated bilirubin. Phototherapy is a safe, effective method for decreasing or preventing the rise of serum unconjugated bilirubin levels and reduces the need for exchange transfusion in neonates.

Aim

This guideline provides health care providers with information to understand the causes of neonatal jaundice, the rationale for the use of phototherapy and outlines the care of neonates receiving phototherapy in order to enhance effective phototherapy delivery and minimise complications of phototherapy.

Definition of Terms

Jaundice: the yellow appearance of the skin that occurs with the deposition of bilirubin in the dermal and subcutaneous tissues and the sclera.
Bilirubin: the orange-yellow pigment of bile, formed principally by the breakdown of haemoglobin in red blood cells at the end of their normal life-span. Neonate’s bilirubin production rate is double that of adults and their clearance of bilirubin is reduced, hence the importance of monitoring levels and detecting jaundice in this early post-natal period.
Bilirubinaemia: the presence of bilirubin in the blood.
Hyperbilirubinaemia: the excess of bilirubin in the blood. Types of Neonatal Hyperbilirubinaemia:
- Unconjugated: most common form of neonatal hyperbilirubinaemia. The bilirubin has not been metabolised and hence cannot be excreted via the normal pathways in the urine and bowel. Unconjugated bilirubin binds with lipids and albumin, and results in the yellow appearance of the skin and sclera. Unconjugated bilirubin can cross the blood-brain barrier and cause neurotoxic effects.
- Conjugated: less common in neonates. The bilirubin has been metabolised and is water soluble, but accumulates in the blood usually due to hepatic dysfunction. Conjugated bilirubin does not cross the blood-brain barrier.
Serum Bilirubin (SBR): reports the unconjugated and conjugated bilirubin levels. This is the usual specimen requested by Medical staff on the pathology slip at RCH. Hyperlink to RCH Specimen Collection handbook.
Total serum bilirubin levels (TSB): measure used when charting serum bilirubin results onto Phototherapy and/or Exchange transfusion charts. TSB is the sum of unconjugated + conjugated serum bilirubin. A TSB can be requested on the pathology slip at RCH, but only the total combined conjugated and unconjugated bilirubin level is reported.
Breast milk jaundice: develops within 2-4 days of birth, is most likely related to limited fluid intake as breast milk supply is established, may peak at 7-15 days of age and may persist for weeks.
Phototherapy: a treatment for jaundice where the exposure of skin to a light source converts unconjugated bilirubin molecules into water soluble isomers that can be excreted by the usual pathways. Blue-green light is most effective for phototherapy as it both penetrates the skin and is absorbed by bilirubin to have the photochemical effect.
Bilirubin encephalopathy: the acute manifestations of bilirubin toxicity seen in the first few weeks after birth. Signs include lethargy, hypotonia and poor suck progressing to hypertonia, opisthotonos, high-pitched cry and eventually to seizures and coma.
Kernicterus: the pathogenic diagnosis characterised by bilirubin staining of the brain stem and cerebellum. Also the term used to refer to chronic bilirubin encephalopathy. Clinical findings include cerebral palsy, developmental and intellectual delay, hearing deficit, dental dysplasia and oculomotor disturbances.
Single Light: One neoBLUE LED phototherapy unit (mini or standard)
Double Lights: Two neoBLUE LED phototherapy unit’s (mini or standard) or One neoBLUE LED phototherapy unit (mini or standard) + One biliblanket
Triple Lights: Three neoBLUE LED phototherapy unit’s (mini or standard) or Two neoBLUE LED phototherapy unit (mini or standard) + One biliblanket

**All phototherapy units are to be set on high intensity at all times, regardless of the amount of units in use. This ensures delivery of adequate amounts of blue light via light emitting diodes (LEDs). Therefore, a single unit is classified as a single light and single, double or triple lights refers to the amount of units not the intensity setting.

**As per Natus neoBLUE LED phototherapy in-service guide (available on the intranet), mini neoBlue LED phototherapy units deliver the same intensity as the standard unit set on high intensity; the only difference is in the surface area coverage.

Assessment

Please note that when charting the TSB level onto the Phototherapy or Exchange Transfusion charts, in the presence of risk factors (sepsis, haemolysis, acidosis, asphyxia, hypoalbuminaemia) TSB values should be plotted on the range 1 lower than the neonate’s gestational age/weight. This is because the risk of developing kernicterus increases in the presence of the above risk factors.
The Phototherapy and Exchange Transfusion charts onto which total SBR is plotted are for the first 7.5 and 5 days of life respectively. After the first 5-7 days continue utilising these charts, as levels plateau and can continue to be documented.

Assess general skin colour whenever measuring and recording vital signs. Ensure the Phototherapy tick box in the EMR Flowsheets is activated and document time of commencement and cessation.Obtain blood sample to measure total serum bilirubin levels (either venous, arterial or capillary)
Document hourly the type and number of light banks and the presence of eye protection.
Obtain blood sample to measure total serum bilirubin levels (either venous, arterial or capillary) Hyperlink to RCH Specimen Collection handbook) Ensure the lights are turned off during sampling so accuracy of current blood levels can be attained. Initially SBR levels may need to be assessed every 4-6 hours until reduction. Follow medical advice and ordering of SBR levels according to acuity of levels and plot on appropriate line of the chart. Observe for signs of lethargy and poor feeding (insert link to assessing for Jaundice)
Observe for signs of lethargy and poor feeding (insert link to assessing for Jaundice)

During phototherapy neonates require ongoing monitoring of:

adequacy of hydration (urine output) and nutrition(weight gain)
temperature
clinical improvement in jaundice
TSB or SBR levels
potential signs of bilirubin encephalopathy

Investigations

Initial TSB/SBR measurement should be requested based on clinical observation and the following factors:
- any neonate <24 hours age with clinically apparent jaundice
- any neonate where there is clinical doubt about the degree of jaundice
- any unwell neonate with jaundice
- any neonate with risk factors for jaundice (ABO/ Rh incompatibility, sepsis, acidosis, asphyxia, hypoalbuminaemia)
Ongoing TSB/SBR measures should be repeated at intervals depending on the initial level and rate of rise. For example: 6 hourly measures may be required if the level is very high and the neonate is being treated with multiple phototherapy lights.
A TSB/SBR may be requested within 24 hours of ceasing phototherapy to assess for rebound hyperbilirubinaemia. Neonates at increased risk of clinically significant rebound hyperbilirubinaemia include those born less than 37 weeks gestation, those not feeding optimally or those with haemolytic disease.
Further Bloods and investigations include
- Maternal and infant blood type
- Direct Coombs test
- Haemoglobin
- Full blood count for red cell morphology; reticulcyte, haematocrit and platelet counts and white blood cell differential
- Urinalysis for reducing substances
- Sepsis screen if sepsis suspected
- G6PD and galactosaemia screens if suspected
- Serum thyroxine and thyroid-stimulating hormone levels

Risk Factors

Mothers with a positive antibody screen
A family history of G6PD deficiency
A previously affected sibling
Cephalhaematoma, bruising and trauma from instrumental birth
Delayed passage of meconium
Prematurity
Dehydration
Inadequate breastfeeding
ABO incompatibility
Rh incompatibility

Management

(link to phototherapy management document)

Nutrition

Breastfed babies who require phototherapy should continue to breastfeed unless clinically contra-indicated due to other pathology; the neonate’s sucking, attachment and mother’s milk supply should be monitored. In the case of infants nearing exchange transfusion level, the infant should not come out of phototherapy to feed as this is a medical emergency. All feeds should be given via a bottle or NGT if feeding is deemed safe

Neonates who are receiving enteral feeds of EBM or infant formula should continue to do so. The total fluid intake (TFI) for a 24 hour period may need to be increased by at least 10% to account for insensible fluid loss when a neonate is receiving phototherapy however this should be guided by hydration status and electrolyte monitoring.
Parenteral nutrition and IV fluids should continue as ordered and may also need to be increased by 10% to account for insensible fluid loss.

Phototherapy

Commence phototherapy once TSB/SBR is greater than the appropriate reference range for neonate’s gestation/weight and presence of risk factors.
Neonates should be nursed naked apart from a nappy under phototherapy and will need to be nursed in an Isolette to maintain an appropriate neutral thermal environment. (Link to:” Ward Management of a Neonate” and “Isolette use in Paediatric Wards”) In severe cases, the nappy may need to be removed and a urine bag applied to maximise skin exposure.
Positon phototherapy units no more than 30.5cm from the patient. neoBLUE® LED phototherapy unit can be positioned as close as 15cm to patient. Refer to specific phototherapy units manufacturing guidelines for more details
Expose as much of the skin surface as possible to the phototherapy light. To maximise skin exposure, dress the baby in a nappy and their protective eye covers only.
Cover the eyes with appropriate opaque eye covers e.g. Natus Biliband® Eye Protector (available from Butterfly ward).
Ensure eye covers are removed 4-6 hourly for eye care during infant cares or feeding. Observe for discharge/infection/damage and document any changes.
Daily fluid requirements should be reviewed and individualised for gestational and postnatal age.
Maintain a strict fluid balance chart.
Breast feeds may need to be limited to 20 minutes if bilirubin level is high to minimise amount of time out of the lights
Monitor vital signs and temperature at least 4 hourly, more often if needed
Cover lipid lines with light resistant, reflective tape to avoid peroxidation
Ensure that phototherapy unit is turned off during collection of blood for TSB/SBR levels, as both conjugated and unconjugated bilirubin are photo-oxidized when exposed to white or ultraviolet light.
Observe for signs of potential side effects.

Potential Complications

Overheating – monitor neonate’s temperature
Water loss from increased peripheral blood flow and diarrhoea (if present)
Diarrhoea from intestinal hypermotility
Ileus (preterm infants)
Rash
Retinal damage
‘bronzing’ of neonates with conjugated hyperbilirubinaemia
Temporary lactose intolerance

Discharge planning and community-based management

Documentation in the neonates discharge letter and Child Health Booklet should include details about TSB/SBR levels and duration of phototherapy treatment.

Family Centered Care

Explain to parents the need for and actions of phototherapy, particularly in relation to the need for skin surface to be exposed to the phototherapy light, and hence the need to care for neonates receiving phototherapy to be nursed in a neutral thermal environment. Potential complications of phototherapy and the need for protective eye coverings during phototherapy treatment should be explained. The need for measuring the TSB and need for blood sampling should also be explained.

Neonates receiving phototherapy (where there are no other contraindications) can have brief periods where the phototherapy is ceased so that they can be cuddled/breastfed and have their eye covers removed for parent-baby interaction to occur.

Special Considerations

Normal hand hygiene measures should be attended to during care of a neonate receiving phototherapy.

More details on the neoBLUE LED lights can be found in the definition of terms.

Companion Documents

RCH Phototherapy Trial Chart - COMING SOON
RCH Exchange Transfusion Chart
RCH Phototherapy competency
RCH: Neonatal Clinical Practice Guideline: Exchange Transfusion http://www.rch.org.au/uploadedFiles/Main/Content/neonatal_rch/EXCHANGE_TRANSFUSION.pdf
RCH Clinical Practice Guideline: Jaundice in early infancy http://www.rch.org.au/clinicalguide/guideline_index/Jaundice_in_Early_Infancy/
RCH Clinical Guideline (Nursing): Ward Management of a Neonate http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Ward_Management_of_a_Neonate/
RCH Policy: Isolette use in Paediatric Wards http://www.rch.org.au/policy/policies/Isolette_Use_in_Paediatric_Wards/

Evidence Table

Click here to view the evidence table for this guideline.

References

Bhutani, V.K. and the Committee on Fetus and Newborn (2011) Phototherapy to prevent severe neonatal hyperbilirubinaemia in the newborn infant 35 or more weeks gestation, Pediatrics 128(4); e1046e1052
http://www.health.vic.gov.au/neonatalhandbook/comditions/jaundice-in-neonates.htm retrieved 12/06/14
Maisels, M.J. & McDonagh, A.F. (2008) Phototherapy for neonatal jaundice, New England Journal of Medicine 358(9): 920-928
Neonatal Hyperbilirubinaemia, retrieved from
http://www.merckmanuals.com/professional/pediatrics/metabolic_electrolyte_and_toxic_disorders_in_neonates/neonatal_hyperbilirubinemia.html 16/01/2014
NICE clinical guideline 98 (2010) Neonatal Jaundice, guidance.nice.uk/cg98
Queensland Maternity and Neonatal Clinical Guideline Neonatal Jaundice: prevention, assessment and management, Queensland Government (2009)

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Jessica Smith, Clinical Nurse Educator, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2018.