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