Neonatal jaundice

Question 1

According to NICE guidelines, what is the assessment process?

Answer 1

Visual inspection, checks at birth, bilirubin level measurement, risk factors for kernicterus, assessment for underlying disease

Question 2

Assessment for baby under 24 hours old with suspected or obvious jaundice?

Answer 2

Measure and record the serum bilirubin level urgently (within 2 hours). Continue to measure the serum bilirubin level every 6 hours until the level is both: below the treatment threshold stable and/or falling.

Question 3

Assessment for baby over 24 hours old with suspected or obvious jaundice?

Answer 3

Measure and record the bilirubin level urgently (within 6 hours

Question 4

Treatment

Answer 4

Phototherapy (short breaks- 30 mins, daily weighing, monitor temp), exchange transfusion, intravenous immunogoblin

Question 5

What is the physiology of bilirubin?

Answer 5

Bilirubin is mainly produced from the breakdown of red blood cells (Hb). Red cell breakdown produces unconjugated (or ‘indirect’) bilirubin, which circulates mostly bound to albumin although some is ‘free’ and hence able to enter the brain. Unconjugated bilirubin is metabolised in the liver to produce conjugated (or ‘direct’) bilirubin which then passes into the gut and is converted to urobilinogen and excreted in urine and faeces

Question 6

What neonatal factors causes physiological jaundice?

Answer 6

Increased HB release (neonatal RBC have shorter life span than adult therefore higher turnover) (polycythaemia- haematocrit of 50-60%- more RBCs= more breakdown) Reduced bilirubin activity (liver enzyme that conjugates bilirubin is only 1% active in 1st week of life ) Increased enterohepatic circulation (increased reabsorption of bilirubin from GI tract)

Question 7

What is jaundice?

Answer 7

Yellow colouration of the skin and sclerae caused by the accumulation of bilirubin (hyperbilirubinaemia) in the skin and mucous membranes Also in gums Physiological- 2-5 days Pathological- within 24hours of birth

Question 8

What is prolonged jaundice?

Answer 8

Jaundice persisting beyond the first 14 days Prolonged jaundice is generally harmless, but can be an indication of serious liver disease

Question 9

What causes pathological jaundice?

Answer 9

Production: Increased haemolysis of red cells Prematurity Decreased albumin binding capacity/Competition for albumin binding sites Lack of or reduction in enzymes and carrier proteins Lack of oxygen and glucose Hepatitis or liver damage slow the rate of transport Congenital biliary atresia Slow bowel motility

Question 10

Why might there be an increased haemolysis of red blood cells and therefore increase in bilirubin production?

Answer 10

Rhesus isoimmunisation or ABO incompatibility RBC defects: Congenital spherocytosis (shortage of red blood cells) , G-6-PD deficiency Sepsis and /or DIC (Disseminated intravascular coagulation is a condition in which blood clots form throughout the body blocking small blood vessels) Bruising and cephalhaematoma or internal haemorrhage Polycythemia–twin to twin or materno-fetal transfusion (delayed cord clamping)–SFD infants–Infants of diabetic mothers

Question 11

Why might prematurity cause jaundice?

Answer 11

Immaturity of the liver Low energy stores Poor feeding Lower levels of SBR will cause brain damage in preterm babies – there are specific SBR threshold charts for preterm babies

Question 12

Why might there be decreased albumin capacity?

Answer 12

Hypoxia and acidosis Infection Prematurity Hypoglycaemia

Question 13

Why might there be competition for albumin binding sites?

Answer 13

Free fatty acids - starvation and cold stress Drugs - sulphonamides, cephalosporins/ diazepam I.V. (Sodium benzoate)/- frusemide and other thiazide diuretics/- heparin

Question 14

Why might there be a lack of or reduction in enzymes and carrier proteins?

Answer 14

Congenital disorders Prematurity

Question 15

Why might there be a lack of oxygen and glucose?

Answer 15

Prolonged stress in utero or any stress in SFD infants Hypoxia at birth

Question 16

Why might hepatitis or liver damage slow the rate of transport?

Answer 16

Metabolic disorders eg: galactosaemia Infection

Question 17

What is congenital biliary atresia?

Answer 17

Rare congenital disorder where part of the liver draining into the bile duct is abnormally formed Early surgery can prevent liver damage so early detection is vital Late diagnosis means the baby will die without a liver transplant very rare liver disorder

Question 18

Why might there be slow bowel motility?

Answer 18

Poor feeding Pyloric stenosis or bowel obstruction (meconium ileus, meconium plug) Congenital hypothyroidism (this is tested for on day 5)

Question 19

At what point would an jaundiced baby require more investigation and possibly treatment?

Answer 19

Occurs within 24 hours Appears within 48 hours SBR continues to rise rapidly between days three and four Jaundice does not subside by day 5-6 Continues after 12-14 days Has abnormally high SBR Baby shows signs of being unwell

Question 20

What is a physical indicator of a very jaundiced baby?

Answer 20

yellow hands and feet

Question 21

Jaundice in 1st 24 hours?

Answer 21

This is always pathological Relates to causes already present at birth, usually blood incompatibility May have been predicted by rising maternal antibody levels SBR rises very rapidly and is a paediatric emergency

Question 22

What happens when jaundice is caused by infection?

Answer 22

SBR tends to rise steadily Starts to rise related to time of infection If intrauterine infection may appear in 48 hours

Question 23

What are the dangers of hyperbilirubinaemia?

Answer 23

In young babies, unconjugated bilirubin can penetrate the membrane that lies between the brain and the blood (the blood–brain barrier). Unconjugated bilirubin is potentially toxic to neural tissue (brain and spinal cord). Entry of unconjugated bilirubin into the brain can cause both short-term and long-term neurological dysfunction (bilirubin encephalopathy)

Question 24

What are the dangers of pathological jaundice?

Answer 24

Bilirubin levels are generally higher than in physiological jaundice Levels remain high for longer Much higher risk of kenicterus The causes may also be harmful to the baby

Question 25

What is kernicterus?

Answer 25

The clinical features of acute or chronic bilirubin encephalopathy, as well as the yellow staining in the brain associated with the former and necrosis of neurones in the brain. The risk is increased in babies with extremely high bilirubin levels. Occur at lower levels of bilirubin in term babies who have risk factors, and in preterm babies. Presents as a progressive development of lethargy, rigidity, high pitched cry and convulsions over a period of 24 hours. 50% of infants die

Question 26

What is the standard midwifery care checking for jaundice in babies?

Answer 26

Check whether there are factors associated with an increased likelihood of developing significant Hyperbilirubinaemia soon after birth examine the baby for jaundice at every opportunity especially in the first 72 hours Check the naked baby in bright and preferably natural light Examination of the sclerae, gums and blanched skin is useful across all skin tones Check nappy for pale chalky stools and dark urine

Question 27

How to measure the bilirubin level?

Answer 27

How to measure the bilirubin level When measuring the bilirubin level:–use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours–if a transcutaneous bilirubinometer is not available, measure the serum bilirubin if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin–Do not use an icterometer

Question 28

Urgent additional care for babies with visible jaundice in the first 24 hours?

Answer 28

Measure and record the serum bilirubin level urgently (within 2 hours) in all babies with suspected or obvious jaundice in the first 24 hours of life Continue to measure the serum bilirubin level every 6 hours for all babies with suspected or obvious jaundice in the first 24 hours of life until the level is both:–below the treatment threshold–stable and/or falling

Question 29

SBR testing?

Answer 29

Always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24 hours of life Always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks gestational age Always use serum bilirubin measurement for babies at or above the relevant treatment threshold for their postnatal age, and for all subsequent measurement

Question 30

SBR testing?

Answer 30

Always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24 hours of life always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks gestational age always use serum bilirubin measurement for babies at or above the relevant treatment threshold for their postnatal age, and for all subsequent measurement

Question 31

What is the importance of feeding jaundiced babies?

Answer 31

Breast milk speeds passage of meconium increasing conversion in bowel to conjugated bilirubin Adequate energy is needed for liver function Adequate fluid is needed if baby is hot under phototherapy Supplementary fluid should be avoided as this reduces intake of breast milk- breastmilk provides adequate fluid

Question 32

What is the management and treatment of hyperbilirubinaemia?

Answer 32

Offer parents or carers information about treatment for hyperbilirubinaemia, including: anticipated duration of treatment reassurance that breastfeeding, nappy-changing and cuddles can usually continue. Breaks should be for up to 30 minutes NICE (2016) Encourage mothers of breastfed babies with jaundice to breastfeed frequently, and to wake the baby for feeds if necessary. Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced

Question 33

How does phototherapy work?

Answer 33

NICE(2016) do not recommend sunlight Perspex covers do not reduce the effectiveness of phototherapy lights but may protect from skin irritation and assist thermoregulation (can be used for babies over 37/40) Phototherapy works by changing bilirubin under the skin from its unconjugated form to non toxic bilirubin products that can be excreted without conjugation by the liver. Works most effectively in 1st 48 hours of use Biliblankets remove the need for eye covering and are generally less stressful for mothers and infants SBR levels should always be checked after phototherapy has been discontinued

Question 34

What is involved in care of the baby receiving phototherapy?

Answer 34

Frequency of observations Regular feeding (breastfeeding preferably) Protect eyes Nurse baby naked Temperature control

Question 35

What is intensified phototherapy?

Answer 35

Phototherapy can be intensified by using another light source or increasing the intensity of the light Do not interrupt phototherapy for feeds, continue with enteral feeds/IV Encourage EBM/feeding support so breastfeeding can resume after phototherapy has stopped

Question 36

What is fibreoptic phototherapy?

Answer 36

Phototherapy given using a single light source that comprises a light generator, a fibreoptic cable through which the light is carried and a flexible light pad, on which the baby is placed or that is wrapped around the baby

Question 37

How does exchange transfusion work?

Answer 37

If the SBR is high then an exchange blood transfusion may be necessary- in SCBU This is a complete changeover of blood (this also removes the maternal antibodies) SBR level needs to be checked 2 hours after the exchange 0.3-0.4% mortality 5-10% permanent sequelae – aortic thrombosis, intraventricular haemorrhage, pulmonary haemorrhage

Question 38

What is the haematocrit?

Answer 38

The ratio of the volume of red blood cells to the total volume of blood

Question 39

What is a haematoma?

Answer 39

Solid swelling of clotted blood within the tissues

Question 40

What is a cephalohaematoma?

Answer 40

Creates a reservoir of RBCs that are eventually broken down