Hyperbilirubinemia: Recognition, Care and Management of Term and Near-Term Infants

Objectives

What is the Problem?

Definition of Terms

Production, Metabolism, Transport and Excretion

Assessment

Practice Standard

Current Treatment

Education

Bibliography

Quiz

Main Lab Page

What is the Practice Standard for managing hyperbilirubinemia in the healthy term newborn?

The following information is adapted from the American Academy of Pediatrics:

Managing Hyperbilirubinemia in Healthy Term Newborns:

The American Academy of Pediatrics (AAP) Practice Standard

*Intensive phototherapy should reduce total serum bilirubin by 1-2 mg/dl within 4-6 hours.  Serum bilirubin should continue to decrease and remain below the threshold level for exchange transfusion.  If this does not happen, phototherapy is considered to have failed.

Equipment Considerations 

Taken from Blackburn and Loper, 1992.

The effectiveness of phototherapy is determined by the energy output from the light source rather than the intensity of the light. Light waves in the blue-green spectrum have the greatest absorbance by bilirubin. Effectiveness of phototherapy can also be attained by maximum irradiance and exposing as much of the skin as possible to the light. More than one source of light can be used to maximize irradiance.

There are no known significant long-term adverse effects of phototherapy.

Effects of Phototherapy

Short-term effects that may occur during therapy include:

Thermal and other metabolic changes:

• Increased environmental and body temperature
• Increased oxygen consumption
• Increased respiratory rate
• Increased skin blood flow
• Decrease in calcium levels

Fluid status changes:

• Increased peripheral flood flow
• Increased insensible water loss, dehydration

Gastrointestinal function changes:

• Abdominal distension
• Increased number and frequency of stools
• Diarrhea (watery, greenish-brown)
• Decreased time for intestinal transit
• Decreased absorption; retention of nitrogen, water and electrolytes
• Altered lactose activity, riboflavin

Activity changes:

• Lethargy
• Irritability
• Decreased eagerness to feed

Body weight changes;

• Decreased initially but generally catches up in two to four weeks

Ocular effect changes:

• Potential for retinal damage from light exposure
• Increased risk of eye infection, corneal abrasion
• Increased intracranial pressure if patches too tight

Skin changes:

• Macular skin rash
• "Bronze Baby Syndrome" from skin deposits of photoproducts of bilirubin decomposition

Hormonal changes:

• Increased in serum gonadotropins (luteinizing and follicle-stimulating hormones)

Hematological changes:

• Increased rate of platelet turnover; thrombocytopenia
  Injury to circulating RBCs; may lead to hemolysis

Psychobehavioral changes:

• Lack of usual sensory experiences
• Isolation
• Visual deprivation
• Increased parental stress
• Alteration in neurobehavioral organization
• Decreased parent-infant interaction

The side effects of phototherapy are usually transient. The nurse must be aware of these side effects in order to assess for them and intervene to reduce potential complications.

There is little agreement as to the bilirubin level at which phototherapy should be started. Click here to read recommendations from Maisels and Newman (1992).

The basis for phototherapy used is prevention of bilirubin toxicity. It does not treat the cause of the hyperbilirubinemia.

What is the Nursing Care Needed During Phototherapy Treatment?

Nursing care during phototherapy supports the goals of treatment and prevents or minimizes side effects.

It is important that the nurse be familiar with the policies and procedures of the hospital and that the manufacturer's recommendations regarding use and care of phototherapy lighting equipment and isolettes be followed.

Irradiance of the bulbs should be verified daily.

Equipment should be properly positioned throughout the treatment.

Infant's eyes should be covered throughout therapy to prevent possible retinal damage from exposure to light.

Eye patches should be checked frequently to ensure that they provide protection, do not cause corneal abrasion, and verify they do not occlude the nares or obstruct the infant's airway.

Infant's temperature should be checked frequently to avoid hyperthermia due to the heat production from the lights.

Warmer or isolette temperature should be monitored and adjusted accordingly.

Measurement of I & O is indicated due to increase in insensible water loss during phototherapy.

Careful monitoring and care of the skin is important to prevent breakdown from loose stools and irritation from the drying effects of phototherapy. Creams and lotions should not be used because of the potential for burns.

Parent teaching should include an explanation of newborn jaundice and hyperbilirubinemia as well as the treatment and monitoring being done.

Provide support and praise to parents for their care of their infant and encourage them to talk to, touch and stroke the baby during this time.

When will phototherapy treatment be discontinued?

There is no consensus on the bilirubin level at which phototherapy may be discontinued. The AAP recommends discontinuing phototherapy when the bilirubin levels are below 14-15 mg/dl. Once phototherapy is discontinued the serum bilirubin may rebound. This is usually mild, less than 1 mg/dl, in the absence of hemolytic disease. With parent education and healthcare provider follow up, the infant's discharge need not be delayed because of this rebound.