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 should parent teaching include, and what strategies ensure that families will receive adequate education and support to promote appropriate follow-up and care?

The most important outcome of parental teaching related to neonatal hyperbilirubinemia is ensuring that the parent(s) understands the importance of and adherence with the infant's follow up plan of care.

It is imperative that the information we provide to these families is clear and concise, and of the appropriate learning level based on their education history. It is also very important that this information stress the potential danger to the infant should the bilirubin levels get dangerously high.

Neonatal conditions that may potentially lead to separation of the infant from mother and father are likely to create feelings of anxiety and fear. The emotions impact how receptive an individual is to learning, and how much information they retain. Therefore, nurses caring for these neonates and their families must provide families with supportive resources to assist them in adhering to the follow up plan of care.

Simple strategies to keep in mind when teaching parents about hyperbilirubinemia:

• Timing is everything!!
  • Initiate discharge-teaching beginning on admission day.
  • Time teaching when parents are alone with their newborn; one to one teaching is optimal. Avoid a time when the room is filled with visitors.
  • Appear calm. Parents can sense the nurse's stress and will be more likely to ask questions and ask for clarification if the nurse is patient.
• Keep it simple!!
  • Avoid technical terms and long definitions that focus on physiology
    Give facts in brief, short segments. Stop frequently to clarify whether information is understood.
  • Further in depth definitions and explanations can be provided when appropriate based on their learning levels.
  • Avoid using absolutes (i.e., "always", "never") when teaching. Parents will remember these words and may not hear past them.

Was what you taught what they heard?

Remember to validate parents' learning. Validate learning by asking the following questions:

• How frequently should your baby be fed?
• If your baby is sleepy when it is time to eat, what are some wake-up techniques you could use?
• Show me how you can check the skin for jaundice/
  How many wet diapers can you expect daily?
• What will you do if your baby starts to appear jaundiced at home?

Demonstration and Hands On Practice

Demonstrate and clearly explain to parents what it means to "blanch" the skin, and how exactly it is done

• Undress the baby in a warm room with natural light, for instance by a window
• Use the tip of the baby's nose or center of the forehead to "blanch" it.
• Blanch means to apply light pressure to that area with one finger, leaving it there for 2-3 seconds, and then releasing it.
• Blanching will cause the skin to change color. Pay close attention to the color of the skin when you release your finger
• A color that is pale pink would be expected. If you notice the skin tone to be yellow, the baby may be jaundiced.

Show the parents what and where the sclera is and how it can be visualized.

• The white part of the eyeball is called the sclera
• To get a good look at the sclera, gently pull downward on the lower eyelid. If you notice the color to be yellowish, your baby may be jaundiced.

Allow parents to get hands on practice with equipment, for instance a biliblanket. This will prepare them for discharge and decrease some of the accompanying anxiety associated with equipment.

Parents are to be instructed on keeping and Intake and Output record for the baby's feedings and diaper changes. Parents are to understand that tracking intake and output is essential to monitor for dehydration. This is also how they can determine "Is my baby getting enough?"

Reassure parents that it is often difficult to remember details about every feeding and diaper change. By keeping a record on paper, it will help them keep better track of the baby's intake and output.

Questions parents frequently ask and how the nurse can respond:

What does jaundice mean?

Jaundice occurs when a yellow pigment called "bilirubin" gathers in the blood and tissue, especially the skin, where you can see it as a yellowish or orangish tint. It usually starts to appear in the newborns face, and if it continues will spread down towards the toes. Nearly all newborns experience some jaundice within the first two to four days of life.

Points to clarify with parents:

If the jaundice is physiologic -

• It is not a disease, and it is nearly always harmless
• It is not an infection
• It is not contagious
• It is not life long
• It is treatable-stressing compliance with follow up plan
• It is nearly always harmless with no adverse after effects, as long as bilirubin does not reach dangerous levels

So, if jaundice is such a "normal" condition, why all the concern?"

There are some situations that may cause the amount of bilirubin to rise to a very dangerous level, and lead to brain damage.

Today, health care providers monitor levels very carefully and treat newborns before levels get high enough to cause problems.

It is very important to monitor your newborn at home, alert the health care provider of any changes, and follow the treatment plan

FACT: Although jaundice can be "normal" and treatable, causes of kernicterus continue to be reported. One registry includes 90 cases in the US from 1984 to the present in which three of the newborns died and all others sustained brain damage. It is also stated that this is probably happening more than clinicians know about (JCAHO, 2001)

How do I know if my baby is jaundiced?

Skin

Teach caregiver to undress baby to check the amount of yellow in the skin
Check skin in natural light - for instance a warm room lit up from sunlight
Blanch the skin (as previously instructed) and check the amount of yellow color. If the baby was jaundiced in the hospital, has it gotten worse? If so, call the health care provider.

Fact: Visual assessment of the skin is often unreliable in newborns with dark skin. Therefore it is very important to teach parents other signs the newborn may exhibit (JCAHO 2001).

Eyes

Teach caregiver to check baby's eyes for jaundice. Look at the sclera (as previously instructed).
I
If sclera is yellow, call the health care provider.

Intake and Output

Keep a record of how much the baby eats and the number of wet and dirty diapers because changes in eating and voiding can be a sign of jaundice or indicate that the jaundice is increasing.

The baby should eat about eight times a day, or about every one to three hours for breastfeeding and about every two to four hours for formula fed newborns.

If the baby starts to eat less frequently, let your health care provider know.

The baby should have two to three wet diapers the first four days of life. After the fourth day, expect five to eight wet diapers daily.

If the number of wet diapers decreases, let your health care provider know.

The baby's urine should be light yellow, if it is dark yellow, red or pink let the health care provider know.

The baby will have one to two stools per day if breastfeeding and at least one stool every two days if formula feeding. When recording the number of stools, note the stool's color. Jaundiced newborns may have pale/light colored stools.

Baby's Behavior

The baby's behavior may change if they are becoming jaundiced or if the bilirubin level is increasing.

A newborn sleeps most of the day, but should wake up for feedings

If the baby starts to sleep through feedings, becomes a lazy eater (sleepy when nursing and weak suck) or falling asleep before the feeding has ended, these are signs of jaundice.

If the baby is limp, floppy and lethargic, let your health care provider know immediately.

Another sign of increasing jaundice is if the baby's cry becomes high-pitched.

How does the health care provider know if my baby is getting better?

Most health care providers will monitor the baby's bilirubin level closely during this time

Monitoring is done by getting a sample of the baby's blood, usually by pricking their heel, toes or fingers. As the numbers start to get lower, the baby will be improving.

The baby may also be more alert, wake up to eat more frequently and be less lethargic.

The baby's color may not start to improve immediately. If the skin was very dark yellow to orange, it may take up to two weeks to seen an improvement in skin color.

Anytime there is lack of certainty about whether or not the baby is jaundiced, call the health care provider.