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

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Assessment

The goal of assessment is to identify infants at risk for hyperbilirubinemia who require follow-up or treatment to lessen the risk of bilirubin encephalopathy and kernicterus.

In 1994, the American Academy of Pediatrics published its Practice Parameter: Management of Hyperbilirubinemia in the Healthy Term Newborn. It identified infants at risk by:

• Careful history-taking of the newborn and mother
• Visual identification of jaundice before discharge

What are the Key Aspects Contained in the Maternal/Newborn History?

The following aspects of the maternal/newborn history should be reviewed:

• Family: Sibling with jaundice, familial disorders associated with jaundice, such as G6PD deficiency.
• Perinatal/Obstetric: Maternal prenatal testing results for ABO and Rh (D) blood type and serum screen for unusual isoimmune antibodies, neonatal factors that increase risk for jaundice, such as infection, bruising or cephalohematoma.
• Infant: Gestational age: course since birth, including pattern of feeding and behavior, timing of symptoms of jaundice.

What information is Essential in Performing a Visual Assessment?

Shortened hospital stays of 24-48 hours for non-operative deliveries have decreased the time available for visual assessment of jaundice. However, visual assessment alone is insufficient to assess the degree or severity of jaundice because of subjective interpretation of skin color and tone. Objective measurements are needed.

Physical examination includes assessment of skin and scleral color, bruising cephalohematoma and/or other signs of birth trauma. Jaundice cannot be visualized until the serum bilirubin level reaches 5-7mg/dl. Skin assessment for bilirubin is made by blanching the skin. Jaundice is usually seen first in the sclera and head and progresses in a cepalocaudal direction from face to trunk and then to the lower extremities.

Jaundice is assessed most effectively by placing the unclothed newborn in a well-lit warm area, preferably in the natural daylight. Gentle pressure should be applied to the skin, blanching it to reveal the underlying color of the skin and the subcutaneous tissue. Variability in observer assessments make visual evaluation of estimation of the degree of jaundice subjective and unreliable.

Is the Timing of the Occurance of Jaundice Important?

Rapidly increasing jaundice that begins at least 24 hours of age should raise concern and may be indicative of a hemolytic process. Such infants are not healthy and determination of the underlying cause and treatment is started immediately. Health care providers should be aware that excessive hemolysis may still be present even if jaundice appears after 24 hours. It is important to monitor these infants to identify other factors that might put them at risk for hyperbilirubinemia.

What Factors Should be Considered When Assessing a Jaundiced Infant?

Factors that suggest the possibility of hemolytic disease include:

• Family history of significant hemolytic disease
• Onset of jaundice before age 24 hours
• A rise in serum bilirubin levels more than 0.5mg/dl/hour
• Pallor, hepatosplenomegaly
• Rapid increase in the total serum bilirubin (TSB) level after 24-48 hours (consider G6PD deficiency)
• Ethnicity suggestive of inherited disease (G6PD deficiency, etc.)
• Failure of phototherapy to lower the TSB level

Clinical signs suggesting the possibility of other diseases such as sepsis or galactosemia include:

• Vomiting
• Lethargy
• Poor feeding
• Hepatosplenomegaly
• Excessive weight loss
• Apnea
• Temperature instabililty
• Tachypnea

Signs of cholestatic jaundice suggesting the need to rule out bilirary atresia or other causes of cholestasis include:

• Dark urine or urine positive for bilirubin
• Light colored stools
• Persistent jaundice for >3 weeks

What are the Key Assessment Parameters and Strategies?