Maternity - Newborn, part 5: Hyperbilirubinemia - Symptoms, Treatment, Phototherapy, and Nursing Care
November 27, 2021 Updated: January 17, 2022 6 min read
Hi, I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about hyperbilirubinemia, and also about phototherapy. I'm going to be following along using our maternity flashcards, which are available on our website leveluprn.com if you want to get a set for yourself. And if you already have a set, I would encourage you to follow along with me. Okay, let's get started. So first up, we're going to be talking about hyperbilirubinemia. So let's just break that word down. Hyper, meaning higher than expected or elevated; bilirubin, referring to bilirubin; and emia, referring to blood. So hyperbilirubinemia literally means higher than expected levels of bilirubin in the blood. So that's kind of the breakdown just of that term. Now, this is going to typically result in jaundice, which is how we're going to identify it and diagnose it. So the pathophysiology is that red blood cells break down. Bilirubin is formed by that breakdown. And then we have increased bilirubin levels. But we have two types of jaundice in the newborn. We have physiologic jaundice and pathologic jaundice. Just by the names, I hope you can tell that pathologic is the worst one. There's a pathology associated with it. So physiologic jaundice, it's common, it's mild, it's transient, meaning it'll go away. And this is just due to the fact that the infant does not have a mature liver, which would typically process that bilirubin that is created by the breakdown of red blood cells. So this is usually going to begin on day two to four of life, and it's going to peak between four to five days of life, and resolves within two weeks. Typically, it never occurs within the first day of life. In contrast with pathologic jaundice, which does occur within the first day of life, which is why it is always abnormal for there to be jaundice in the first day of life of a newborn. I want you to hear it again. It is always abnormal for jaundice to be present in the first day of life because pathologic jaundice is caused by hemolysis due to maternal-fetal blood type incompatibility. This is very bad. This is an ABO incompatibility that is going to occur within the first 24 hours. We're going to see a rapid rise in those bilirubin levels, and that is bad news bears. Bilirubin levels peaking over a couple of days, jaundice happening in two to four days, that's not so terrifying. First day of life, we have a mismatch between mom and baby's blood. That is a big deal, pathologic jaundice. I really hope you're hearing that first day of life thing. So what are we going to see in hyperbilirubinemia? The big thing is just going to be jaundice. We can see that in the skin. We can also see it in the eyes and the mucous membranes. You will talk about probably if you're in maternity, how we actually measure those jaundice levels using a light meter, and it is placed on the baby's skin. A light is sort of like flashed onto the skin and the meter reads how yellow that baby is. Then there's a calculator where you put in the reading. You put in how old the baby is and it tells you where their risk is: are they low risk, low intermediate risk, that sort of thing, and then we can figure out how severe that jaundice is.
Now let's talk about some of the labs and diagnostics and things like that. So the labs would be a bilirubin greater than five milligrams per deciliter. But, I would say we're not going to be testing that bilirubin level in the baby's blood unless they're having a really, really high reading transcutaneously. This is not invasive versus drawing blood is invasive. The treatment. The big treatment that you're probably familiar with is going to be phototherapy. So that's going to be using light to break down that bilirubin. We can also encourage increased frequency of breastfeeding, and a blood exchange transfusion may be necessary in the case of pathologic jaundice. So complications here. Well, kernicterus is going to be the biggest one, which is a type of brain damage that occurs when unconjugated bilirubin crosses the blood-brain barrier, and it can cause permanent neurological dysfunction. So this would be like cerebral palsy, seizures, hearing loss, cognitive and hearing impairment, but, again, permanent brain damage. So nursing care would be: we need to know when did the jaundice start, right? Was it before 24 hours of life or after? Big deal. And then, we need to provide care during phototherapy, which we will talk about in a minute. And then, the parental teaching is going to be feed the baby often, right? That's going to help to promote bilirubin excretion through the stool. And that we kind of expect them to have these loose, frequent green stools because that bilirubin has color to it that is going to be excreted in the stool. For me, personally, with my daughter, she had pretty high jaundice levels, but not enough to need phototherapy, but just enough for them to be like, "Hey, you know, kind of keep an eye on this at home." So they actually encouraged us to go for frequent walks outside so that she could get sort of like the poor man's phototherapy. She's getting UV exposure when we're going for these walks outside and helping to break down that bilirubin.
So lastly, let's talk about phototherapy and what that entails from a nursing perspective. So phototherapy is placing the baby under UV lights, and that's going to help to break down bilirubin. Or there are also things called bili blankets, and they are blankets that have these lights in them. So same idea, just a different setup. So there's some bold red text here that's very important that I want you to pay attention to. But first and foremost, baby should go in wearing just a diaper and something to cover the eyes. So we're not putting them in in a full cute outfit, right? We're trying to expose their skin to the light to help break down the bilirubin, so we want them to be as exposed as possible. So we do need to protect their eyes with a special mask. And that's going to be just if they are in the bili lights. Not so much for bili blankets. As with any sort of patient at all, we need to make sure that we're turning them every two hours, right, so we don't have pressure injuries. We need to monitor baby's temperature. I'm putting them under hot lights. I need to make sure that they are not getting too hot. So we also then need to monitor for dehydration. Same idea here We're checking the urine output to see how many wet diapers we're getting. We're checking baby's weight. We're looking at those mucous membranes; that sort of an idea here. We are not putting lotion on the baby. Think about if I put lotion on and then put you under a tanning bed, right? You could end up burned from that lotion getting hot, heating up. So same idea here. We're keeping the baby's skin dry because we don't want to accidentally burn them with any sort of heated-up lotion or liquid or moisturizer, or anything like that. We would, of course, keep rechecking those bilirubin levels every 6 to 12 hours. And if we have a bili blanket, then we would want to encourage the parents to hold the baby during this time and everything. We're not going to hold off on feeding this baby or anything along those lines. We need to make sure baby is having all of their basic physiological needs met. But we are going to make sure that they are wearing just a diaper, that their skin is dry, and we're checking their temperature and their hydration status.
I hope that review was helpful for you. I'm going to ask you some quick questions so that you can test your knowledge and see if you picked up on some key facts, which I hope you did, because I think I feed them into your heads just a little this time. Let me know how you do in the comments. Okay, first up, I want to know when does physiologic jaundice occur? Physiologic jaundice. Next up, I want you to tell me two treatments for hyperbilirubinemia. I gave you three. You tell me two. And lastly, for an infant receiving phototherapy, what should they be wearing when they are placed under the lights? Let me know how you do in the comments. Thanks so much, and happy studying.
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