Neonatal Jaundice

Neonatal jaundice or hyperbilirubinemia is a common condition that occurs in a newborn infant. According to statistics by the Queensland clinical guidelines, relatively 60% of term and 80% of preterm babies are at risk developing neonatal jaundice during the first week of origin(Queensland Clinical Guidelines, 2017). Jaundice is caused by elevated levels of bilirubin in the blood and takes about 2 to 4 days after birth to be physically visible. The neonate presents with a yellowish appearance resulting from the deposition of bilirubin in the skin as a result of increased red cell breakdown and decreased bilirubin excretion. This essay will focus on Jennifer a neonate born preterm due to premature rupture of membranes (PPROM) at 33 weeks gestation

who now at 2 days of age becomes clinically jaundiced. This paper will critically evaluate the pathophysiology of neonatal jaundice and further discusses the role of nursing in providing a family-centered approach to neonatal care.

Neonatal jaundice or hyperbilirubinemia ’ is a build up of a chemical called bilirubin in the blood and tissues of a neonate (Lauer & Spector, 2018). Bilirubin which is normally processed by the liver, takes longer to process in a neonate and thus six out of ten newborns are prone to jaundice to a certain degree and it is extremely common among premature babies (Bhutani, 2012). Jaundice usually appears on the second or third day and premature babies born before 37 weeks’ gestation are at higher risk of developing hyperbilirubinemia. Neonatal jaundice is the development of increased levels of bilirubin in the blood leading to a yellow discoloration of the s sclera the whites of the eyes and skin, due to bilirubin being deposited in elastin-rich tissues. It is a result of an increased breakdown of red blood cells and or a decreased excretion of bilirubin from the hepatic system (McGillivray & Evans, 2011). Bilirubin is continuously formed in humans, and newborn infants produce relatively more bilirubin than of an adult. Jaundice is not particularly a disease but rather is a symptom indicating the presence of a disease affecting the bilirubin during the hepatic process  (Queensland Clinical Guidelines, 2017). In preterm neonates, high levels of circulating bilirubin potentially have more severe consequences that have potential to develop brain damage due to less serum albumin concentration with poor bilirubin binding sites and more permeable blood-brain barrier (Bhutani, 2012). In the bloodstream bilirubin is bound to albumin and once the albumin binding sites are saturated, increased blood levels of unconjugated bilirubin develops. In the preterm neonate, the form of unconjugated bilirubin can be extremely toxic and it is common for infants to have excessive bilirubin production and a correspondingly elevated uptake of unconjugated bilirubin (Bhutani, 2012). The unconjugated bilirubin had the ability to cross the blood-brain barrier where its neurotoxicity could potentially damage the brain tissues. The regions of the neonate's brain most vulnerable to excess bilirubin are those controlling hearing and motor function, which can be damaging and lead to consequences such as athetoid cerebral palsy, deafness and paralysis of ocular muscles in surviving infants (Gotink et al., 2013).

Unconjugated bilirubin is not water soluble and thus must be attached to albumin to travel to the liver in the plasma.

The bilirubin in the liver is transported across the hepatic cell membranes, where it binds to ligandin a hepatic protein for the process of conjugation. An enzyme in the liver conjugates bilirubin, which converts it to water-soluble bilirubin pigments that can be excreted into the bile and exit the body. Bilirubin pigments which are not excreted from the gut can be assimilated back into the circulation as unconjugated bilirubin. This process primarily recycles the bilirubin, which is also known as enterohepatic recirculation. Thus, neonates with reduced conjugation or excretion of bilirubin are at immense risk of acquiring

hyperbilirubinemia.

There are severe risk factors associated with hyperbilirubinemia such as Premature birth and Birthing trauma such as excessive bruising in the neonate being some of the issues found in the case of Jennifer. Jennifer was prematurely born at 33 weeks gestation and thus may not be able to metabolize bilirubin sufficiently and the amount produced in the system may be overwhelming for the neonate. Jennifer's mother Sian also had a premature rupture of membranes and spontaneous labor causing Trauma during birth which can be related as to why Jennifer had facial bruising at the time of birth. Birthing trauma can cause the neonate to have excessive bruising or injuries thus resulting in the increased production of bilirubin in the body and the early breakdown of more red blood cells (Queensland Clinical Guidelines, 2017).

In neonates hyperbilirubinemia is common and the majority of the time is a natural transition that resolves within the first week of life with the maturing of the liver.

If the concentration of unconjugated bilirubin in the blood is too high, and it breaches the blood-brain barrier and bilirubin encephalopathy occurs the consequences are severe (Lauer & Spector, 2018). Jennifer being a Premature neonate at 33 weeks gestation with very high levels of total serum bilirubin(TSB) count at 2 days post birth, requires close monitoring and medical treatments in order to prevent the severe effects of prolonged hyperbilirubinemia. Jennifer who is 48 hours post birth has TSB level at 220 micromols/L and should be considered for phototherapy and repeated bilirubin measurement in six hours. Normally in neonates, the TSB measurement should be (-- removed HTML --) 250 micromols/L immediate treatment of phototherapy is required (National Collaborating Centre for Women’s and Children’s Health, 2011). Phototherapy is an effective treatment method for neonatal jaundice where the exposure of the epidermis to a source of light could convert the unconjugated bilirubin molecules into water-soluble isomers that can be eliminated without further metabolism by the liver (Fisher & Lakshman, 2015). Phototherapy is similar to a transcutaneous medicine and when phototherapy occurs, an infusion of discrete photons of energy intake by the bilirubin(Stokowski, 2011). Effective phototherapy penetrates

the light-exposed skin and is absorbed by bilirubin molecules to have the photochemical effect. The primary aim of phototherapy is to diminish the elevated serum bilirubin levels and prevent the accumulation of its toxins in the brain, where it can cause the serious, permanent neurological complications. Therefore During phototherapy neonates requires ongoing monitoring of appropriate nutrition and hydration and, along with temperature measurements and clinical improvement in jaundice TSB levels, and potential signs of bilirubin encephalopathy (National Collaborating Centre for Women’s and Children’s Health, 2011). The photoproducts of bilirubin require elimination from the body and therefore an ongoing assessment of the infant’s urine output and bowl moment is crucial not only of hydration but also of elimination of bilirubin.

Neonatal jaundice and treatment necessarily separates the neonate from its mother and can be anxious and stressful for the whole family. Jennifer’s parents who have had 4 children previous have never had been exposed to neonatal jaundice and therefore can be particularly worried and nervous for Jennifer. It is important for a neonatal nurse to understand the situation to be empathetic and deliver appropriate family-centered neonatal nursing care. It is the responsibility of the neonatal nurses to educate the parents about the need for and actions of phototherapy, particularly in relation to the need for skin surface to be exposed to the phototherapy light, and hence the need to care for neonates receiving phototherapy to be nursed in a neutral thermal environment. The Potential complications of phototherapy also need to be addressed along with the need for protective eye coverings during phototherapy treatment should be explained. Neonates receiving phototherapy can have brief periods where the phototherapy can be safely interrupted at feeding time in order to allow continuation of breastfeeding and parental interaction and skin to skin contact.

Hyperbilirubinemia or neonatal jaundice in newborn infants are common however the risk factors are more severe in preterm neonates such as Jennnifer. appropriate treatment interventions and management of neonatal jaundice is impeccable to decree the severe effects of Hyperbilirubinemia. The nurses play a big role in the safe and appropriate care of the neonate with jaundice along with giving support to the family members involved, providing a family-centered approach to neonatal care.