Newborn Jaundice: A Comprehensive Guide for Nurses

Newborn jaundice is a common condition characterized by the yellow discoloration of a newborn’s skin and sclera caused by elevated levels of bilirubin in the blood (hyperbilirubinemia). While often benign, untreated severe jaundice can lead to serious complications such as kernicterus. Nurses play a critical role in early identification, management, and education of parents about jaundice in newborns.

Understanding Bilirubin and Jaundice

Bilirubin is a yellow pigment produced during the breakdown of red blood cells (RBCs). In newborns:

• Production:
  • Increased breakdown of fetal hemoglobin leads to higher bilirubin production.
• Immaturity of the Liver:
  • The newborn liver is less efficient in conjugating bilirubin, which delays its excretion.
• Excretion:
  • Unconjugated bilirubin is metabolized in the liver and excreted in bile through stool.

Types of Newborn Jaundice

Physiological Jaundice:

• Occurs in most newborns due to immature liver function.
• Onset: Typically appears after 24 hours of life.
• Peak: Days 2–4.
• Resolution: By day 10–14.

Pathological Jaundice:

• Appears within the first 24 hours of life or persists beyond 2 weeks.
• Causes:
  • Hemolytic Disorders: ABO or Rh incompatibility, G6PD deficiency.
  • Infections: Sepsis, TORCH infections.
  • Metabolic Disorders: Hypothyroidism, galactosemia.
  • Obstructions: Biliary atresia.

Breastfeeding Jaundice:

• Due to inadequate breastfeeding leading to dehydration and delayed stooling.
• Onset: Within the first week of life.

Breast Milk Jaundice:

• Caused by substances in breast milk that inhibit bilirubin conjugation.
• Onset: After the first week of life.

Risk Factors for Newborn Jaundice

• Prematurity (<37 weeks gestation).
• Exclusive breastfeeding (with poor feeding or dehydration).
• Hemolytic diseases (e.g., Rh or ABO incompatibility).
• Family history of jaundice.
• Bruising or cephalohematoma (due to increased RBC breakdown).
• Maternal diabetes.
• Delayed passage of meconium.

Clinical Presentation

Symptoms:

• Yellow discoloration of the skin and sclera.
• Progresses from head to toe as bilirubin levels rise.
• Lethargy or poor feeding in severe cases.
• Dark urine and pale stools (indicating obstructive jaundice).

Severe Symptoms (Signs of Kernicterus):

• High-pitched crying.
• Hypotonia or hypertonia.
• Arching of the neck and back (retrocollis/opisthotonos).
• Seizures.
• Poor feeding or refusal to feed.

Diagnosis

1. Clinical Assessment:

Blanching Test:

• Apply gentle pressure to the skin to observe yellowing underneath.

Assess for progression of jaundice:

• Head to toe distribution.

2. Laboratory Tests:

• Total Serum Bilirubin (TSB): Used to confirm and quantify hyperbilirubinemia.
• Direct vs. Indirect Bilirubin:
  • Indirect (unconjugated): Physiological jaundice.
  • Direct (conjugated): Indicates pathological causes (e.g., biliary atresia).
• Blood Tests:
  • Complete Blood Count (CBC).
  • Blood type and Coombs test for hemolytic causes.

3. Transcutaneous Bilirubinometer:

• A non-invasive device for estimating bilirubin levels.
• Follow-up with serum bilirubin testing if levels are high.

4. Other Tests (if indicated):

• G6PD enzyme levels.
• Liver function tests.
• Infection screening (e.g., blood cultures, CRP).

Management of Newborn Jaundice

1. Phototherapy:

Indication:

• First-line treatment for hyperbilirubinemia.

Mechanism:

• Converts unconjugated bilirubin into a water-soluble form (lumirubin) that can be excreted in urine and stool.

Types:

• Conventional phototherapy (blue light).
• Fiber-optic blankets for home use.

Nursing Care During Phototherapy:

• Expose as much skin as possible (while protecting eyes and genitalia).
• Monitor temperature to prevent hypothermia or hyperthermia.
• Ensure adequate hydration and feeding.
• Check bilirubin levels every 4–6 hours initially.

2. Exchange Transfusion:

• Indicated for severe hyperbilirubinemia or risk of kernicterus.
• Replaces the infant’s blood with donor blood to remove excess bilirubin and antibodies.

3. Breastfeeding Support:

• Encourage frequent breastfeeding (8–12 times daily) to enhance bilirubin excretion.
• Provide lactation support for mothers with breastfeeding challenges.

4. IV Fluids:

• Administer if dehydration is contributing to jaundice.

Nursing Interventions

1. Monitoring:

• Regularly assess skin and sclera for signs of jaundice.
• Monitor vital signs, especially during phototherapy.
• Track daily weight, urine output, and stool frequency.

2. Parental Education:

• Teach parents how to recognize worsening jaundice (e.g., yellowing progressing below the chest).
• Emphasize the importance of frequent feeding.
• Explain the purpose and procedure of phototherapy.

3. Supportive Care:

• Provide eye protection during phototherapy.
• Maintain skin integrity by changing positions and keeping skin clean and dry.

4. Documentation:

• Record bilirubin levels, treatment interventions, and infant responses.
• Document feeding patterns and parental education efforts.

Complications of Newborn Jaundice

Kernicterus (bilirubin encephalopathy):

• Deposition of unconjugated bilirubin in the brain, causing irreversible damage.
• Symptoms: Developmental delays, cerebral palsy, hearing loss.

Prolonged Jaundice:

• Persistent jaundice beyond 2 weeks may indicate underlying conditions like biliary atresia or hypothyroidism.

Prevention

1. Early Feeding:

• Initiate breastfeeding within the first hour of life to promote stooling and bilirubin excretion.

2. Monitor High-Risk Infants:

• Screen for jaundice in the first 48 hours, especially in preterm or low-birth-weight infants.

3. Parental Awareness:

• Educate parents on feeding frequency and the importance of follow-up care.

Complications of Newborn Jaundice

• Kernicterus (bilirubin encephalopathy): Deposition of unconjugated bilirubin in the brain, causing irreversible damage.
• Prolonged Jaundice: Persistent jaundice beyond 2 weeks may indicate underlying conditions like biliary atresia or hypothyroidism.

Conclusion

Newborn jaundice is a common and usually benign condition, but early recognition and treatment are essential to prevent severe complications. Nurses play a critical role in assessing jaundice, implementing interventions such as phototherapy, and educating parents on proper newborn care. Through vigilant monitoring and timely action, nurses can ensure positive outcomes for affected infants.