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Hyperbilirubinemia

Hyperbilirubinemia: A Research Paper

Abbey Duarte

Department of Nursing, Jackson College

NRS 211: Care of Women and Neonates

Sarah Holda

April 21, 2020

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Hyperbilirubinemia

Neonatal jaundice, or hyperbilirubinemia, is a condition that is caused by the breakdown

of red blood cells, which, as a result of newborn transitional physiology, results in the build-up of

bilirubin in the infant’s circulation (Moncrieff, 2018). The condition is characterized by its

yellow-orange pigmentation of the skin, sclera, and other body tissues. It is estimated that about

60% of fullterm newborns and about 80% of preterm newborns show some degree of

hyperbilirubinemia during the first days of their lives (de Souza Fernandes, 2016).

Pathophysiology

When red blood cells are broken down, bilirubin is produced as a result of the

breakdown of the heme component of hemoglobin. This occurs in phagocytic monocytes and

macrophages in various tissues of the body and first results in a form of bilirubin called

unconjugated bilirubin. This is lipid-soluble rather than water-soluble, so it is then transported to

the liver for metabolism bound to albumin. In the liver it undergoes conjugation to produce

conjugated bilirubin, which is more water-soluble and can thus be excreted in urine and bile. The

transitional physiology of the newborn is such that there is an imbalance between the production

and clearance of bilirubin, resulting in its build up in the circulation. This is due to several

aspects of newborn physiology which include an increased red blood cell load, decreased

albumin binding, immaturity of liver conjugating enzymes, and decreased intestinal bacteria and

motility. As the liver conjugating system also requires oxygen and glucose to function efficiently,

hypoxia and hypoglycemia may also slow down this process and increase the risk of

hyperbilirubinemia (Moncrieff, 2018).

Physiologic Jaundice

Jaundice can be classified as physiologic or pathologic. Physiologic jaundice, the most

common cause of newborn jaundice, usually appears after the first 24 hours of life as a result of
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breakdown of red blood cells and liver immaturity. Jaundice is also more likely to occur when

babies are breastfed, particularly when they are having difficulties establishing effective feeding

and when there is weight loss due to inadequate intake. This is because reduced fluid and

calorific intake can result in increased recirculation of bilirubin. Encouraging early and frequent

feeding (8-12 feedings every 24 hours) is key to enhancing gut motility, promoting the

establishment of intestinal bacteria, and ensuring adequate hydration to increase the removal of

bilirubin from the intestines, as well as preventing its reabsorption (Moncrieff, 2018). Another

subtype of physiologic jaundice associated with breastfeeding is called breast milk jaundice. This

occurs slightly later, usually at two to four days of age and can last up to 12 weeks (Pearsall &

Morrow, 2016). Breast milk jaundice is thought to be due to factors in the breast milk itself that

enhance the recirculation of bilirubin (Moncrieff, 2018). However, if no pathologic source is

found with evaluation, breastfeeding can usually continue.

Pathologic Jaundice

Pathologic jaundice is less common but important to recognize in order to treat potential

underlying causes. There is a long list of causes which can be grouped into the following

categories: genetic, anatomical, metabolic, infective, blood group incompatibility, and trauma.

Newborn babies with pathologic jaundice will often develop the problem within the first 24

hours of their life. These babies also tend to be unwell, which can lead to poor feeding,

irritability and unusual sleepiness. They may also present with more widespread and obvious

jaundice and have problems with dark urine and pale stool (Pearsall & Morrow, 2016).

Risks to the Patient/Long Term Consequences

As bilirubin levels increase, binding sites on albumin become saturated and bilirubin,

being lipid-soluble, is able to cross the blood-brain barrier and accumulate in the brain
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Hyperbilirubinemia

(Moncrieff, 2018). Bilirubin can be toxic to the tissue of the brain and spinal cord, causing

conditions known as acute and chronic bilirubin encephalopathy (Pearsall & Morrow, 2016).

Symptoms of acute bilirubin encephalopathy may include lethargy, poor feeding, irritability and

hypotonia. As the damage worsens, this may progress to irritability, high- pitched cry, increasing

hypertonia, arching of the back, and extension of the neck back towards the spine. The most

severe and irreversible manifestations are referred to as chronic bilirubin encephalopathy, or

kernicterus, and include athetoid cerebral palsy, movement disorders, auditory dysfunction, and

upward gaze paralysis. It can also lead to seizures and death (Moncrieff, 2018).

Nursing Interventions

With infants now being sent home from the hospital earlier, often within 48 hours of

birth, it is nearly impossible to assess and manage jaundice, ensure breastfeeding is appropriately

established and proper support is offered before discharge. Early discharge from the hospital is

associated with readmission for jaundice, and breastfed and late preterm infants are particularly

at risk. In addition, significant hyperbilirubinemia may be detected later in the community than it

would be in the hospital, resulting in higher bilirubin levels when infants are readmitted, and

poorer outcomes (Moncrieff, 2018). This is why thorough assessments of the baby at follow-up

appointments are so crucial. The nurse must be aware of any underlying risk factors and be able

to recognize any deviations from the norm. Risk factors include gestational age at birth under 38

weeks, breastfed babies, a sibling with jaundice requiring treatment, male children, maternal age

over 25, maternal diabetes mellitus, and European, Asian or Native American ethnicity (Pearsall

& Morrow, 2016). The assessment of the baby should be performed in a well-lit room and if

jaundice is suspected, a bilirubin measurement should be taken by obtaining a blood sample to

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Hyperbilirubinemia

measure total serum bilirubin (TSB), since visual assessment of jaundice is not always reliable

(Moncrieff, 2018).

No Treatment Necessary

Treatment of neonatal jaundice depends on a variety of factors, the main one being the

underlying cause of the jaundice. With physiologic or breast milk jaundice, no treatment may be

an appropriate option if the infant has a bilirubin level below the treatment threshold and there

are no signs or symptoms of pathologic jaundice. In this case, the nurse must reassure the parents

that neonatal jaundice is very common and is often harmless and temporary (Pearsall & Morrow,

2016). The nurse must also educate the parents on the importance of frequent feedings to

mitigate jaundice, and the importance of being aware of frequency of voiding and stooling, as

well as any changes to stools to ensure that the baby is receiving adequate hydration (Moncrieff,

2018).

Phototherapy and Exchange Transfusion

For the infant that has a bilirubin level above the treatment threshold and/or an

underlying cause of the jaundice, such as trauma, a good treatment option is phototherapy.

Phototherapy is a non-invasive treatment method that uses fluorescent and halogen lighting

equipment in order to expel bilirubin in the urine and feces through the mechanisms of photo

isomerization and photo oxidation (de Souza Fernandes, 2016). Another less common option is

called exchange transfusion, which is the replacement of the newborn’s high bilirubin containing

blood with donor blood containing normal levels of bilirubin. This option is only indicated if the

infant has signs of bilirubin encephalopathy and considered if the risk of kernicterus is high or

jaundice is not responding to phototherapy (Pearsall & Morrow, 2016).

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Hyperbilirubinemia

For most babies, jaundice is most commonly physiologic and is usually harmless and

does not indicate an underlying disease. However, jaundice can also become highly pathologic

and elevated levels of bilirubin can be neurotoxic. Knowing this can be very scary and stressful

for parents who have a baby with jaundice, but the key to easing their stress and preventing

complications lies in a thorough education around the nature of neonatal jaundice, what to look

out for, and how to mitigate its effects. More importantly risk stratification, appropriate follow

up, surveillance, and support are essential duties of the nurse to prevent what should be a normal

physiological process from becoming pathological (Moncrieff, 2018).

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Hyperbilirubinemia

References

de Souza Fernandes, J. I., Teixeira Reis, A., da Silva, C. V., & Peixoto da Silva, A. (2016).

Motherly challenges when facing neonatal phototherapy treatment: a descriptive study.

Online Brazilian Journal of Nursing, 15(2), 188–195.

Moncrieff, G. (2018). Bilirubin in the newborn: Physiology and pathophysiology. British Journal

of Midwifery, 26(6), 362–370.

https://doi-org.ezproxy.jccmi.edu/10.12968/bjom.2018.26.6.362

Pearsall, R., & Morrow, G. (2016). Jaundice in newborns. World of Irish Nursing & Midwifery,

24(2), 51–53.