HYPERBILIRUBINEMIA

I. Introduction

     Bilirubin is a yellowish pigment that is made during the breakdown of red blood cells.
Bilirubin passes through the liver and is eventually excreted out of the body. Bilirubin attached
by the liver to glucuronic acid, a glucose-derived acid, is called direct, or conjugated bilirubin.
Bilirubin not attached to glucuronic acid is called indirect, or unconjugated bilirubin. All the
bilirubin in our blood together is called total bilirubin.
     In a newborn, higher bilirubin is normal due to the stress of birth. Normal indirect bilirubin
would be under 5.2 mg/dL within the first 24 hours of birth. But many newborns have some kind
of jaundice and bilirubin levels that rise above 5 mg/dL within the first few days after birth.
Additionally, normal reference ranges may vary from lab to lab.
     Hyperbilirubinemia is the elevation of serum bilirubin levels that is related to the hemolysis
of RBCs and subsequent reabsorption of unconjugated bilirubin from the small intestines. The
condition may be benign or place the neonate at risk for multiple complications or untoward
effects. 
     The newborn‘s liver is immature, which contributes to jaundice. The liver cannot clear the
blood of bile pigments that result from the normal postnatal destruction of red blood cells. The
normal rise in bilirubin levels in preterm infants is slower than in full-term infants. It lasts longer,
which predisposes the infant to hyperbilirubinemia or excessive bilirubin levels in the  blood.
     Physiological jaundice is the most common type of newborn hyperbilirubinemia. This
unconjugated hyperbilirubinemia or indirect hyperbilirubinemia presents in newborns after 24
hours of life and can last up to the first week. Neonatal jaundice is the main reason for admission
from home to a neonatal unit. Pathological jaundice is defined as the appearance of jaundice in
the first 24 hours of life due to an increase in serum bilirubin levels greater than 5 mg/dl/day,
conjugated bilirubin or direct hyperbilirubinemia levels ≥ 20% of total serum bilirubin, peak
levels higher than the normal range, and the presence of clinical jaundice greater than two weeks.
Breast milk jaundice occurs in breastfed newborns between the first and third day of life but
peaks by day 5 to 15, with a decline occurring by the third week of life.

II. Objectives

General objectives:
     The goal of hyperbilirubinemia treatment is to avoid bilirubin concentrations that may result
in kernicterus. Phototherapy remains an effective therapeutic intervention that decreases bilirubin
concentrations, thereby preventing elevated bilirubin levels associated with permanent
conditions.

Specific Objectives
Knowledge:
● To define and list out the factors for hyperbilirubinemia.
● To educate parents about proper infant feeding practices.
● To describe the consequences of hyperbilirubinemia.
Skills:
● To perform preventive measures of hyperbilirubinemia.
● To improve and regulate hyperbilirubinemia.
● To demonstrate means of assessing the infant for increasing bilirubin levels (e.g.,
blanching the skin with digital pressure to reveal the color of the skin, weight monitoring,
or behavioral changes).

Attitude:
● To practice the appropriate nursing intervention/management for the patient
 ● To promote a healthy environment for the mother and the baby.
● To discuss possible long-term effects of hyperbilirubinemia and the need for continued
assessment and early intervention.

III. Nursing Health History

     Baby Sarah was born six hours ago by vaginal delivery after 22 hours of labor at 36 weeks
gestation because of premature rupture of membranes. She weighed 9 lbs 0 ounces (4090 g) with
an APGAR score of 8 at one minute and 9 at 5 minutes. Her newborn assessment revealed a
cephalohematoma on the right-posterior aspect of her head. All other assessment data is within
normal limits. Sarah has breastfed once since birth for seven minutes. She is noted to be sleepy
when breastfed and not an aggressive feeder, consistent with her gestational age. She has voided
once since birth, but has not passed stools yet.

IV.  Physical Examination

Anthropometry
 Head circumference: 33 cm
 Chest circumference: 31 cm
 Mid arm circumference (both): 9.5 cm
 Mid-thigh: circumference (both): 12 cm
 Weight: 3.2 kg (4090g)
 Height: 49.5 cm

Head to Toe examination:

● Head: Normal, No any sign of hydrocephalus, etc.
● Eye: Normal, No any sign of ophthalmia neonatorum, redness, secretion, Bitot‟s sign etc.
● Nose: Normal, no any abnormal discharge, no redness.
● Ear: Normal, ear recoil normal, no any secretion.
● Mouth: Normal. Epstein pearl- absent, redness- absent, cleft palate and cleft lips- Absent
● Face: Normal, No any facial dysmorphism. Skin: No any cyanosis, petechiae rashes, birth
mark.
● Neck: Normal, No webbing neck, no any swelling.
● Chest: Normal chest movement, no any mass formation.
● Abdomen: normal umbilical cord, no any sign of hernia, liver, spleen normal.
● Extremities: Normal, no any oligodactyly, polydactyly, club foot, calcaneo valgus and
varus.
● Genital organ: Labia majora is full; Labia minora thickened

Respiratory system:
● Chest bi- symmetrical, normal chest movement, no added sound RR- 49/min
● Cardio-vascular system: S1,S2 Heard, No murmurs, HR-148/min
● Per-abdomen: Soft, no any prominent veins, no any organomegaly

Central nervous System: Reflexes:

● Moro reflex- Intact
● Sucking reflex- Intact
● Rooting reflex-Intact
● Step reflex-
● Intact Grasp reflex-Intact
● Tonic neck reflex- Intact
● Plantar reflex- Intact
Vital Signs:
HR: 148/min
RR: 49/min
Temp: 37.5

V. Anatomy and Physiology

Anatomy of the Liver

The liver is the largest
solid organ in the body. It removes
toxins from the body’s blood
supply, maintains healthy blood
sugar levels, regulates blood
clotting, and performs hundreds of
other vital functions. It is located
beneath the rib cage in the right
upper abdomen.The liver is
reddish-brown and shaped
approximately like a cone or a
wedge, with the small end above
the spleen and stomach and the
large end above the small
intestine. It weighs between 3 and
3.5 pounds.

Four lobes of liver

The liver consists of four lobes: the larger right lobe and left lobe, and the smaller
caudate lobe and quadrate lobe. The left and right lobe are divided by the falciform (“sickle-
shaped” in Latin) ligament, which connects the liver to the abdominal wall. The liver’s lobes can
be further divided into eight segments, which are made up of thousands of lobules (small lobes).
Each of these lobules has a duct flowing toward the common hepatic duct, which drains bile
from the liver.
Parts
The following are some of the most important individual parts of the liver:

● Common Hepatic Duct: A tube that carries bile out of the liver. It is formed from
the intersection of the right and left hepatic ducts.
● Falciform Ligament: A thin, fibrous ligament that separates the two lobes of the
liver and connects it to the abdominal wall.
● Glisson’s Capsule: A layer of loose connective tissue that surrounds the liver and its
related arteries and ducts.
● Hepatic Artery: The main blood vessel that supplies the liver with oxygenated
blood.
● Hepatic Portal Vein: The blood vessel that carries blood from the gastrointestinal
tract, gallbladder, pancreas, and spleen to the liver. 
● Lobes: The anatomical sections of the liver.
● Lobules: Microscopic building blocks of the liver.
● Peritoneum: A membrane covering the liver that forms the exterior.

Key Facts
● The liver filters all of the blood in the body and breaks down poisonous substances,
such as alcohol and drugs.
● The liver also produces bile, a fluid that helps digest fats and carry away waste.
● The liver consists of four lobes, which are each made up of eight sections and
thousands of lobules (or small lobes).

Functions of the Liver

The liver is an essential organ of the body that performs over 500 vital functions. These
include removing waste products and foreign substances from the bloodstream, regulating blood
sugar levels, and creating essential nutrients. Here are some of its most important functions:

● Albumin Production: Albumin is a protein that keeps fluids in the bloodstream

from leaking into surrounding tissue. It also carries hormones, vitamins, and
enzymes through the body.
● Bile Production: Bile is a fluid that is critical to the digestion and absorption of fats
in the small intestine.
● Filters Blood: All the blood leaving the stomach and intestines passes through the
liver, which removes toxins, byproducts, and other harmful substances.
 ● Regulates Amino Acids: The production of proteins depend on amino acids. The
liver makes sure amino acid levels in the bloodstream remain healthy.
● Regulates Blood Clotting: Blood clotting coagulants are created using vitamin K,
which can only be absorbed with the help of bile, a fluid the liver produces.
● Resists Infections: As part of the filtering process, the liver also removes bacteria
from the bloodstream. 
● Stores Vitamins and Minerals: The liver stores significant amounts of vitamins A,
D, E, K, and B12, as well as iron and copper.
● Processes Glucose: The liver removes excess glucose (sugar) from the bloodstream
and stores it as glycogen. As needed, it can convert glycogen back into glucose.
● Excretion of Bilirubin: Bilirubin, derived from the heme of worn-out red blood cells
is absorbed by the liver from the blood and secretion into bile. If there is an
accumulation of bilirubin, the skin and eyes turn yellow.

VII. Pathophysiology

Bilirubin is a yellowish pigment that is made during the breakdown of red blood cells.
Bilirubin passes through the liver and is eventually excreted out of the body. Higher than usual
levels of bilirubin may indicate different types of liver or bile duct problems. Sometimes, higher
bilirubin levels may be caused by an increased rate of destruction of red blood cells.

Bilirubin metabolism

Bilirubin is a waste product produced by the breakdown of red blood cells. Bilirubin is
the end-product of heme metabolism; the liver is the site for bilirubin metabolism.

● Bilirubin is one of the breakdown products of hemoglobin.

● When RBCs are destroyed, the breakdown products are released into the circulation,
where the hemoglobin spits into heme and globin.

● The body uses the globin (protein) and heme is converted to conjugated bilirubin.

● In the liver the bilirubin is conjugated with glucuronosyltransferase.

● This conjugated bilirubin is excreted into the bile.

● In the intestine, bacterial action reduces the conjugated bilirubin into urobilinogen and
stercobilinogen.

● Normally the body is able to maintain a balance between the destruction of RBCs and the
use or excretion of the body.

● When this balance is upset, bilirubin accumulates in the body causing jaundice.
 ● Types of Hyperbilirubinemia

PHYSIOLOGICAL JAUNDICE PATHOLOGICAL JAUNDICE

● Not appear before 2nd or 3rd day in ● Appears within the 1st day (24 hours
term baby. after birth).

● In premature baby, it appears after 3rd ● Needs longer time or disappears.

or 4th day.
● In term newborn, it disappears by the
end of 7th day while premature lasts
for 9 to 10 days.
● Serum bilirubin exceeds12 mg/dl
● Serum bilirubin exceeds the daily raise
of physiological jaundice.

● The total level of total serum bilirubin ● Cause kernicterus in indirect

never exceeds 12mg/dl in full-term hyperbilirubinemia.
newborn and 15mg/dl in preterm
● Treatment is important as soon as
newborn and the direct bilirubin does
possible.
not exceed 1mg/dl of the total
bilirubin. ● The newborn looks sick, poor sucking,
pale, abnormal stool and urine color.
● No kernicterus.

● Requires no treatment.

● The newborn is good sucker, no

anemia, not sick, normal stool and
urine color.

Kernicterus

It is also called bilirubin encephalopathy and is caused by the deposition of the

unconjugated bilirubin in the brain. It results in the yellowish staining of the brain tissue and the
necrosis of neurons and occurs if the concentration of the unconjugated bilirubin reaches toxic
level.

Stages of Kernicterus

● Stage 1: poor motor reflex, poor feeding, vomiting, high-pitched cry, decreased tone and
lethargy.

● Stage 2: opisthotonos, seizures, fever, oculogyric crises and paralysis of upward gaze.
Many newborns die in this phase.

● Stage 3: spasticity is decreased at about one week of age (a symptomatic)

● Stage 4: progressive spasticity, deafness, and mental retardation.

Causes:

● Prematurity

● Breast milk

● Excess production of bilirubin (hemolytic disease, bruises)

 ● Enzyme deficiency, bile duct obstruction

● Sepsis

● Diseases like hypothyroidism, IDM

● Genetic predisposition

Signs and Symptoms:

● Bilirubin level: 6.1 mg/dL

● Jaundice

● Lethargy

● High-pitched Cries

● Irritable

● Arching her neck or body backward

VI. Diagnosis and Laboratory

Laboratory Test Of Hyperbilirubinemia In Neonates

Liver and biliary tests are useful in the differential diagnosis of jaundice from bilirubin
overproduction (hemolysis), decreased uptake (Gilbert disease), decreased conjugation
(hepatocellular disease, familial, drug-induced, pregnancy; obstructive bile duct disease).

Direct and indirect bilirubin levels. A blood test can determine if the bilirubin is bound with
other substances by the liver so that it can be excreted (direct), or is circulating in the blood
circulation (indirect).

Coomb's test looks for antibodies that may stick to your red blood cells and cause red blood
cells to die to early.

Postnatal History

Lung - expanded

Activity - Alert

Color - Pink

APGAR score- 1st min- 8/10, 5th min. 10/10 10th min. 10/10

Ballard score- 40 (40th week of gestational age)

No any congenital anomalies

No any abnormal secretion from umbilical cord

Vital Signs

HR - 148/min

RR - 49/min

Temp. 37.5 °C
Anthropology

Head circumference 33 cm

Chest circumference 31 cm

Mid arm circumferences (both) 9.5 cm

Mid thigh circumferences (both) 12 cm

Height 49.5 cm

Weight 3.2 kg

Bilirubin Investigation

Hemoglobin% - 17.8gm%

Blood group- O positive

CRP- Negative

Bilirubin level (Before treatment) -Total – 11.8 mg/dl

Direct bilirubin- 1.2 mg/dl

Indirect bilirubin- 10.6 mg/dl

Bilirubin level (after treatment) - Total – 5.8 mg/dl

Direct bilirubin- 0.6 mg/dl

Indirect bilirubin- 5.2 mg/dl

Blood Type - A positive

Hepatitis B - negative

GSB - negative

Blood Sugar - >50 mg/dl

Hematocrit - 48%

Reflexes

Moro reflex- Intact

Sucking reflex- Intact

Rooting reflex-Intact

Step reflex- Intact

Grasp reflex-Intact

Tonic neck reflex- Intact

Planter reflex- Intact

VIII. Drug Study

IX. Nursing Care Plan
X. Discharge Plan

Discharge Planning for Neonatal Hypothermia

PLANNING  •After health teaching about the effects of hyperbilirubinemia to the
newborn, the client will be able to identify the characteristics and
implications of the condition, Lastly, he or she would have the
knowledge to keep the baby’s bilirubin levels in check. 
MEDICINE  •Advise parents to continue the newborn’s medications at home as
prescribed by the doctor. 
TREATMENT  •Provide parents with an appropriate written explanation of home
phototherapy, potential problems, and safety precautions. 
HEALTH •Discuss home management of mild or moderate physiological
EDUCATION  jaundice, including increased feedings (preferrably breastfeeding), and
diffused exposure to sunlight (checking infant frequently) 
 
• Provide information about jaundice, pathophysiological factors,
implications of hyperbilirubinemia. 

 
OUT PATIENT •Advise parents to monitor baby for untoward signs and symptoms
FOLLOW-UP VISIT   and a follow-up check up a week later after discharge. 
 
DIET  •Advises the parents of the baby to increase frequency of feedings
(preferrably breastfeeding)