NEONATAL

JAUNDICE
Puan Rohimah bt Ismail
 At the end of lecture the students be able to:

1. Define neonatal jaundice

2. State the etiology of neonatal jaundice.
3. State the pathophysiology of neonatal
jaundice

LEARNING 4.
5.
State the type of neonatal jaundice
State clinical manifestation of neonatal

OUTCOME
jaundice
6. Explain treatment for neonatal jaundice
7. Explain nursing intervention for neonatal
jaundice.
8. Appreciate the knowledge in caring
patient with neonatal jaundice
Definition
Jaundice is a yellow color of the
skin and sclera of eye cause by
excess bilirubin in the blood.

(American Academy of Pediatrics ,2004)

Etiology

After baby born, immature Hemoglobin will be

broken down and produce heam, globin and iron.

Haem become biliverdin and form unconjugated

bilirubin. Increased level of unconjugated bilirubin
will cause neonatal jaundice

Globin and iron are used by the body to make

protein
 Pathophysiology of
jaundice
After born, RBC will broken and produce biliverdin (unconjugated bilirubin),
This substance is fat soluble and lead to neonatal jaundice

Unconjugated bilirubin bind with albumin and transported to liver .

In liver, it combined with glucuronic acid and become conjugated bilirubin which is
water soluble

Conjugated bilirubin will be excreted by biliary system into small intestine. Normal
bacteria change to urobilinogen and will excreted by faces and small amount in urine.
Clinical
Manifestation
❑Yellow color of skin.
❑Begin on face and moves
down to chest, leg and
soles.
❑Sometimes have extreme
tiredness and poor feeding.
Cont…
❑The urine color is dark, while the
stool appears normal.
❑High levels of bilirubin can cause
high-pitched crying, apnea, seizures
and arched backs in the infants
Type of
neonatal
jaundice
❑Physiological jaundice
❑Pathological jaundice
❑Breast feeding
jaundice
❑Breast milk jaundice
 ❑Affect 50% of term and 80% of premature babies.

❑Appear after 24 hours

Physiological ❑Maximum intensity by 4th – 5th in term and 7th day in

preterm

jaundice ❑Serum level less than 15 mg/dl

❑Clinically not detectable after 14 days.

Cause of
physiological
jaundice
A) Increased red cell breakdown

-In uterus fetus need large

hemoglobin

- After birth, hemoglobin broken down

and resulting unconjugated bilirubin
(biliverdin)

B) Decreased albumin-binding
capacity

- Newborns have lower albumin and

decreased albumin-capacity.

- This reducing transport of bilirubin to

the liver for conjugation.
 C) Enzyme deficiency
Enzyme activity are lower during first 24 hrs
after birth.
This reducing bilirubin conjugation in the liver.

Cont… D) Increased enterohepatic circulation .

Newborn bowel lacks the normal bacteria that
break down conjugated bilirubin to
urobilinogen.
Newborn also have increase in beta-
glucuronidase enzyme which change
conjugated bilirubin back into the
unconjugated state.
Enterohepatic
circulation
The substances excreted by
the liver are absorbed by
the intestinal mucosa and
returned to the liver due to
increased beta-
glucuronidase enzyme in
intestinal.
Pathological
jaundice
❑Appear within 24
hours of age
❑Serum bilirubin > 15
mg/dl
❑Jaundice persisting
after 14 days
❑Stool clay / white color
and urine staining
yellow
 Appearing within 24 hours of age
Hemolytic disease of newborn :

❖Blood type/group incompatibility

Cause of
✓-including Rhesus( RhD) and ABO
Pathological incompatibility.
Jaundice ✓If mother RhD negative and baby RhD-
positive, this will cause severe hemolysis.
✓-if mother blood group type O,baby A or
B.
✓This also will cause severe hemolysis.
 ❖Infection :
✓TORCH which includes
Toxoplasmosis, Other (syphilis,
varicella-zoster, parvovirus B19),
Rubella, Cytomegalovirus (CMV),
and Herpes infections
Cont… ✓bacteria
❖G6PD deficiency
✓G6PD maintains the integrity of
the cell membrane. A deficiency
results in increased heamolysis
 ❖Sepsis
✓lead haemoglobin breakdown
Cont…
❖Polycythaemia
✓too many red cells.
 Appearing between 24 – 72 hours of life
Sepsis
polycythemia
Concealed hemorrhage
Intraventricular hemorrhage
Increased entero - hepatic circulation

Cont.. After 72 hours of life

Sepsis
Cephalhematoma
Neonatal hepatitis
Extra hepatic biliary atresia
Breast milk jaundice
Metabolic disorder
 ❑Breast feeding jaundice occur early.
❑It is due to lack of breast milk.
Breast ❑It is often associated with poor
passaged of meconium.
feeding ❑Treatment should be aimed at
jaundice supporting breastfeeding while
supplementing as needed to avoid
extreme weight loss, dehydration and
worsening jaundice.
 ❑More less occur.
❑It is probably caused by factors in the
breast milk that block certain proteins
in the liver that break down bilirubin.
❑Usually weight gain good and the
Breast milk baby otherwise well.
jaundice ❑Jaundice might persist as late as 3-4
weeks.
❑Treatment usually interrupt breast
feeding for while.
 J – Jaundice within first 24 hour of life
A – A sibling who has jaundice
U – Unrecognized hemolysis
Risk factor N - Non optimal sucking
of jaundice D – deficiency of G6PD
I – Infection
C - Cephalhematoma/ bruising
E - East Asian
Complication
1. Acute Bilirubin
Encephalopathy
- Is the condition when
bilirubin passing into
the brain.
2. Kernicterus
- Occurs if acute
bilirubin encephalopathy
causes permanent
damage to the brain.
Signs-
symptoms of
kernicterus
Early stage

✓poor feeding,

✓abnormal cry,

✓hypotonia.

Intermediate phase

✓stupor,

✓Irritability

✓hypertonia.

Late

✓no feeding,

✓Opisthotonus

✓apnea,

✓seizures and death.

Opisthotonus
❑It is a state of severe
hyperextension in an
individual’s head, neck
and spinal column enter
arching position.
3. Blindness
4. Mental Retardation
5. Cerebral Palsy
6. Deafness
Treatment
❑Application of fluorescent light to the infant’s
exposed skin used to breakdown the bilirubin in the
skin.

❑Phototherapy reduce levels of unconjugated bilirubin

and reduce for neurotoxicity or kernicterus.

❑Skin that expose to phototherapy light, converts fat-

soluble unconjugated bilirubin into water-soluble
bilirubin.

1. Phototherapy
Phototherapy
Conventional phototherapy
Triple unit intense phototherapy
Side-effects of
phototherapy
❑Hyperthermia,
❑Increased fluid loss and
dehydration.
❑Damage to the retina from
the high intensity light.
❑Lethargy or irritability,
❑Decreased eagerness to
feed.
❑Skin rashes and skin
burns.
2.Breast
feeding
❑Encourage early breastfeeding
frequent breast feeding.
Breast feeding supplies :
✓glucose to liver ( increase
enzyme)
✓increase bowel motility.
✓increase normal flora.
✓Increase albumin-banding
capacity.
✓Decrease enterohepatic
reabsortion.
 ❑Excess bilirubin is removed
from baby during blood
exchange.
3. Exchange ❑Erythrocytes are replaced with
transfusion blood compatible with both the
mother’s and infant’s serum.
Nursing care
 ❑ Check the power of phototherapy light
✓ Power must be 30-40 uW/cm2/nm.

❑ Place the baby about 45-50 cm from light with

entire skin expose.
✓ To get effective phototherapy, the distance of
light and baby should be 45-50 cm.
Cont ….
❑ Change the position every 2 hourly.
✓ To expose entire body to phototherapy.

❑ Maintain thermo neural environment

✓ Thermo neutral will provide least amount of
oxygen is consumed for metabolism
 ❑Maintain thermo neural environment
Thermo neutral will provide least amount of oxygen is
consumed for metabolism
Thermo neural is an environment that keeps body
temperature at an optimum point at which the least
amount of oxygen is consumed for metabolism.

Cont… ❑Use eye shields to cover the eyes without occluding

the nose.
✓Eye shields will protect retina damage

❑Encourage to frequency breast feeding.

✓breastfeeding will increase bowel motility and normal
bowel flora
 ❑Monitor bilirubin level everyday.
✓ hyperbilirubinemia can cause toxicity in
brain.

❑Clean skin with warm water and

observed for rashes, dryness and
excoriation.
✓ Complication of phototherapy will cause
Cont… skin dryness, rashes and excoriation.

❑ Monitor fluid intake and output

✓ hyperbilirubinemia will cause lethargy
and baby not interest to breastfeeding.
DEVELOP OTHER RELATED IDENTIFY GOAL PLAN NURSING
NURSING DIAGNOSIS INTERVENTIONS RELATED
TO THOSE PROBLEMS

STUDENT’S ACTIVITY
Group
Impaired skin integrity related to
hyperbilirubinemia during using
phototherapy.

Deficient fluid volume related to inadequate

fluid intake during photo-therapy.

Risk for recurrent jaundice related to

knowledge deficit.
references

B.Black, J.M & Hawks J.H (2010) Medical Surgical

Nursing (8th Ed). Singapore, Sounders Elsevier.
Kozier, B Erb, G, Berman, A.J & Burke, K. (2001).
Fundamental of Nursing : concepts, process and
practice, (5th Ed). New Jersey. Practice hall.