Physiological Jaundice in the Neonate - Essay Example

? London South Bank Faculty of Health and Social Care Number: Pre-Registration BSc (Hons) Midwifery Cohort: 09/12 (S) Module Name: The Compromised Neonate Module Reference: MWY _6 _009 Assignment Title: Physiological Jaundice in the Neonate Word Count: 3181 Research Article on Neonatal Physiological Jaundice Care Arora, Mohandas, Ridout and Aladangady published an article in 2011 which focuses on the use of a range of thresholds in the treatment of neonatal jaundice by phototherapy and exchange transfusion, as well as in finding out how many number of hours therapy are needed before the bilirubin levels become stabilised and within the tolerable limits of neonates. It was found out that out of the 72 units contacted by the researchers, more than 50% of these were using charts similar to the National Institute for Health and Clinical Excellence (NICE) guidelines in 2010, while the rest were either using formulas for computing the bilirubin levels or using individual bilirubin charts for every infant (Arora, et al., 2011). Results also showed that the time needed for stabilisation of bilirubin levels increases along with the gestational age of the neonate. In addition, despite the various methods employed for the treatment of neonatal jaundice and the wide ranges in the treatment levels used, there has been an overall median plateau of around 72 hours for the stabilisation of bilirubin levels in most of the neonates. However, because the date of the release of the NICE guidelines was in proximity with the release of this article, it can be inferred that the national guidelines were not yet fully disseminated in most hospitals and other neonatal units during the time the participating units were contacted, as suggested by the conclusion of the article in the high variability and wide variations in the threshold levels used among the 72 units contacted by the researchers. While the chosen article does not directly refer to the NICE guidelines, it pushes the importance of the creation of and use of standardised methods of treatment so as to prevent either the overtreatment or under-treatment of neonatal jaundice among a significant number of infants (Arora, et al., 2011). The article is also relevant to the scenario for this paper since it discusses both the use of phototherapy to treat neonatal jaundice, as well as in discussing the importance of using guidelines in managing bilirubin levels for improving the symptoms of neonatal jaundice. Physiological Jaundice in the Neonate Jaundice is a condition which is caused by the accumulation of bilirubin or broken down red blood cells in various parts of the body, and is most visible as a yellow discolouration in the sclera of the eyes and on the skin starting from the head and moving down to the lower regions of the body (Robertson & South, 2007). The yellow colour is attributed to the inability of the infants’ bodies to rapidly catabolise foetal red blood cells through the liver and to expel these through bowel movement. While there are two forms of bilirubin circulating in the neonate’s blood: the unconjugated bilirubin (fat-soluble) and the conjugated bilirubin (water soluble), it is the unconjugated bilirubin which causes the yellow discolouration due to its fat-soluble nature earning its capacity to enter cellular membranes and becoming deposited in tissues such as the skin, gums, and eyes (Percival, 2002). As a result the bilirubin that builds up in the bloodstream due to the slow breakdown of red blood cell catabolism can reach to about 5-7mg/dL or 85.5-119.7?mol, binding to fatty deposits within the neonatal body and causing the yellow discolouration (Varney, et al., 2004). This amount of bilirubin build-up in the infant’s bloodstream is enough to give off the typical yellow discolouration of the skin among those affected, with the intensity of the colour associated with an increase in bilirubin accumulation. Up to 50% of neonates are typically affected by this condition and usually does not pose grave problems unless issues or complications arise such as the appearance of discolouration symptoms within less than 24 hours after birth, having blood or Rh factor incompatibilities between the mother and the new born, or having birth defects such as liver or bile problems or enzyme deficiencies (Percival, 2002). It is important to address the bilirubin accumulation in the neonate’s body as early as possible as the lack of prompt treatment could cause various mental impairments such as kernicterus, cerebral palsy and bilirubin encephalopathy, all of which could greatly affect the growth and development of the child’s central nervous system (Murray & Roberts, 2007). A valuable tool in assisting on the administration of appropriate treatment to neonates with jaundice is the consensus-based bilirubin threshold level chart for neonates with varying gestational ages set by the National Institute for Health and Clinical Excellence in 2010. The use of charts such as this reflects the gradual plateau in the effects of the treatment method to the bilirubin levels of the neonate, guiding the carer to the appropriate actions as needed (Arora, et al., 2011). Precisely combining the detection of bilirubin levels and applying the proper intervention while characterising the neonate’s jaundice type assures proper management of neonatal jaundice and its eventual improvement. Neonatal jaundice can either be physiological or pathological in nature. Physiological jaundice accounts for most of the unimportant neonatal jaundice cases, and the symptoms usually appear more than 24 hours of being born, and are usually managed through monitoring of the infant’s bilirubin levels for 6-12 hour intervals, and administering the appropriate intervention depending on the infant’s bilirubin levels (National Institute for Health and Clinical Excellence, NICE, 2010). Interventions include phototherapy sessions and exchange transfusion, depending on the detected bilirubin levels in the blood, and published guidelines are used in order to choose the appropriate intervention for the neonate. It is expected that in such cases, the infants having physiological jaundice reach normal bilirubin levels in a few days after letting the body adjust to normal metabolic processes or with the assistance of interventions. However, if the symptoms appear within less than 24 hours after being born, if the bilirubin levels continuously rise despite interventions, if blood tests reveal that there are Rh and blood type incompatibilities between the mother and the infant, or if the infant suffered from infections, then the condition is considered as pathological jaundice (Boxwell, 2010). This form of neonatal jaundice can be considered to be multi-factorial, as it is also possible that the infant may have birth defects such as biliary obstruction, hepatocellular dysfunction, and upper intestinal tract obstructions which along with the slow catabolism of foetal red blood cells contribute to the rapid build-up of bilirubin within the neonate’s body (Jacob, 2012). Therefore, in order to give the appropriate intervention for the child, the caregiver must be able to use various ways in assessing whether or not to administer treatment to the child, as well as in choosing the most appropriate intervention methods as possible since more aggressive treatment methods such as exchange transfusion might not only be unnecessary but also could increase the risks for survival. For this paper, the treatment of a neonate with physiological jaundice using the set guidelines by the NICE shall be described. The preferred research method of choice is descriptive research, via case study method, wherein the neonate is observed as well as treated using testable hypotheses, as well as having results in line with previously-published studies on neonatal jaundice. In relation to this, an article by Arora, Mohandas, Ridout and Aladangady in 2011 was chosen in further explaining the effects of the care given to the neonate. The article was chosen mainly since it delves on the use of various hospitals in therapy methods such as phototherapy in improving neonatal jaundice, its results correspond to the chart outcomes based on NICE guidelines, as well as explaining how the effects of the treatment methods worked for the neonate patient. In order to describe the methods utilised to care for a 37-week old neonate observed to have physiological jaundice (as the symptoms appeared within two days after birth), it shall first be mentioned that aside from the conditions observed from the infant, as well as the circumstances of how the mother has decided to feed the child, and the similar occurrence of jaundice in an older sibling, no other ways of identifying the patient and the mother using personal information such as names, addresses, dates of births, among others shall be mentioned in this report, as per the guidelines set forth by the Nursing and Midwifery Council with regards to patient information confidentiality (Nursing and Midwifery Council, NMC 2010). The child cared for in the Neonatal Unit (NNU) was a pre-term infant, being born at 37 weeks gestation period. The child was observed to be normal until the initial appearance of the signs of jaundice 24 hours after being born. The yellow discolouration of the sclera and the face were very visible and therefore prompted the carers to do a blood test to detect bilirubin levels in the blood four hours after the symptoms first appeared. It was found out that the total serum bilirubin (TSB) levels were at 14.5 mg/dL or 247.95 ?mol/L which were considered to be rather high as shown in the threshold levels for infants aged 24-30 hours old, and these results were published in the NICE guidelines (see Appendix A.) Single light source phototherapy was initiated immediately and bilirubin blood levels were monitored regularly. Four hours after the therapy was first initiated, it was observed that the bilirubin dropped to 14 mg/dL or 239.4 ?mol/L, then dropped further to 13 mg/dL or 222.3 ?mol/L after the next four hours. Six hours after, the bilirubin levels were at 12.5 mg/dL or 213.75 ?mol/L, and after another six hours the levels were down and stable at 10 mg/dL or 171 ?mol/L. Phototherapy was stopped and after 12 hours the baby was administered another blood test, which showed that the bilirubin has dropped to 9 mg/dL or 153.9 ?mol/L, suggesting that the jaundice will not be returning to high levels. The decreasing levels of bilirubin prompted to stop the phototherapy but carers still performed blood tests every 6-12 hours to check if the bilirubin levels were constantly decreasing as the neonate gets older. In addition to the above information, aside from the child having an older sibling who also had neonatal jaundice and needed treatment, the mother also chose to breastfeed the baby, which she did at 2-3 hour intervals for 30 minutes during the whole progression of the phototherapy. Also, the baby only wore diapers and shades for eye protection during the course of the therapy. The intervention for the baby’s observed physiological jaundice was performed in accordance with the guidelines published by NICE, with regards to the care of neonatal jaundice, stating that upon reaching the bilirubin threshold levels requiring phototherapy, treatment must be administered as soon as possible along with monitoring of the infant’s bilirubin levels 4-6 hours after initiation (NICE, 2010). The relevance of using phototherapy was based on early researches which were able to prove that the exposure of bilirubin to certain wavelengths of light could increase the rate of degradation from an insoluble form which tends to attach to fatty tissues, to a much more soluble form which is readily excreted by the body through the faeces (de Almeida, 2004). Thus, it is through phototherapy that excess bilirubin present in the skin could be removed from the body, and it is through this method that this toxic by-product of heme breakdown could be safely removed from the infant’s body without the use of highly-invasive procedures. In the course of any form of therapy for neonatal jaundice, blood bilirubin levels must be constantly monitored in order to gauge whether or not to continue with the phototherapy, since the gradual rise or stagnation of bilirubin levels after a certain period of phototherapy might indicate other underlying problems such as liver and intestinal tract problems, metabolic and other predisposing factors such as low concentrations of binding agents for rapid excretion of bilirubin (e.g. albumin) (Ali, et al., 2012). However, since there has been an observed decrease in the TSB 32 hours after the initial treatment and it continuing well after 44 hours from the first treatment, it can be inferred that the child initially had physiological jaundice and successfully responded to prompt phototherapy, in addition to the expected plateau and stabilisation in the TSB levels (Arora, et al., 2011). As the result of early intervention using phototherapy, the child was able to reach low-intermediate risk levels after reaching 9 mg/dL or 153.9 ?mol/L TSB 44 hours after birth (see Appendix B). It was observed that based on the child’s history, some risk factors associated with the development of physiological jaundice among neonates were inferred to as possible causes for onset, and most of these have been described in various papers and other publications. These risks include having an older sibling who also had neonatal jaundice and had been treated for it, having an ABO or Rh factor incompatibility with the mother and the possibility of infection during delivery (Boxwell, 2010). In the case of this child, it was the fact that an older sibling also had neonatal jaundice and had to receive treatment that increased the risks for the child to develop neonatal jaundice as well. Such risks are important to take note of since any one of these could increase the chances that the next offspring would also contract jaundice sometime after birth (Ali, et al., 2012). These entail the increased alertness of carers in looking for visible symptoms of jaundice during the first few days of life. Thus it was necessary that information with regards to the child’s elder sibling also developing jaundice after being born was disclosed by the mother so as to alert carers that the child has an increased risk of developing jaundice similar to the older sibling and must be monitored accordingly. This kind of information also supports the need to implement interventions such as phototherapy should carers start seeing the appearance of symptoms such as yellowing of the child’s sclera and face and if TSB levels were estimated to be above the threshold. In addition to finding out if there are possible risk factors on developing neonatal jaundice based on history and family records, it is also important to know if a mother has chosen to exclusively breastfeed her child since it could happen that during the therapy, breastfeeding could increase risks to the neonate on developing physiological jaundice. This is because it has been known that inadequate feeding of the neonate could result to electrolyte imbalances which not only prevents the effective removal of excess bilirubin through bowel movement and neonatal growth, but also prevents phototherapy from being successful (Bertini, et al., 2001; Roberton & South, 2007). In some instances, breast feeding can also increase the risks of developing neonatal jaundice as breast milk could cause the enteric absorption of excess bilirubin which is mostly in the unconjugated form, and potentially cause the prolonging of the jaundice among the neonates (Percival, 2002). Thus it was important to also note whether or not the mother chose to breastfeed her child, as it could affect the detected TSB levels in the bloodstream either positively or negatively. In this case, it was important to find out that the mother has been breastfeeding the infant exclusively, which could have been one of the few factors as to why the decrease in the child’s TSB levels were gradual but steady. Lastly, it was essential that carers must not only rely on a single method of determining the TSB levels of a child suspected to have neonatal jaundice, since it is possible that some methods might have increased bias and therefore could affect the carer’s assessment, or is may be possible that the child’s skin or eyes may not reflect the high amounts of bilirubin in the blood, which could eventually prevent the prompt detection of high bilirubin levels and hamper treatment (Mishra, et al., 2007). While seeing the neonate showing signs of yellow discolouration may be enough to tell whether the child indeed has neonatal jaundice or not, it alone is not enough to exactly pinpoint how much bilirubin is circulating in the baby’s blood. Other methods such as non-invasive procedures in obtaining the bilirubin levels in the blood such as using BiliCheck gives a faster reading compared to actually drawing out blood must also be utilised as much as possible since this gives sufficient information to prompt carers in performing additional tests that could further prove or disprove the child’s jaundice onset, such as measuring the TSB levels or detecting ABO or Rh antibodies in the child’s blood (Bhutani, et al., 2000). In finding out whether the bilirubin levels in the bloodstream are high enough to be toxic or not, this further narrows down the plan of actions of carer in providing interventions, as getting accurate readings of the bilirubin levels could dictate on whether to provide phototherapy to the child or if exchange transfusion is needed to further remove high-levels of bilirubin from the bloodstream (Ali, et al., 2012). This is in order to prevent inappropriate use of invasive treatment procedures, which are considered to be additional health risks among neonates having jaundice. It was through this method that phototherapy was chosen as the more appropriate choice for the child cared for in the NNU based on the guidelines released by the NICE. Aside from relying mostly on the bilirubin levels in the neonate, other potential risk factors must also be ruled out through invasive tests, such as the detection of organ problems such as liver or bile problems, full blood count, metabolic disorders such as glucose-6-phosphate dehydrogenase (G6PD) deficiency, microbiological analysis of stools and urine for signs of infections, and checking the baby’s blood type and antibodies against the mother’s, to further rule out the possibility that the neonate’s jaundice would be pathological instead of physiological (NICE, 2010). This is because any delays in proper detection could increase the risks of both short and long-term neurological dysfunction with regards to the capability of unconjugated bilirubin to enter the central nervous system (Kirpalani, et al., 2007). Thus apart from checking the child’s TSB levels and finding out whether these levels are high enough to merit removal through either invasive (exchange transfusion) or non-invasive (phototherapy), the use of other kinds of blood tests can help carers to be better informed on what kind of intervention is suitable, appropriate and timely for the neonate’s condition. Neonatal jaundice is characterised by the accumulation of yellow pigment called bilirubin from the slow breaking down and excretion of red blood cells by the liver. This condition happens in about 50% of all infants, which gradually decreases unless other factors such as infection, metabolic problems and organ deficiencies were ruled out. It is important that infants presenting this condition be given proper intervention as soon as possible since bilirubin is considered to be neurotoxic and could cause neurological impairment, especially with the unconjugated form having the ability to enter cells due to its fat-soluble properties. Guidelines released by the NICE in 2010 with regards to the care of neonatal jaundice were used in caring for a neonate in NNU, after the symptoms of jaundice appeared 24 hours after being born. Based on the guidelines, it was deduced that the child has physiological jaundice since the symptoms only appeared after 24 hours, otherwise it would have been pathological jaundice, which requires prompt treatment. The child initially had 14.5 mg/dL or 247.95 ?mol/L TSB, and according to the guidelines needed immediate phototherapy. This was successfully reduced to 10 mg/dL or 171 ?mol/L after 32 hours of treatment. TSB levels were continuously observed every 4-6 hours, after which the therapy was stopped and observations were made after another 12 hours to check whether the TSB levels would rise again. Final TSB was reduced to 9 mg/dL or 153.9 ?mol/L, showing that the levels were stable and gradually decreasing, which can be expected after at least 36 hours of treatment. While the various methods used to decrease TSB levels were backed up by earlier studies, it is also important not to solely rely on a single method in assessing the bilirubin levels in neonates since it is possible that other factors that contributed to the high TSB could be overlooked such as infection or sepsis and blood type incompatibility between parent and mother, and that the appropriate treatment method might not be administered promptly. The guidelines by NICE were able to assist decision-making in terms of administering the suitable treatment for the compromised neonate. It was appropriate that the child was given phototherapy after finding out that based on the table for assessing bilirubin thresholds, the detected TSB level of 247.95 ?mol/L required immediate phototherapy, which was within the range that needs immediate phototherapy treatment (220-370 ?mol/L) as mentioned in Arora, et al.. In addition, this plan of action was based on the familial history of the child, wherein an older sibling was also born with neonatal jaundice and was given treatment, in addition to the mother choosing to exclusively breastfeed the infant, both of which are risk factors in the onset of the condition. Thus, aside from monitoring the bilirubin levels of the child, knowing the mother’s history in pregnancy also helped in assisting the carer in finding and giving the intervention method which is appropriate, effective, timely and less stress-inducing for the infant. References Ali, R., Ahmed, S., Qadir, M. & Ahmad, K., 2012. Icterus Neonatorum in Near-Term and Term Infants. Sultan Qaboos Univ Med J., 12(2), p. 153–160. Arora, P.K., Mohandas, S., Ridout, D. & Aladangady, N., 2011. Range of Thresholds Used for Treatment of Neonatal Hyperbilirubinemia at Different Gestational Ages across Neonatal Units in Great Britain. International Journal of Clinical Medicine,2, p. 593-598. Bertini, G., Dani, C., Tronchin, M. & Rubaltelli, F., 2001. Is Breastfeeding Really Favoring Early Neonatal Jaundice?. Pediatrics, 107(3), p. doi: 10.1542/peds.107.3.e41. Bhutani, V. et al., 2000. Noninvasive Measurement of Total Serum Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia. Pediatrics, 106(2). Boxwell, G., 2010. Neonatal Intensive Care Nursing. Oxon: Routledge. de Almeida, M., 2004. When should we start phototherapy in preterm newborn infants?. J. Pediatr. (Rio J.) , 80(4), p. http://dx.doi.org/10.2223/JPED.1197 . Jacob, A., 2012. 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London: Jones and Bartlett Publishers International. Bibliography Ali, R., Ahmed, S., Qadir, M. & Ahmad, K., 2012. Icterus Neonatorum in Near-Term and Term Infants. Sultan Qaboos Univ Med J., 12(2), p. 153–160. Arora, P.K., Mohandas, S., Ridout, D. & Aladangady, N., 2011. Range of Thresholds Used for Treatment of Neonatal Hyperbilirubinemia at Different Gestational Ages across Neonatal Units in Great Britain. International Journal of Clinical Medicine,2, p. 593-598. American Academy of Pediatrics - Subcommittee on Hyperbilirubinemia, 2004. Management of Hyperbilirubinemia in the Newborn Infant 35 Or More Weeks of Gestation. Pedriatrics, 114(1), pp. 297-316. Bernaldo, A. & Segre, C., 2004. Bilirubin dosage in cord blood: could it predict neonatal hyperbilirubinemia?. Sao Paulo Med. J. , 122(3), pp. http://dx.doi.org/10.1590/S1516-31802004000300005 . Bertini, G., Dani, C., Tronchin, M. & Rubaltelli, F., 2001. Is breastfeeding really favoring early neonatal jaundice?. 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Arch Dis Child Fetal Neonatal Ed, 92(2), pp. F83-F88. National Collaborating Centre for Women's and Children's Health, 2010. Neonatal Jaundice. London: Royal College of Obstetricians and Gynaecologists. National Institute for Health and Clinical Excellence, 2010. Neonatal Jaundice. London: National Institute for Health and Clinical Excellence. National Institute for Health and Clinical Excellence, 2012. Neonatal Jaundice: Evidence Update March 2012. Manchester: National Institute for Health and Clinical Excellence. Nursing and Midwifery Council, 2010. The Code - Standards of contact, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council. Percival, P., 2009. Jaundice and Infection. In: D. M. Fraser & M. A. Cooper, eds. Myles Textbook for Midwives. Edinburgh: Churchill Livingstone Elsevier Science. Price, D. & Gwin, J., 2007. Pediatric Nursing: An Introductory Text. 10th ed. St. Louis, MO: Saunders Elsevier. Rennie, J. & Roberton, N., 2002. A Manual of Neonatal Intensive Care. London: Arnold Publishing. Roberton, D. & South, M., 2007. Practical paediatrics. 6th ed. s.l.:Elsevier Health. Skae, M., Moise, J. & Clarke, P., 2005. Is current management of neonatal jaundice evidence based?. Arch Dis Child Fetal Neonatal Ed, Volume 90, p. F540. Society of Hospital Medicine, 2010. Neonatal jaundice. Journal of Hospital Medicine, 5(S2), pp. 25-26. Varney, H., Kriebs, J. & Gegor, C., 2004. Varney's Midwifery. 4th ed. London: Jones and Bartlett Publishers International. Appendix A Table 1. Consensus-based bilirubin thresholds for babies 38 weeks and above with gestational hyperbilirubinaemia (NICE, 2010). Appendix B Figure 1. Hour-specific nomogram for total serum bilirubin (TSB) levels (Bhutani, et al., 1999, as cited in Ali, et al., 2012). Read More