Contributed by David Wilson, MS, RNC
Approximately 60 to 80% of all newborns will become jaundiced in the first few weeks of life. In the majority of cases the jaundice is transient and self-resolves or essentially is benign. There is however a small percentage of neonates who will require early evaluation and management to prevent acute bilirubin encephalopathy and kernicterus which cause both temporary and permanent damage to the basal ganglia and brainstem nuclei. The ongoing dilemma in the management of neonatal jaundice is that it is as yet unknown which infants will develop severe kernicterus and what antecedents including an elevated unconjugated (indirect) will lead to poor outcome in every neonate; there is no known single marker for the development of kernicterus in any given neonate.
The American Academy of Pediatric, Subcommittee on Hyperbilirubinemia (2004) recently revised the 1994 guidelines on the management of neonatal hyperbilirubinemia in term and near-term infants born at 35 weeks' or more gestation. A synopsis of these guidelines is outlined below. For a complete review of the guidelines the reader is directed to the AAP 2004 reference. In addition, a web site for family questions related to hyperbilirubinemia is available in English and Spanish at Question and Answers: Jaundice and Your Newborn.
One of the key tenets of the new guidelines is the promotion and support of successful breastfeeding. The nurse is crucial in the support of the mother who wishes to breastfeed her newborn; the successful establishment of a latch-on and subsequent feeding enhance the metabolism and excretion of unconjugated bilirubin.
The second key feature of the guidelines which directly impacts nurses is the establishment of nursery protocols for the identification and evaluation of jaundice in the newborn. Jaundice within the first 24 hours of life in any newborn requires investigation as to its cause and progress. The neonatal or mother-newborn nurse is key in the early identification of neonatal jaundice. However, it must be emphasized that visual estimation of jaundice varies from one individual to the next and such estimates are not reliable regardless of the person's experience in such matters.
With early discharge of both mother and newborn it is essential that newborns who are
jaundiced during their hospitalization or who are at greater risk for severe
hyperbilirubinemia after discharge are identified and followed for evaluation. One tool
which assists in the quantification of newborn jaundice is the nomogram developed by
Bhutani and colleagues (1999). This tool assigns categories of low risk, medium risk,
and high risk for total serum bilirubin (TSB) levels according to hours after birth and
the predicted likelihood of developing hyperbilirubinemia requiring treatment after
discharge from the hospital. As an example, a newborn who is 35 weeks gestation or more,
with a birthweight of 2000 grams and above, with a serum bilirubin level of 5 mg/dL or
less would be considered as being in the low risk category for developing severe
hyperbilirubinemia. Further examples of risk zones at 24 hours are as follows: low
intermediate risk, TSB 5-6 mg/dL; high intermediate risk, TSB 6-8 mg/dL; and high risk
category, TSB 
8 mg (95th percentile). These categories were derived
by measuring TSB in over 2800 well newborns who were followed after discharge from the
hospital. This nomogram does not represent the natural course of neonatal
hyperbilirubinemia. It is recommended that every newborn undergo a bilirubin risk
assessment according to the hour-specific nomogram; the serum bilirubin may be collected
at the time of the metabolic screening to decrease the need for additional blood
sampling.
The use of transcutaenous bilirubin (TcB) monitors with greater specificity (estimate
TSB within 2 to 3 mg/dL of serum TSB) has also become an important tool in the
evaluation of neonatal hyperbilirubinemia. The revised AAP guidelines suggest that TcB
may be used in place of serum measurements if the TSB is below 15 mg/dL. With some
ethnic groups TcB measurement norms have not been established and the monitors are not
useful once phototherapy has been initiated. The new guidelines recommend that all
healthy newborns 35 weeks' gestation be assessed for the risk of development of
severe hyperbilirubinemia before discharge from the hospital.
In addition to evaluation of the infant's TSB or TcB reading, a number of risk factors for development of severe neonatal hyperbilirubinemia should be considered. These include but are not limited to the following: previous sibling treated with phototherapy for hyperbilirubinemia, blood group incompatibility and positive direct antiglobulin test (formerly Coombs' test) and hemolytic disease such as G6PD deficiency, gestational age 35-36 weeks, exclusive breastfeeding with significant weight loss and poor feeding, East Asian ethnicity, jaundice in the high risk zone, and jaundice noticed before 24 hours of age.
It is now recommended that healthy infants (35 weeks) receive follow up
assessment of bilirubin by a qualified health care professional within 3 days of
discharge if discharged at <24 hours and a risk assessment with tools such as the
hour-specific nomogram or TcB; likewise, newborns discharged at 24 to 47.9 hours should
receive follow up evaluation within 4 days (96 hours), and those discharged between 48
and 72 hours should receive follow up within 5 days. Earlier follow up and assessment
may be required for infants with risk factors and those with no risk factors may be seen
at greater intervals depending on the risks identified.
The focus of this guideline is aimed at protecting newborns from the development of kernicterus or acute bilirubin encephalopathy as defined by the Academy of Pediatrics (2004) and standardizing the care each newborn receives during and after birth and hospitalization. Guidelines for initiation of phototherapy according to TSB levels and risk factors are beyond the scope of this update; the reader is referred to the published guideline for further management including definitions of intensive phototherapy and guidelines for exchange transfusion.
The implications of these guidelines for nurses caring for newborns and their mothers are significant. Nurses are the health professionals who spend most of their time caring for newborns and mothers in the first few days of the newborn's life. It is incumbent on the nurse to evaluate the newborn for jaundice in the first few days of its life and prior to discharge from the birth hospital. In addition, the establishment of successful breastfeeding involves vigilance and intervention by the neonatal or mother/newborn nurse and lactation consultant; helping establish successful breastfeeding in the first few days of life will enhance the metabolism and excretion of unconjugated bilirubin, thus decreasing the risk of adverse outcomes from hyperbilirubinemia. The nurse is also in an optimal position to provide parents important discharge instructions regarding jaundice, and to assist in the follow up of infants who are at risk for hyperbilirubinemia once they are discharged from the hospital. The nurse's contribution to a successful transition for the newborn and family by collaborating with other health professionals in the implementation of these guidelines is important in the overall scheme of preventative health care for children and their families.
July 8, 2004