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Neonatal Jaundice

Neonatal Jaundice
Neonatal Jaundice
Neonatal Jaundice

What Is Hyperbilirubinemia?

What Is Hyperbilirubinemia?  Hyperbilirubinemia (also known as jaundice) is an increased level of bilirubin in
What Is Hyperbilirubinemia?  Hyperbilirubinemia (also known as jaundice) is an increased level of bilirubin in

Hyperbilirubinemia (also known as jaundice) is an increased level of bilirubin in the blood

bilirubin : A substance in the blood that is produced by the breakdown of red blood cells. It is released in the

unconjugated form.

Unconjugated bilirubin is fat-soluble. It cannot be excreted in bile or urine and is absorbed by the SQ fat,

causing a yellowish discoloration of the skin

Jaundice is observed during the 1st wk in approximately 60% of term infant and 80% of preterm infant.

Hyperbilirubinemia can be toxic, with high levels resulting in an encephalopathy known as kerni-cterus.

Conjugation of bilirubin

Conjugation of bilirubin  The liver must conjugate the bilirubin (change it into a water-soluble form)
Conjugation of bilirubin  The liver must conjugate the bilirubin (change it into a water-soluble form)

The liver must conjugate the bilirubin (change

it into a water-soluble form) in order for the body to excrete it through the biliary tree into

the gut.

Conjugated bilirubin is further catabolised by

intestinal flora & It forms a major component

of bile in faeces (This gives the characteristic

orange colour to faeces).

A small amount is passed in the urine

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When deconjugated in the

intestine:

When deconjugated in the intestine:  The bilirubin is absorbed across the intestinal mucosa and returned
When deconjugated in the intestine:  The bilirubin is absorbed across the intestinal mucosa and returned

The bilirubin is absorbed across the intestinal

mucosa and returned to the circulation.

Travels in plasma, bound to albumin. Enters the

liver cells with the aid of Y & Z carrier proteins

Becomes conjugated with glucoronic acid by an enzyme Glucuronyl Transferase

Hypoxia or hypothermia may compromise

bilirubin conjugation

Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin.

BILIRUBIN
BILIRUBIN
 UNCONJUGATED  Final product of heme degeneration  Water-insoluble  Tightly complexed to serum
 UNCONJUGATED
 Final product of heme
degeneration
 Water-insoluble
 Tightly complexed to
serum albumin
 Cannot be excreted in
urine
 Free form is toxic
 Lab test: Total bilirubin
minus direct bilirubin
 Requires O2 and
 Normal values 0,2-1.4
mg/dl
glucose
 CONJUGATED  Water-soluble  Loosely bound to serum albumin  Excess amounts are excreted
 CONJUGATED
 Water-soluble
 Loosely bound to
serum albumin
 Excess amounts are
excreted in urine
 Nontoxic

Lab test: measured by direct bilirubin

Risk factors for jaundice

Risk factors for jaundice JAUNDICE  J - aundice within first 24 hrs of life 
Risk factors for jaundice JAUNDICE  J - aundice within first 24 hrs of life 

JAUNDICE

J - aundice within first 24 hrs of life

A - sibling who was jaundiced as neonate

U - nrecognized hemolysis

N on-optimal sucking/nursing

D - eficiency of G6PD

I - nfection

C ephalhematoma /bruising

E - ast Asian/North Indian

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Types of Jaundice

Types of Jaundice  Physiologic Jaundice.  Breast milk Jaundice  Pathologic Jaundice OR  Early
Types of Jaundice  Physiologic Jaundice.  Breast milk Jaundice  Pathologic Jaundice OR  Early

Physiologic Jaundice.

Breast milk Jaundice

Pathologic Jaundice OR

Early Onset

Late Onset

Physiologic Jaundice

Physiologic Jaundice  Clinical jaundice appears at 2-3 days.  Total bilirubin rises by less than
Physiologic Jaundice  Clinical jaundice appears at 2-3 days.  Total bilirubin rises by less than

Clinical jaundice appears at 2-3 days.

Total bilirubin rises by less than 5 mg/dl (86 umol/L) per day.

Peak bilirubin occurs at 3-5 days of age.

Peak bilirubin concentration in Full-term infant <12mg/dl (205.2 umol/L)

Peak bilirubin concentration in Premature infant <15mg/dl (257umol/L)

Clinical jaundice is resolved by 2 weeks in the term infant by 3-4 weeks in the Preterm infant.

Factors Associated with Physiological

Jaundice

Factors Associated with Physiological Jaundice Polycythemia & Hyperbilirubinemia  An infant has more RBCs than an
Factors Associated with Physiological Jaundice Polycythemia & Hyperbilirubinemia  An infant has more RBCs than an

Polycythemia & Hyperbilirubinemia

An infant has more RBCs than an adult ( Hb:18-19g/dl), and the lifespan of an RBC is shorter in neonates ( 80

days).

Increased RBCs and a shorter lifespan leads to increased destruction of RBCs, which leads to more bilirubin in the

blood, which leads to hyperbilirubinemia

Prematurity & Hyperbilirubinemia

Premature infants are more susceptible to

hyperbilirubinemia due

to: Immature hepatic system

Delayed enteral feedings (Hypoglycaemia ) Decrease in serum albumin levels

Hypoxia /asphyxia, Hypothermia

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Breastfeeding Jaundice

Breastfeeding Jaundice  Due to insufficient milk production by mom or intake by baby;  Supplemental
Breastfeeding Jaundice  Due to insufficient milk production by mom or intake by baby;  Supplemental

Due to insufficient milk production by mom or intake by baby; Supplemental water or dextrose-water administration may decreases breast milk production Decreased volume and frequency of feedings Decrease gut motility & delayed stooling

milk production  Decreased volume and frequency of feedings  Decrease gut motility & delayed stooling
milk production  Decreased volume and frequency of feedings  Decrease gut motility & delayed stooling

Breastfeeding Jaundice Management

Breastfeeding Jaundice Management  Increase frequency of feedings to more than 10 per day  Formula
Breastfeeding Jaundice Management  Increase frequency of feedings to more than 10 per day  Formula

Increase frequency of feedings to more than 10

per day

Formula supplement if infant has decline in

weight gain, delayed stooling, and continued

poor caloric intake

Breastfeeding should be continued to maintain breast milk production

Neutral thermal environment

Prevent hypoglycaemia & hypoxia

Avoid constipation

Phototherapy for bilirubin 17-22mg/dl

environment  Prevent hypoglycaemia & hypoxia  Avoid constipation  Phototherapy for bilirubin 17-22mg/dl
environment  Prevent hypoglycaemia & hypoxia  Avoid constipation  Phototherapy for bilirubin 17-22mg/dl

BreastMILK Jaundice

BreastMILK Jaundice  Occurs later in life (Day 6 to 14)  Bili 12 to 20
BreastMILK Jaundice  Occurs later in life (Day 6 to 14)  Bili 12 to 20

Occurs later in life (Day 6 to 14)

Bili 12 to 20

May stay high for 1-2 months

Etiology: Unclear; Substances in maternal milk, such as alpha glucuronidases, and nonesterified fatty acids, may inhibit normal bilirubin metabolism

Management

-Breastfeeding may be temporarily interrupted -With formula substitution, the total serum bilirubin level should decline rapidly over 48 hours,confirming the diagnosis

-With formula substitution, the total serum bilirubin level should decline rapidly over 48 hours,confirming the diagnosis
-With formula substitution, the total serum bilirubin level should decline rapidly over 48 hours,confirming the diagnosis

Pathologic Jaundice

Pathologic Jaundice  Anything OTHER THAN physiologic or breastfeeding or breastmilk jaundice!!  Jaundice within 24
Pathologic Jaundice  Anything OTHER THAN physiologic or breastfeeding or breastmilk jaundice!!  Jaundice within 24

Anything OTHER THAN physiologic or

breastfeeding or breastmilk jaundice!!

Jaundice within 24 hours after birth

Rapidly rising total serum bilirubin

concentration level higher than 17 in a full- term newborn

Other features of concern include prolonged

jaundice

Evidence of underlying illness

Elevation of the serum conjugated bilirubin

level to >2 mg per dL or more than 20% of the

Elevation of the serum conjugated bilirubin level to >2 mg per dL or more than 20%
Elevation of the serum conjugated bilirubin level to >2 mg per dL or more than 20%

total serum bilirubin

Common causes of pathological Jaundice

Common causes of pathological Jaundice a. hemolytic diseases: ABO, Rh incompatibility b. Glucose-6-phosphate (G-6-PD)
Common causes of pathological Jaundice a. hemolytic diseases: ABO, Rh incompatibility b. Glucose-6-phosphate (G-6-PD)

a. hemolytic diseases:

ABO, Rh incompatibility

b. Glucose-6-phosphate (G-6-PD)

deficiency

Rh hemolytic disease
Rh hemolytic disease

People who are Rh+ have the Rh antigen on their

RBC’s. People who are Rh- do not.

If blood that is Rh+ enters the body of a person who is Rh-, the body reacts as it would to any foreign substance, and develops antibodies that destroy the invading antigen (this is called “sensitization”).

Rh incompatibility is when the mother lacks the Rh factor

on the surface of her red blood cells and her baby is

born with the Rh factor on his or her red blood cells

It does not occur with the first born child

Increased destruction of red blood cells leads to increased bilirubin in the blood; therefore, leading to hyperbilirubinemia

Clinical Presentation

Clinical Presentation  Varies from mild jaundice and anemia to hydrops fetalis  Erythroblastosis fetalis:
Clinical Presentation  Varies from mild jaundice and anemia to hydrops fetalis  Erythroblastosis fetalis:

Varies from mild jaundice and anemia to hydrops fetalis Erythroblastosis fetalis: This occurs as the baby's organs are unable to handle the anemia. The heart begins to fail and large amounts of fluid build up in the

baby's tissues and organs. A fetus

with hydrops is at great risk of being stillborn. RBC destruction and

anemia cause bone marrow to

release erythroblasts, hence the

name “erythroblastosis fetalis”)

RBC destruction and anemia cause bone marrow to release erythroblasts, hence the name “erythroblastosis fetalis”)
RBC destruction and anemia cause bone marrow to release erythroblasts, hence the name “erythroblastosis fetalis”)

Risks during labor and delivery

include:

Risks during labor and delivery include:  asphyxia and splenic rupture .  Postnatal problems include:
Risks during labor and delivery include:  asphyxia and splenic rupture .  Postnatal problems include:

asphyxia and splenic rupture.

Postnatal problems include:

Pulmonary hypertension

Pallor (due to anemia)

Edema (hydrops, due to low serum albumin)

Respiratory distress

Coagulopathies (↓ platelets & clotting factors)

Jaundice

Kernicterus (from hyperbilirubinemia)

Hypoglycemia (due to hyperinsulinemnia from islet cell hyperplasia)

Treatment for Rh Incompatibility
Treatment for Rh Incompatibility

There is an injection called Rh immune globulin which is given to pregnant women at 28 weeks of pregnancy and

within 72 hours of delivering an infant

who is born Rh positive This injection prevents the mother’s body from forming antibodies against the Rh factor found on fetal red blood cells

If the mother is already sensitized, meaning her body has already made

antibodies against the Rh factor, the injection will be ineffective

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ABO Blood Incompatibility

ABO Blood Incompatibility  ABO incompatibility occurs with any blood type; however, it is more common
ABO Blood Incompatibility  ABO incompatibility occurs with any blood type; however, it is more common

ABO incompatibility occurs with any blood type;

however, it is more common if the mother has type O

blood and the infant has blood type A or B

Fetal cells cross the placenta and enter the mother’s bloodstream

When this occurs the mother’s body forms antibodies

against the fetal cells

Those antibodies are then small enough to cross back through the placenta into the baby’s circulation and cause destruction of red blood cells

Increased destruction of red blood cells leads to increased bilirubin in the blood; therefore, leading to hyperbilirubinemia

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Clinical Presentation

Clinical Presentation  The first fetus can be affected.  IgG are the only antibodies that
Clinical Presentation  The first fetus can be affected.  IgG are the only antibodies that

The first fetus can be affected.

IgG are the only antibodies that can cross the placental barrier, and usually most of the antibodies formed are IgM, so this condition is usually much milder

than the Rh issue.

When delivered, infants may present with mild anemia or normal hemoglobin levels

Clinical Features Of Hemolytic

Disease

Clinical Features Of Hemolytic Disease Clinical Features Rh ABO Frequency Unusual Common Anemia Marked
Clinical Features Of Hemolytic Disease Clinical Features Rh ABO Frequency Unusual Common Anemia Marked

Clinical Features

Rh

ABO

Frequency

Unusual

Common

Anemia

Marked

Minimal

Jaundice

Marked

Minimal to moderate

Hydrops

Common

Rare

Hepatosplenomegaly

Marked

Minimal

Kernicterus

Common

Rare

Laboratory Features Of Hemolytic

Disease

Laboratory Features Of Hemolytic Disease Laboratory Features blood type of Mother blood type of Infant Direct
Laboratory Features Of Hemolytic Disease Laboratory Features blood type of Mother blood type of Infant Direct

Laboratory Features

blood type of Mother

blood type of Infant Direct Commb’s test

Indirect Commb’s test

Hyperbilirubinemia

Rh

Rh negative

Rh positive Positive

Positive

marked

ABO

O

A or B Negative

Usually positive

Variable

Coombs test

Coombs test Positive -RH - ABO -MINOR blood group incompat Negative -Cephalhematoma -Breast milk jaundice -Infection
Coombs test Positive -RH - ABO -MINOR blood group incompat Negative -Cephalhematoma -Breast milk jaundice -Infection
Coombs test Positive -RH - ABO -MINOR blood group incompat Negative -Cephalhematoma -Breast milk jaundice -Infection

Positive

-RH

- ABO

-MINOR blood group incompat

Coombs test Positive -RH - ABO -MINOR blood group incompat Negative -Cephalhematoma -Breast milk jaundice -Infection

Negative

-Cephalhematoma

-Breast milk jaundice

-Infection -Asphyxia -RDS -Galactosemia -Rare disorders

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Direct Coombs Test

Direct Coombs Test  “The direct coombs test is a direct measure of the amount of
Direct Coombs Test  “The direct coombs test is a direct measure of the amount of
Direct Coombs Test  “The direct coombs test is a direct measure of the amount of

“The direct coombs test is a direct measure of the amount of maternal antibody coating the infant’s red blood cell” If the antibody is present, the test is positive

Indirect Coombs Test

Indirect Coombs Test  “The indirect coombs test measures the effect of a sample of the
Indirect Coombs Test  “The indirect coombs test measures the effect of a sample of the
Indirect Coombs Test  “The indirect coombs test measures the effect of a sample of the

“The indirect coombs test measures the effect of a sample of the infant’s serum (which is thought to contain maternal antibodies) on unrelated adult RBCs”

“If the infant’s serum contains antibodies, they will interact with and coat these adult RBCs (positive test)”

Glucose-6-Phosphate Dehydrogenase

G6PD

Glucose-6-Phosphate Dehydrogenase G6PD  The function of G6PD enzyme is to initiate an oxidation/reduction reaction.
Glucose-6-Phosphate Dehydrogenase G6PD  The function of G6PD enzyme is to initiate an oxidation/reduction reaction.

The function of G6PD enzyme is to initiate an

oxidation/reduction reaction. Enzyme to maintenance of RBC life)

Oxidation is the loss of electrons and reduction is the gain of electrons

which leads to hemolysis of red blood cells

Increased hemolysis of red blood cells leads to increased levels of bilirubin, which then leads to

hyperbilirubinemia

Clinical Manifestations

Clinical Manifestations • Usually no evidence of hemolysis is apparent until 48- 96 hours after the
Clinical Manifestations • Usually no evidence of hemolysis is apparent until 48- 96 hours after the

Usually no evidence of hemolysis is apparent until 48-

96 hours after the patient has ingested a substance which has oxidant properties (Antipyretic,Sulfonamide, Anti malarial producing an acute and severe hemolytic

syndrome called FAVISM, Hb level become very low, and increased reticulocyte count

- Jaundice

- Anemia

- Hydrops

- Massive enlargement of the liver & spleen

- Bilirubin encephalopathy (Kernicterus)

Kernicterus

Kernicterus  Kernicterus is a rare, irreversible complication of hyperbilirubinemia  If bilirubin levels become
Kernicterus  Kernicterus is a rare, irreversible complication of hyperbilirubinemia  If bilirubin levels become

Kernicterus is a rare, irreversible complication of hyperbilirubinemia If bilirubin levels become markedly elevated, the unconjugated bilirubin may

cross into the blood brain barrier and

stain the brain tissues

If staining of the brain tissues occurs there is permanent injury sustained to

areas of the brain which leads to neurological damage

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Complication

Complication Kernicterus: Phase 1 ( 3-4 day): Hypotonia Decreased alertness; Poor feeding Diminished Moro reflex High
Complication Kernicterus: Phase 1 ( 3-4 day): Hypotonia Decreased alertness; Poor feeding Diminished Moro reflex High

Kernicterus:

Phase 1 ( 3-4 day): Hypotonia

Decreased alertness; Poor feeding Diminished Moro reflex High pitched cry

Phase 2 (≥ 1 wk):

Irritability or Seizures; muscle spasms & back arching

Hypertonia,

Phase 3 ( by 3 yrs of age):

Hypotonia

G 6 P D deficiency

G 6 P D deficiency Diagnosis Low G6PD activity in red blood cells ( normal range
G 6 P D deficiency Diagnosis Low G6PD activity in red blood cells ( normal range

Diagnosis Low G6PD activity in red blood cells (normal range, 4.613.5 U/g Hb). Treatment

When hemolysis has occurred =>

Red blood cell transfusion

Prevention

Avoiding oxidant substances

Jaundice-Diagnosis

Jaundice - Diagnosis • Visual assessment (least reliable) • Check bilirubin level: Total bilirubin at birth
Jaundice - Diagnosis • Visual assessment (least reliable) • Check bilirubin level: Total bilirubin at birth

Visual assessment (least reliable)

Check bilirubin level: Total bilirubin at birth is less than

3mg/dL.

Check complete blood count

Check reticulocyte count

Coombs test ( DAT).

Blood groups & types

G6PD level

Albumin level: A normal albumin level in a term infant is between 2.6 - 3.6 g/dL

groups & types • G6PD level • Albumin level: A normal albumin level in a term

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Visual assessment (least reliable)

Visual assessment (least reliable)  Skin yellowing  Not visible if bili <4  “Visual assessment
Visual assessment (least reliable)  Skin yellowing  Not visible if bili <4  “Visual assessment

Skin yellowing

Not visible if bili <4

“Visual assessment of

jaundice is most accurate

when the infant’s skin is blanched with light digital

pressure in a well-lit

room”

“As bilirubin levels rise, the accuracy of visual assessment decreases”

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Dermal Zones of Jaundice

Dermal Zone

Bilirubin range ( mg%)

1

4.5-8

2

5.5-12

3

8-16.5

4

11-18

5

> 15

Dermal Zone Bilirubin range ( mg%) 1 4.5-8 2 5.5-12 3 8-16.5 4 11-18 5 >

Treatments

Treatments  Intrauterine transfusion  Early Delivery  If labor is induced, fetal lung maturity must
Treatments  Intrauterine transfusion  Early Delivery  If labor is induced, fetal lung maturity must

Intrauterine transfusion Early Delivery

If labor is induced, fetal lung maturity must be

determined using the lecithin/sphingomyelon

(L/S) ratio to avoid respiratory distress syndrome

Encourage frequent feedings

Intravenous hydration

Intravenous immune globulin (IVIG) has been used to decrease bilirubin levels due to hemolytic anemia; 1 gm/kg inhibits AB that cause RBC

destruction

Phototherapy

Exchange transfusion

levels due to hemolytic anemia; 1 gm/kg inhibits AB that cause RBC destruction  Phototherapy 

Maisel’s Chart

Sr Bilirubin (mg/dl)

 

Birth

 

Age in hrs

 

weight

< 24

24 48

49 72

>72

<5

 

All

       

5-9

 

All

Phototherapy if hemolysis

     
 

< 2500g

Phototherapy if hemolysis

 

PHOTOTHERAPY

10-14

>

2500g

 

Investigate if bilirubin > 12mg%

15-19

< 2500g

EXCHANGE

Consider Exchange

>

2500g

 

Phototherapy

> 20

 

All

 

EXCHANGE

 

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Phototherapy

Phototherapy  The therapy uses a blue light (420-470 nm) that converts bilirubin so that it
Phototherapy  The therapy uses a blue light (420-470 nm) that converts bilirubin so that it

The therapy uses a blue light (420-470 nm) that converts bilirubin so that it can be excreted in the urine and feces.

1 - Maximizing energy delivery :

- Distance should be no greater than 50 cm and may be

reduced down to 10-20 cm if temperature homeostasis is monitored to reduce the risk of overheating.

- Cover the inside of the bassinet with reflecting material; white linen works well ( aluminum foil).

These simple expedients can multiply energy delivery by several fold.

2- Maximizing the available surface area.

The infant should be naked except for diapers and the eyes should be covered to reduce risk of retinal damage.

Phototherapy- Cont.

Phototherapy- Cont.  May be provided using lightweight, fiber-optic blankets ( bili blankets). The baby is
Phototherapy- Cont.  May be provided using lightweight, fiber-optic blankets ( bili blankets). The baby is

May be provided using lightweight, fiber-optic blankets ( bili blankets). The baby is wrapped in the blanket. The eyes are not covered.

A combination of a fiber-optic light source in the mattress under the baby and a standard

phototherapy light source above

Nursing diagnoses:

Nursing diagnoses:  Body temperature, risk for imbalanced related to use of phototherapy.  Risk for
Nursing diagnoses:  Body temperature, risk for imbalanced related to use of phototherapy.  Risk for

Body temperature, risk for imbalanced related to use of phototherapy.

Risk for Fluid volume deficient related to phototherapy.

Risk for Fluid volume deficient related to phototherapy.  Family processes, interrupted, related to prolonged

Family processes, interrupted, related to prolonged hospitalization of infant, or risk for rehospitalization for therapy

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Jaundice

Jaundice Nursing Assessment and Diagnosis  Identify the newborn at risk: assess for jaundice.  Monitor
Jaundice Nursing Assessment and Diagnosis  Identify the newborn at risk: assess for jaundice.  Monitor

Nursing Assessment and

Diagnosis

Identify the newborn at risk:

assess for jaundice.

Monitor bilirubin levels.

Risk for Altered Parenting related to parenting a

newborn with jaundice.

Risk for Injury related to use of phototherapy.

Fluid Volume Deficit related

to increased insensible water

loss and frequent loose stools.

Nursing Plan and Implementation

Monitor temperature for

hyperthermia or

hypothermia.

Apply eye patches over newborns closed eyes.

Turn off lights when drawing blood for repeat bilirubin.

Maintaining a neutral thermal environment.

Observe for signs of dehydration and perineal excoriation.

Weigh daily

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Nursing care of infant receiving phototherapy

Nursing care of infant receiving phototherapy  Perform hand wash  Obtain V/S including axillary temperature
Nursing care of infant receiving phototherapy  Perform hand wash  Obtain V/S including axillary temperature

Perform hand wash

Obtain V/S including axillary temperature

Place baby naked in cradle or incubator except the diaper

Apply eye coverings

Monitor temp q 4hr

Fluids q2 hr to avoid dehydration

Change position q 2 hr

Weigh q12 hr, I &O, assess hydration, Weight diapers before discarding

Observe stools & urine for darkening, skin

Monitor bili levels Q 12 hr or daily, turn the phototherapy lights off while the blood is drawn.

Cluster care activities

Discontinue phototherapy & remove eye patches at least once per shift. Also discontinue phototherapy and remove patches when feeding the infant & when the parents visit.

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Nursing consideration

Nursing consideration  Accurate charting is important nursing responsibility and includes: 1. Times that
Nursing consideration  Accurate charting is important nursing responsibility and includes: 1. Times that

Accurate charting is important nursing responsibility and includes:

1. Times that phototherapy is started and stopped.

2. Proper shielding of the eyes.

3. Type of fluorescent lamp.

4. Number of lamps.

5. Distance between surface of lamps and infant

6. Use of phototherapy in combination with an incubator or

open bassinet.

Occurrence of side effects .as: loose, greenish stools, transient

skin rashes, hyperthermia, increase metabolic rate, dehydration, electrolyte disturbances as hypocalcemia,

Oxidize essential fatty acids, decreases vitamins and

calcium in premature infants lead to adverse effect on cell

growth Tanning/Bronze Baby Syndrome

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Phototherapy Precautions

Phototherapy Precautions  Ensure patent airway  Maintain constant body temperature by using incubator 
Phototherapy Precautions  Ensure patent airway  Maintain constant body temperature by using incubator 

Ensure patent airway

Maintain constant body temperature by using incubator

Maintain fluid balance by increasing intake and minimizing loss

Assure skin integrity

frequent diaper changes ( perianal excoriation due to irritating effect of diarrhea stools).

water baths

no lotions or oils on skin

position to avoid skin irritation

Careful technique when repeatedly drawing labs

Warm foot before procedure

Avoid areas of previous puncture

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NEONATAL EXCHANGE

TRANSFUSIONS

NEONATAL EXCHANGE TRANSFUSIONS  Exchange transfusion is a critical therapeutic procedure in babies with, or who
NEONATAL EXCHANGE TRANSFUSIONS  Exchange transfusion is a critical therapeutic procedure in babies with, or who

Exchange transfusion is a critical therapeutic procedure in babies with, or who are likely to develop, neurotoxic levels of bilirubin. Historically it was one of the most common procedures performed in neonatal

services. Three factors have led to exchange

transfusions becoming less commonly performed,

namely:

1. The effective prevention of rhesus iso-immunisation

with prophylactic Anti D for rhesus negative mothers;

2. Foetal intrauterine transfusions; and,

3. The recognition that well babies born at term with

physiological jaundice can tolerate higher levels of

bilirubin than previously thought

Exchange Transfusion

Exchange Transfusion  An exchange transfusion is used only in extreme cases when phototherapy has failed
Exchange Transfusion  An exchange transfusion is used only in extreme cases when phototherapy has failed

An exchange transfusion is used only in extreme cases when phototherapy has failed

The process for an exchange transfusion involves

small amounts of blood being removed from the

infant and then replaced with the same amount of donor RBCs and plasma The exchange replaces ~ 87% of the circulating blood volume and decreases the bilirubin level by ~ 55%

Mechanism: removes bilirubin and antibodies from circulation and correct anemia

Management of Exchange

Transfusion

Management of Exchange Transfusion  NPO, aspirate stomach contents, suction airway prior  Informed consent signed
Management of Exchange Transfusion  NPO, aspirate stomach contents, suction airway prior  Informed consent signed

NPO, aspirate stomach contents,

suction airway prior

Informed consent signed by parents

Check blood typing

Restrain infant & Place under radiant warmer

Exchange transfusions are performed using a one catheter or two catheter push-pull method under a septic technique

N.B: Blood Volume = 70-90 ml/kg for term and 85-110 ml/kg for preterm infants

method under a septic technique  N.B: Blood Volume = 70-90 ml/kg for term and 85-110

4646

Two Catheter Push-pull Technique

Two Catheter Push-pull Technique Blood is removed from the artery while infusing fresh  blood through
Two Catheter Push-pull Technique Blood is removed from the artery while infusing fresh  blood through

Blood is removed from the artery while infusing fresh

blood through a vein at the same rate.

 

In

Out

 

Umbilical vein

Peripheral artery

OR

Umbilical vein

Umbilical artery

OR

Peripheral vein

Peripheral artery

OR

Peripheral vein

Umbilical artery

One Catheter Push-pull Technique

One Catheter Push-pull Technique  This can be done through an umbilical venous catheter. Exceptionally, an
One Catheter Push-pull Technique  This can be done through an umbilical venous catheter. Exceptionally, an

This can be done through an umbilical venous catheter. Exceptionally, an umbilical artery catheter can be used.

Ideally, the tip of the UVC should be in the IVC/right atrium (at or just above the diaphragm), position should be checked by

an X-ray. Catheter is usually removed after

each exchange.

Withdraw blood over 2 minutes, infuse slightly faster.

What type of blood to give

fetus:

What type of blood to give fetus:  CMV negative  Irradiated  Fresh Whole Blood
What type of blood to give fetus:  CMV negative  Irradiated  Fresh Whole Blood

CMV negative Irradiated Fresh Whole Blood (to avoid Ca ++ ), less than 7 days old Group O, -negative (Maternal blood if possible)

Exchange Therapy Complications

Exchange Therapy Complications  Air embolism  Vasospasm  Infarction or arrythmias  Infection  Death
Exchange Therapy Complications  Air embolism  Vasospasm  Infarction or arrythmias  Infection  Death

Air embolism

Vasospasm

Infarction or arrythmias Infection

Death

Thrombocytopenia

Transfusion Reactions

Transfusion Reactions  Rare in neonates  Signs & symptoms in neonates  Temperature instability 
Transfusion Reactions  Rare in neonates  Signs & symptoms in neonates  Temperature instability 

Rare in neonates Signs & symptoms in neonates

Temperature instability

Reaction at infusion site, flushing of skin, urticaria, rash

Vomiting or diarrhea

Wheezing or acute respiratory distress

Hypotension, shock, tachycardia

Sudden rise in bilirubin

Acute bleeding from venipunctures or surgical sites

Transfusion Reactions

Transfusion Reactions  What to do if you suspect a transfusion reaction  Stop the transfusion
Transfusion Reactions  What to do if you suspect a transfusion reaction  Stop the transfusion

What to do if you suspect a transfusion reaction

Stop the transfusion immediately

Begin treatment for any new, emergent problems

Notify the physician

Notify the blood bank Blood bank may request a fresh blood sample