Community health nursing department Mansoura university

Forth level Faculty of nursing

First semester 2019/2020

Developing Health education program for

Antenatal mother about neonatal jaundice

Prepared by:

Under supervision:
 Outline
1. Objectives.

2. Introduction about neonatal jaundice.

3. literature review.

I) Neonatal jaundice

 Definition of neonatal jaundice

 Types of neonatal jaundice

 Pathophysiology of neonatal jaundice

 Pathophysiology of jaundice in biliary obstruction of neonatal

jaundice
 Causes of neonatal jaundice

 Risk Factors of neonatal jaundice

 Signs and Symptoms of neonatal jaundice

 Diagnosis of neonatal jaundice

 Treatment of neonatal jaundice

 Nursing care management of neonatal jaundice

 Management of breast-feeding jaundice of neonatal jaundice

 Complication of neonatal jaundice

 Health education of neonatal jaundice

II) Health education program

Aim of the project

Project process

Results

Reflection

- project as teaching methods

- project as a topic
 Objectives
General objective:

At the end of project , the antenatal mother will develop knowledge

and practice about neonatal jaundice

Specific objectives:

At the end of project, the antenatal mother will be able to :

1) Define neonatal jaundice.

2) Classify types of neonatal jaundice.
3) Discuss pathophysiology of neonatal jaundice.
4) Discuss pathophysiology of jaundice in biliary obstruction of
neonatal jaundice.
5) Identify causes of neonatal jaundice.
6) Explain risk factors of neonatal jaundice.
7) List signs and symptoms of neonatal jaundice.
8) Determine diagnosis of neonatal jaundice.
9) Enumerate treatment of neonatal jaundice.
10) Enumerate nursing care management of neonatal
jaundice.
11) Enumerate management of breastfeeding jaundice of
neonatal jaundice.
12) Discuss complications of neonatal jaundice.
13) Acquire health education of neonatal jaundice.
Introduction

Jaundice is the most common condition that requires medical attention

and hospital readmission in newborns. The yellow coloration of the skin
and sclera in newborns with jaundice is the result of accumulation of
unconjugated bilirubin.

In most infants ,unconjugated hyperbilirubinemia reflects a normal

transitional phenomenon .However, in some infants, serum bilirubin
levels may rise excessively, which can be cause for concern because
unconjugated bilirubin is neurotoxic and can cause death in newborns and
lifelong neurologic sequelae in infants who survive (kernicterus). For
these reasons, the presence of neonatal jaundice frequently results in
diagnostic evaluation.

Most infants born between 35 weeks' gestation and full term need no
treatment for jaundice .Rarely, an unusually high blood level of bilirubin
can place a newborn at risk of brain damage, particularly in the presence
of certain risk factors for severe jaundice.

About 5-10% of all newborns require intervention for pathological

jaundice. It is a common disorder worldwide and accounts for 75% of
hospital readmissions during the first week of life. In Egypt, severe
neonatal hyperbilirubinemia accounted for 33% of total admissions to the
outborn neonatal ICU (NICU).

Jaundice usually appears first on the face and then moves to the chest,
belly, arms, and legs as bilirubin levels get higher. The whites of the eyes
can also look yellow. Jaundice can be harder to see in babies with darker
skin color. The baby's doctor or nurse can test how much bilirubin is in
the baby's blood.
some babies need close monitoring and early jaundice management as
Preterm Babies born that before 37 weeks, or 8.5months, of pregnancy or
Babies with Feeding Difficulties.

The best way to accurately measure bilirubin is with a small blood

sample from the baby's heel. This results in a total serum bilirubin (TSB)
level. If the level is high, based upon the baby's age in hour.

Treatment More frequently are breast feeding, phototherapy, exchange

blood these methods are enough to efficiently get rid of bilirubin.

When severe jaundice goes untreated for too long, it can cause a
condition that called kernicterus. Kernicterus is a type of brain damage
that can result from high levels of bilirubin in a baby's blood. It can cause
athetoid cerebral palsy and hearing loss. Kernicterus also causes problems
with vision and teeth and sometimes can cause intellectual disabilities. so
Early detection and management of jaundice can prevent kernicterus.

We developing our health education program for antenatal mother

about neonatal jaundice because Health education is essential if people
are to learn how to live healthy lives and avoid diseases. It helps them
understand what health is and how to look after it, also about the need for
health services and disease- control programs.
Health education can show people that good health and health services
are a basic human right; it can explain that health services are important
for development.
 Neonatal jaundice
Definition
Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin
in a newborn baby due to high bilirubin levels.

Jaundice happens when a chemical called bilirubin builds up in the baby’s blood.
During pregnancy, the mother’s liver removes bilirubin for the baby, but after birth
the baby’s liver must remove the bilirubin. In some babies, the liver might not be
developed enough to efficiently get rid of bilirubin. When too much bilirubin builds
up in a new baby’s body, the skin and whites of the eyes might look yellow.

Types

 Physiological Jaundice

It is the most abundant type of newborn hyperbilirubinemia, having no serious

consequences. Neurodevelopmental abnormalities including as athetosis, loss of
hearing, and in rare cases intellectual deficits, may be related to high toxic level of
bilirubin.

Jaundice attributable to physiological immaturity which usually appears between

24–72 h of age and between 4th and -5th days can be considered as its peak in term
neonates and in preterm at 7th day, it disappears by 10–14 days of life. Unconjugated
bilirubin is the predominant form and usually its serum level is less than 15 mg/dl.
Based on the recent recommendations of the AAP, bilirubin levels up to 17–18 mg/dl
may be accepted as normal in term of healthy newborns.

 Pathological Jaundice

Bilirubin levels with a deviation from the normal range and requiring intervention
would be described as pathological jaundice. Appearance of jaundice within 24 hours
due to increase in serum bilirubin beyond 5 mg/dl/day, peak levels higher than the
expected normal range, presence of clinical jaundice more than 2 weeks and
conjugated bilirubin (dark urine staining the clothes) would be categorized under this
type of jaundice.
Pathophysiology

Jaundice results from high levels of bilirubin in the blood. Bilirubin is the normal
breakdown product from the heme catabolism, and thus is formed from the
destruction of red blood cells.

Under normal circumstances, bilirubin undergoes conjugation within the liver,

making it water-soluble. It is then excreted via the bile into the GI tract, the majority
of which is egested in the feces as urobilinogen and stercobilin (the metabolic
breakdown product of urobilinogen). Around 10% of urobilinogen is reabsorbed into
the bloodstream and excreted through the kidneys. Jaundice occurs when this pathway
is disrupted.

Pathophysiology of jaundice in biliary obstruction

Accumulation of bilirubin in the bloodstream and subsequent deposition in the skin

causes jaundice (icterus). Conjunctival icterus is generally a more sensitive sign of
hyperbilirubinemia than generalized jaundice. Total serum bilirubin values are
normally 0.2-1.2 mg/dL. Jaundice may not be clinically recognizable until levels are
at least 3 mg/dL.

Urine bilirubin is normally absent. When it is present, only conjugated bilirubin is

passed into the urine as it is water soluble. This may be evidenced by dark-colored
urine seen in patients with obstructive jaundice or jaundice due to hepatocellular
injury. However, reagent strips are very sensitive to bilirubin, detecting as little as
0.05 mg/dL.

Thus, urine bilirubin may be found before serum bilirubin reaches levels high
enough to cause clinical jaundice.

Causes

 Internal bleeding (hemorrhage)

 An infection in your baby's blood (sepsis)
 Other viral or bacterial infections.
 An incompatibility between the mother's blood and the baby's blood.
 A liver malfunctions.
 An enzyme deficiency.
 Risk Factors

About 60% of all babies have jaundice. Some babies are more likely to have severe

jaundice and higher bilirubin levels than others. Babies with any of the following risk

factors need close monitoring and early jaundice management:

 Preterm Babies

Babies born before 37 weeks, or 8.5 months, of pregnancy might have jaundice

because their liver is not fully developed. The young liver might not be able to get rid

of so much bilirubin.

 Babies with Darker Skin Color

Jaundice may be missed or not recognized in a baby with darker skin color.

Checking the gums and inner lips may detect jaundice. If there is any doubt, a

bilirubin test should be done.

 East Asian or Mediterranean Descent

A baby born to an East Asian or Mediterranean family is at a higher risk of

becoming jaundiced. Also, some families inherit conditions (such as

G6PDdeficiency), and their babies are more likely to get jaundice.

 Feeding Difficulties

A baby who is not eating, wetting, or stooling well in the first few days of life is

more likely to get jaundice.

 Sibling with Jaundice

A baby with a sister or brother that had jaundice is more likely to develop jaundice.
 Bruising

A baby with bruises at birth is more likely to get jaundice. A bruise forms when

blood leaks out of a blood vessel and causes the skin to look black and blue. The

healing of large bruises can cause high levels of bilirubin and your baby might get

jaundice.

 Blood Type

Women with an O blood type or Rh negative blood factor might have babies with

higher bilirubin levels. A mother with Rh incompatibility should be given Rhogam.

Signs and Symptoms

Jaundice usually appears first on the face and then moves to the chest, belly, arms,

and legs as bilirubin levels get higher. The whites of the eyes can also look yellow.

Jaundice can be harder to see in babies with darker skin color. The baby’s doctor or

nurse can test how much bilirubin is in the baby’s blood.

 Drowsiness.

 Pale stools - breast-fed babies should have greenish-yellow stools, while those of

bottle fed babies should be a greenish-mustard color.

 Poor sucking or feeding.

 Dark urine - a newborn's urine should be colorless.

 See your baby’s doctor the same day if your baby:

 Is very yellow or orange (skin color changes start from the head and spread to the

toes).

 Is hard to wake up or will not sleep at all.

 Is not breastfeeding or sucking from a bottle well.

 Is very fussy.

 Does not have enough wet or dirty diapers.

Get emergency medical help if your baby:

 Is crying inconsolably or with a high pitch.

 Is arched like a bow (the head or neck and heels are bent backward and the body

forward).

 Has a stiff, limp, or floppy body.

 Has strange eye movements.

Diagnosis

Yellowing of the skin and the whites of the eyes is the main sign of infant jaundice

usually appears between the second and fourth day after birth.

To check for infant jaundice, press gently on your baby's forehead or nose. If the skin

looks yellow where you pressed, it's likely your baby has mild jaundice. If your baby

doesn't have jaundice, the skin color should simply look slightly lighter than its

normal color for a moment.

Examine your baby in good lighting conditions, preferably in natural daylight.

In many cases, the likely underlying cause can be elicited from the history, with the

investigations simply confirming suspicions. Hence, whilst a complete list of

investigations is given below, these should be tailored to the clinical features of the

patient.

Before leaving the hospital with your newborn, you can ask the doctor or nurse

about a jaundice bilirubin test.

A doctor or nurse may check the baby’s bilirubin using a light meter that is placed

on the baby’s head. This results in a transcutaneous bilirubin (TcB) level. If it is high,

a blood test will likely be ordered.

 The best way to accurately measure bilirubin is with a small blood sample from the

baby’s heel. This results in a total serum bilirubin (TSB) level. If the level is high,

based upon the baby’s age in hours and other risk factors, treatment will likely follow.

Repeat blood samples will also likely be taken to ensure that the TSB decreases with

the prescribed treatment.

Bilirubin levels are usually the highest when the baby is 3 to 5 days old. At a

minimum, babies should be checked for jaundice every 8 to 12 hours in the first 48

hours of life and again before 5 days of age.

Laboratory Tests

Any patient presenting with jaundice should have the following bloods taken:

Liver function tests (LFTs(

Coagulation studies (PT can be used as a marker of liver synthesis function)

FBC (anemia, raised MCV, and thrombocytopenia all seen in liver disease) and U&Es

Specialist blood tests.

Treatment

The bilirubin levels for initiative of phototherapy varies depends on the age and

health status of the newborn. However, any newborn with a total serum bilirubin

greater than 359 mol/l ( 21 mg/dL) should receive phototherapy.

1) Phototherapy

Babies with neonatal jaundice may be treated with colored light called

phototherapy, which works by changing trans-bilirubin into the water-soluble

bilirubin.

The phototherapy involved is not ultraviolet light therapy but rather a specific

frequency of blue light. The light can be applied with overhead lamps, which means

that the baby's eyes need to be covered, or with a device called a Bili blanket, which

sits under the baby's clothing close to its skin

Nursing care for those infants receiving Phototherapy

1. Cover the infant's eyes and genital organs.

2. The infant must be turned frequently to expose all body surface areas to the light.

3. Check Serum bilirubin level /4-12 hours.

4. Each shift, eyes are checked for evidence of discharge or excessive pressure on

the lids and eye care should be done using warm water, then apply eye drops or

ointment.

5. Eye cover should be removed during feeding, and this opportunity is taken to

provide visual and sensory stimuli.

6. Avoid oily lubricants or lotion on the infant's exposed skin, because this can act as

a barrier that prevent penetration of light through the skin.

7. Increase feeds in volume and calories. Add 20 % additional fluid volume to

compensate for insensible and intestinal water loss

8. Intake and output chart.

Phototherapy side effects include

1) Hyperthermia.

2) Dehydration due to increased insensible water loss.

3) Watery diarrhea.

4) Hypoglycemia.

5) Retinal damage.

6) Erythema.

7) Bronze baby syndrome.

8) Upset of maternal infant interaction.

2) Blood exchange transfusion

This procedure removes bilirubin and hemolytic antibodies and corrects anemia An

umbilical catheter is inserted under aseptic technique via the umbilical vein and

threaded into the inferior vena cava. A double blood volume exchange is done (2 x 85

x body weight).

Technique: Depending on infant's weight, 5 - 20 ml of blood is withdrawn within

15-20 seconds and the same volume of transfused blood is infused over 60-90 sec.

Fresh blood is to be used. If the blood is citrated, calcium gluconate may be given

after an infusion of 100 ml of donor's blood to prevent hypocalcemia.

Type of blood for exchange transfusion

 In neonates with Rh incompatibility, use Rh negative blood that has been cross-

matched with the mother's blood.

 In neonates with ABO incompatibility, use O positive or O negative group blood

that has been cross-matched with the mother's blood.

 In other hemolytic cases e.g. G6PD, use the infant's blood group after cross-

matching.

Complications from blood exchange transfusion

 Thrombosis, myocardial infarction.

 Heart failure, arrest.

 Infection: HIV, and hepatitis.

 Hypothermia or hyperthermia

 Rash (allergic reaction).

Nursing care management

Part of routine physical assessment includes observing for evidences of jaundice at

regular intervals. Jaundice is most rely - apply assessed by observing infant skin color

from head to toe and the color of sclerae and mucus membrane. Applying direct

pressure to skin , especially over bone prominences such as the tip of the nose or

sternum cause blanching and allows the yellow stain to be more pronounced.

The nurse should observe the infant in natural daylight for true assessment of color.

The transcutaneous bilirubin is useful screening device to detect neonatal jaundice in

full term infants. Because phototherapy reduces the accuracy of instrument.

A careful history from the parents may reveal significant familial patterns of

hyperbilirubinemia (e.g. older siblings of the infant ) .

 Other consideration in assessment includes the family's ethnic origin (e.g. higher

incidence of Asian infants) ; type of delivery (induction of labor) and infant

characteristics such as significant weight loss after birth , gestational age , sex and

bruising.

Assess the method and frequency of feeding as well as the infant's hydration status.

In general, healthy term newborns under 1 week of age will have a number of

voiding's roughly to the number of days in age up to the fifth or sixth day, at which

time adequate voiding is considered to be 6 to 10 times per day( e.g. day2 = 2void ,

day3 = 3void and so on ) Encourage parents to keep a log number of feedings.

Show the parents how to remove dipper's outer plastic layer and observe the AGM

granules for yellowish green moisture that is indication of urine.

Basic nursing care of infant with hyperbilirubinemia differs from any newborn infant

only in management of specific therapy.

Prevention of physiologic and breast feeding jaundice may be possible with early

introduction of feedings and frequent nursing without water supplement . Make every

effort to provide optimum thermal environment to reduce metabolic needs.

Management of breast-feeding jaundice

Recommendation of prevention and management of early onset of breastfed infant

include encouraging frequent breast feeding preferably 1.5 to 2 hours; avoiding

glucose water formula and water supplementation and monitoring for early stooling.

The infant's weight, voiding and stooling should be evaluated along with

breastfeeding pattern. parents are taught to evaluate number of voids and evidence of
adequate breastfeeding after the infant is home and are encouraged to call primary

care practitioner if there are indications the infant is not feeding well , is difficult to

arouse for feedings or is not voiding or stooling adequately.

Bilirubin levels are monitored in late onset jaundice and treatment options vary.

Whenever possible, offer parents the option of continuing breastfeeding , provided

that the jaundiced infant is closely monitored for additional contributing factors .

Home phototherapy and continued breastfeeding are option for the family of a

newborn with mild to moderate hyperbilirubinemia.

Complication

Kernicterus is a rare but serious complication of untreated jaundice in babies. It's

caused by excess bilirubin damaging the brain or central nervous system.

If significant brain damage occurs before treatment, a child can develop serious and

permanent problems, such

 Cerebral palsy (a condition that affects movement and co-ordination).

 Hearing loss (which can range from mild to severe).
 Learning disabilities.
 Involuntary twitching of different parts of their body.
 Problems of maintaining normal eye movements (kernicterus have a tendency to
gaze upwards or from side to side rather than straight ahead).
 Poor development of the teeth.
Health education

Discharge planning that health care provider should take care from

He should Identify babies at risk for neonatal jaundice

◦ Consider pre-discharge measurement of TcB

• Provide written and verbal information to parents

Health care provider should Review

* Baby less than 72 hours of age at discharge within 2 days

of going home

* Jaundice increasing or presents after 10 days

* Poor feeding or losing weight

* Pale stools, dark urine babies

Home care advices that parents should take care from them to help their child to

be well

* Watch your baby for signs of jaundice returning or getting worse

* Your baby’s skin or the whites of the eyes turn yellow.

* If jaundice gets worse, the yellow color will move from the eyes to your baby's face.

Then it will move down your baby's body toward the feet.

* Breastfeed your baby often, at least 8 to 12 times every 24 hours. (Most babies with

jaundice get better after eating for several days because the bilirubin is removed from

the body in the stools.)

* Talk with your baby's healthcare provider about feedings if you are bottle-feeding

your baby.
 Tell parents that they should call baby's healthcare provider if their baby

Is not interested in feeding 8 to 12 times every 24 hours

Has pale skin

Has pale or grayish stool or bowel movements

Has jaundice that gets worse (yellow color moving toward the feet)

Has jaundice that does not improve by 2 weeks of age

Has a fever Has jaundice that gets worse (yellow color moving toward the feet)

Has jaundice that does not improve by 2 weeks of ag

Has a fever

Is fussy or crying a lot

Is vomiting

Is fussy or crying a lot

Is vomiting

Has fewer wet or soiled diapers per day than expected. As a general rule,

newborns who are getting enough milk will be stooling 3 to 4 times a day by their

fourth day of life. Their stool should be yellow rather than black, brown, or green

by day 5. They will probably also have at least one wet diaper for each day of age

in the first week (one the first day, two the second day, and so on).

Look for jaundice daily during the first week of life.

 mother should Check the naked baby for jaundice in bright and preferably natural

light, by blanching the skin with gentle finger pressure over the chest. parents should

know that Presence of jaundice needs to be confirmed by healthcare providers; blood

tests may be required.

 Tell parents that Jaundice in the first 48 hours of life needs urgent review by

healthcare providers.
 Mother should Continue breastfeeding even if the baby is jaundiced. Contact the

healthcare provider for assistance with breastfeeding if needed.

 Advise mother that Untreated jaundice may lead to deafness and brain damage.

 Tell parents that Phototherapy is a safe and effective form of treatment for NNJ.

 Parents should know that Traditional and alternative methods of treating jaundice are

unproven and likely to be ineffective.

 Advise mother to avoid Exposing the baby to sunlight as a form of treatment as it may

be harmful due to dehydration and sunburn.

 They should know factors that influence the development of significant

hyperbilirubinemia.

 They should know how to check the baby for jaundice.

 They should know what to do if they suspect jaundice.

 They should know the importance of recognizing jaundice in the first 24 hours and of

seeking urgent medical advice.

 They should know the importance of checking the baby's nappies for dark urine or

pale chalky stool.

 They should know the fact that neonatal jaundice is common, and reassurance that it

is usually transient and harmless.

 They should know that breastfeeding can usually continue.

 They should provide lactation/feeding support to breastfeeding mother's whose baby

is visibly jaundice.
Health education program

Definition
Health education program is structure developing to learn how to live healthy lives

and avoid diseases. It helps them understand what health is and how to look after it,

also about the need for health services and disease- control programs.

Steps of Planning of Health Education Program

1- Collection of baseline data and information

2- identification the health problems and health education needs

3- Establishment of goals and objectives

4- Define the content

5- identify the target group

6- Decide appropriate method and media

7- Develop a detail plan of action

8- Determine the time and techniques for evaluation

Reference
https://www.cdc.gov/ncbddd/jaundice/index.html
https://www.cdc.gov/ncbddd/jaundice/facts.html
https://www.who.int/home
https://www.researchgate.net/figure/Steps-of-planning-a-health-education-
program_fig1_320497034
http://www.pard-lb.org/en/what-we-do/template-features-2/introduction-to-
health-education

https://www.ncbi.nlm.nih.gov/books/NBK65113/

Advanced Pediatric Nursing book prepared by Pediatric Nursing Staff at Mansoura

university