Pathological jaundice | CHAPTER 18 | Pediatric Nursing

Pathological jaundice – Health of the children has been considered as the vital importance to all societies because children are the basic resource for the future of humankind. Nursing care of children is concerned for both the health of the children and for the illnesses that affect their growth and development. The increasing complexity of medical and nursing science has created a need for special area of child care, i.e. pediatric nursing.

Pediatric nursing is the specialized area of nursing practice concerning the care of children during wellness and illness. It includes preventive, promotive, curative and rehabilitative care of children. It emphasizes on all round development of body, mind and spirit of the growing individual. Thus, pediatric nursing involves in giving assistance, care and support to the growing and developing children to achieve their individual potential for functioning with fullest capacity.

Pathological jaundice

Pathological jaundice is referred to as an elevation of TSB (total serum bilirubin) levels to the extent where treatment of jaundice is more likely to result into benefit than harm.

[Ref-Vinod Paul/8h/172)

Or,

Pathologic jaundice include the appearance ofjaundice within 24 hours after birth, a rapidly rising total serum bilirubin concentration (increase of more than 5 mg per dL per day), and a total serum bilirubin level higher than 17 mg per dL in a full-term newborn.

Or,

Neonatal jaundice is considered pathological if it appears 1 day of age, persistent beyond 2 weeks; total serum bilirubin levels exceed 15 mg/dl or conjugated serum bilirubin is > 2 mg/dl or 20% of total bilirubin; rise in serum bilirubin level is more than 0.5 mg /dl/hour; or associated with signs of illness.

Kramer’s rule to determine degree of jaundice:

Difference between physiological and pathological jaundice:

Types of Hyperbilirubinemia:

1. Unconjugated hyperbilirubinemia.

2. Conjugated hyperbilirubinemia.

Clinical Assessment of Jaundice:

In newborn:

The jaundice is detected by-

• Blanching the skin with finger.
• Revealing the yellow staining of skin &
• Subcutaneous tissues.

In adults:

• Sclera appears icteric when serum bilirubin exceeds 2 mg/dl.

Note: It is difficult to detect jaundice in eyes of a newborn as unlike adults, neonates keep their eyes shut because of physiological photophobia.

[Ref-Piyush Gupta/1/246]

Laboratory investigations:

1. Serum bilirubin, both direct and indirect

2. ABO and Rh blood grouping of mother ns well as baby

3. Hemoglobin/ Peripheral smear

4. Reticulocyte count.

5. Coombs test of mother as well as baby

6. Blood culture.

7. Liver function tests.

8. G-6 PD enzyme studies

[Ref-Suraj Gupta/11/230]

Management of Neonatal Jaundice:

Principles of management:

The goal of management is to keep the serum bilirubin below neurotoxic levels.

1. Phototherapy and exchange transfusion are the two major effective therapeutic modalities available today.

2. Additional options include – Pharmacotherapy in the form of –

• Phenobarbital.
• Agar-agar
• Albumin infusion.
• N-mesoporphyrin.
• Charcoal etc.

Phototherapy:

First introduced by Cramer, phototherapy has emerged as the most widely used tool for treating unconjugated pattrotogic hyperbilirubinemia. The value of phototherapy in lowering on conjugated hyperbilirubinemia is widely accepted.

1. Phototherapy is the use of ultraviolet light in the treatment of jaundice in the newborn

2. It works by encouraging the liver to excrete bile in the form of unconjugated bilirubin

3. Blue of fluorescent bulbs are commonly used in phototherapy.

4. Prolonged exposure to ultraviolet light may be cause retinal damage; therefore, it is important to keep the infant’s eyes shielded with eye patches when under the light.

5. Care of the baby undergoing phototherapy includes-

• Close monitoring of body temperature.
• Fluid and electrolyte balance.
• Checking of serum bilirubin level at intervals.

Exchange transfusion:

1. An exchange transfusion is used when phototherapy is ineffective and the bilirubin level is rising.

2. Exchange transfusion lowers the bilirubin level by 50 to to 60%

3. During transfusion, the neonate’s antibody-coated red cells and excess bilirubin are removed and replaced by donor blood that contains noncoated red blood cells.

4. Only small amounts of infant’s blood are removed and replaced at a time.

5. The procedure is repeated until the infant’s total blood volume has been diluted with fresh blood.

6. The nurse must be alert for the following complications during transfusion-

• Bradycardia.
• Arrhythmias.
• Infection.
• Thrombosis.
• Hypocalcaemia.
• Fluid overload.

[Ref-Annamma Jacob/24/318 & Suraj Gupta/11/230]

Nursing Intervention of Hyperbilirubinemia of Newborn:

1. The nurse should frequently observe and detect any early changes. The general condition and alertness of the neonate should be noticed. Vital sign also should maintain.

2. The skin color is observed for the increase or decrease in yellowness.

3. The urination is checked for the frequency, amount and color’

4. Any behavior changes, convulsion or sluggishness should be noted and reported. The normal body temperature should be maintained especially when the baby is under phototherapy on of bilirubin and

5. Adequate fluid intake is necessary to help in the excretion of bilirubin intake output should be closely monitored adequate hydration’ When the neonate is under phototherapy, the eyes of the neonates must be protected from the light. The neonate is removed for a short while from the phototherapy to, breast feeding eye contact with the mother, emotional support and for tactile stimulation.

Prevention of Hyperbilirubinemia:

Some degree of jaundice in newborns is normal and not entirely preventable. However, the prevention of significant hyperbilirubinemia and its complications is possible through-

• Proper screening (obtainin bilirubin levels).
• Identifying newborns at high-risk.
• Close surveillance.
• Monitoring of those infants with hyperbilirubinemia.
• Parent education.
• Prompt treatment when deemed medically indicated

Complications of Jaundice:

• Blood-group incompatibility between the mother and her baby.
• Infections and inherited blood disorders and deficiencies, e.g. G6PD deficiency.
• Cerebral palsy.
• Deafness.
• Kernicterus, which is brain damage from very high bilirubin levels.

Read more:

• Nutritional Anaemia | CHAPTER 15 | Pediatric Nursing