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Neonatal Hyperbilirubinemia: A Nursing Overview

Ciera Stevick

School of Nursing, Jackson College

NRS 211: Women and Neonates

Professor Sarah Holda

September 21, 2021

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Abstract

Neonatal hyperbilirubinemia refers to elevated bilirubin levels in newborns resulting in jaundice.

Neonatal hyperbilirubinemia is common and can be physiological or pathological. Physiological

hyperbilirubinemia often resolves without treatment, and pathological hyperbilirubinemia is

commonly treated with phototherapy using UV lights. Administration of blood transfusion or IV

immunoglobulin are other treatments associated with pathological hyperbilirubinemia. Left

untreated, neonatal hyperbilirubinemia can progress to kernicterus or bilirubin encephalopathy,

which causes neurological complications that may or may not cause permanent damage. Proper

assessment and parental education are important to timely diagnosis and treatment of

hyperbilirubinemia.
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Neonatal hyperbilirubinemia occurs when excess bilirubin, a byproduct of the breakdown

of red blood cells, is present in the blood of a neonate. The hallmark sign of hyperbilirubinemia

is jaundice, which presents as a yellowing of the skin, eyes, and mucous membranes. Jaundice

associated with neonatal hyperbilirubinemia usually begins in the cephalic region and moves

downward to the trunk and extremities (The Children's Hospital of Philadelphia, 2014).

According to the CDC, about 60% of all newborns experience jaundice (2020). Neonatal

hyperbilirubinemia can be split into two main categories: physiological hyperbilirubinemia and

pathological hyperbilirubinemia. The former is usually self-limiting, while the latter requires

prompt treatment to avoid neurological complications associated with kernicterus. The most

common treatment for neonatal hyperbilirubinemia is phototherapy under UV light, but severe

cases may require blood transfusion.

As previously mentioned, bilirubin is created when red blood cells are broken down. In a

fetus, the placenta is responsible for excreting bilirubin. After birth, the newborn’s liver is

responsible for converting unconjugated bilirubin to conjugated bilirubin, which can then be

excreted by the liver. It is not uncommon for the immature liver to have difficulty keeping up

with the demand to excrete bilirubin, leading to a buildup of unconjugated bilirubin in the

newborn’s blood. This is the underlying cause of physiological hyperbilirubinemia. Serum levels

of unconjugated bilirubin are less than 15 mg/dL in most physiological hyperbilirubinemia cases,

which is considered within normal range for a term newborn with no other underlying health

issues (Ullah et al., 2016). Most cases of physiological hyperbilirubinemia resolve in about a

week (The Children's Hospital of Philadelphia, 2014). However, bilirubin levels in preterm

infants usually take longer to peak than in term infants (Ullah et al., 2016). Physiological

hyperbilirubinemia should be closely monitored in case treatment becomes indicated.

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Pathological hyperbilirubinemia is described as the presence of jaundice less than 24

hours after birth, an increase in bilirubin levels greater than 5mg/dL/day with peak levels above

the normal range, jaundice that lasts more than two weeks, and/or brown urine caused by

increased levels of conjugated bilirubin in the urine (Ullah et al., 2016). According to the CDC,

the following factors increase a baby’s risk of developing severe hyperbilirubinemia: birth prior

to 37 weeks gestation, having darker pigmented skin, being of East Asian or Mediterranean

descent, having feeding difficulties, having a sibling who had jaundice, having bruises due to

trauma during the birthing process, having Rh-negative blood type, and being born to a mother

with O type blood (2020). Preterm babies born before 37 weeks have a liver that is even more

immature than a term newborn, creating a greater barrier to efficient excretion of bilirubin.

Jaundice is more likely to go undetected in babies with darker skin color, because the yellow

discoloration is not as apparent as it is in babies with lighter skin. Nurses must check the color of

the sclera and the mucous membranes in addition to the color of the skin when assessing for

jaundice. This is especially important in babies with darker skin color (CDC, 2020). Large

bruises caused by trauma during the birth process increase risk for hyperbilirubinemia because

the healing process can result in increased hemolysis and bilirubin (CDC, 2020). Babies born to

a mother with Rh-negative blood or type O blood are at greater risk for hemolytic disorders due

to blood type incompatibility. If a mother with either of these blood types is exposed to fetal

blood, their body begins producing antibodies that can attack the red bloods cells of the fetus.

Increased hemolysis leads to increased bilirubin levels. Feeding problems may lead to

dehydration, which increases the risk for hyperbilirubinemia. Bilirubin is excreted in urine and

stool, and dehydration causes decreased urine and stool output, thus allowing bilirubin to buildup

in the blood (The Children's Hospital of Philadelphia, 2014). People of Eastern Asian and
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Middle Eastern descent are more likely to inherit G6PD deficiency (CDC, 2020). G6PD is an

enzyme in red blood cells, and deficient levels result in a higher rate of hemolysis (Ullah et al.,

2016).

When treatment for hyperbilirubinemia is indicated, the first line choice is usually

phototherapy with UV light. Phototherapy is associated with minimal adverse side effects and is

most effective when skin surface area exposed to the light is maximized (Ullah et al., 2016).

Important nursing considerations with phototherapy are to ensure baby’s eyes are covered

properly, body temperature is checked as indicated, and bilirubin levels are rechecked every 6-12

hours (The Children's Hospital of Philadelphia, 2014). Some babies with severe

hyperbilirubinemia are treated with blood transfusion if rapid decrease in bilirubin levels is

necessary (The Children's Hospital of Philadelphia, 2014). Babies most likely to require

transfusions are those that are experiencing hemolysis due to mother/baby blood type

incompatibility (Ullah et al., 2016). Babies experiencing hemolysis due to blood type

incompatibility may also be treated with IV immunoglobulins to decrease the rate of hemolysis

(Reddy, 2021).

If hyperbilirubinemia is left untreated it can lead to kernicterus (bilirubin

encephalopathy), which is defined as serum levels of unconjugated bilirubin above 25 mg/dL

(Reddy, 2021). High levels of unconjugated bilirubin can cause neurological damage because its

lipid solubility allows it to cross the blood-brain barrier (Reddy, 2021). Bilirubin encephalopathy

can be acute or chronic and may or may not cause permanent neurological damage. Acute

kernicterus is associated with weakness, lethargy, poor feeding, and hypotonia, while chronic

kernicterus is associated with hypotonia, hyperreflexia, developmental delays, visual defects,

auditory defects, and choreoathetoid cerebral palsy (Reddy, 2021). Chronic kernicterus is the
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form most likely to cause lasting damage. Kernicterus is rare because most babies are

successfully treated for hyperbilirubinemia before it progresses to kernicterus.

Nurses play an important role in assessing signs and symptoms of hyperbilirubinemia and

educating parents of newborns on what to look out for. Parents should seek medical advice for

their newborn if the skin is yellow/orange, baby is sleeping excessively or not at all, having

trouble feeding, is excessively fussy, or is not passing enough urine or stool (CDC, 2020).

Another important nursing implication regarding jaundice is to prioritize teaching effective

breastfeeding because if a baby is not feeding properly, they are more prone to dehydration and

jaundice (Wells et al., 2013). Nurses must also follow up with other members of the health care

team to ensure compliance to protocols regarding hyperbilirubinemia screening (Wells et al.,

2013). With proper physical assessment, risk factor assessment, and education of the family,

babies are more likely to receive proper care if hyperbilirubinemia arises, which is important in

avoiding potential long term complications associated with kernicterus.

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References

Centers for Disease Control and Prevention. (2020, December 8). What are jaundice and
kernicterus? Centers for Disease Control and Prevention. Retrieved September 21, 2021,
from https://www.cdc.gov/ncbddd/jaundice/facts.html.

The Children's Hospital of Philadelphia. (2014, August 24). Hyperbilirubinemia and jaundice.
Children's Hospital of Philadelphia. Retrieved September 21, 2021, from
https://www.chop.edu/conditions-diseases/hyperbilirubinemia-and-jaundice.

Reddy, D. K. (2021, June 15). Kernicterus. StatPearls [Internet]. Retrieved September 21, 2021,
from https://www.ncbi.nlm.nih.gov/books/NBK559120/.

Ullah, S., Rahman, K., & Hedayati, M. (2016, May). Hyperbilirubinemia in neonates: Types,
causes, clinical examinations, preventive measures and treatments: A narrative review
article. Iranian journal of public health. Retrieved September 21, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935699/.

Wells, C., Ahmed, A., & Musser, A. (2013). Strategies for Neonatal Hyperbilirubinemia: A
Literature Review. Nursing Center. Retrieved September 21, 2021, from
https://www.nursingcenter.com/cearticle?an=00005721-201311000-00011.