PERAWATAN PADA

HIPERBILIRUBINEMIA
Siti Yuyun Rahayu Fitri
Fakultas Keperawatan
Universitas Padjadjaran
Definisi
Hiperbilirubinemia merupakan keadaan dimana trjadi
peningkatan serum bilirubin yg ditandai dg jaundice
Bilirubin
It is the end product of haem breakdown.
 Unconjugated (indirect acting)
 Conjugated (direct acting)
Jaundice is an yellowish
discoloration of the skin,
sclera and mucous mem-
branes which is rarely
perceptible until the serum
bilirubin level exceeds 7.0 mg/dl
Acute Bilirubin Encephalopathy: clinical nervous system
findings caused by bilirubin toxicity
Kernicterus: chronic, permanent clinical sequelae of
bilirubin toxicity
Apa itu
Jaundice/Hiperbilirubinemia??
 Hyperbilirubinemia is an increase in the serum
bilirubin characterized by jaundice
Jaundice is bilirubin that is deposited in the skin and
mucous membranes. Jaundice is an yellowish
discoloration of the skin, sclera and mucous
membranes which is rarely perceptible until the
serum bilirubin level exceeds 7.0 mg/dl

 Lysis of red blood cells releases haem from haemoglobin,

haem is then converted to bilirubin and excreted.
Produksi bilirubin

 Produksi
bilirubin terbentuk dari degradasi Hb pada RES.
 Neonatus>>.
 1 gr Hb=35 mg bilirubin indirek
 Bilirubin indirek yaitu bilirubin yg bereaksi tdk
langsung dg zat diazo, tdk larut dlm air, dan larut
dlm lemak
Transportasi bilirubin
 Bilirubin indirek ini akan diikat oleh albumin, yg
akan ditransport ke hepar.
 Bilirubin ditransfer melalui membran sel ke dlm
hepatosit
 Di hepatosit bil akan terikat pada ligandin
(protein Y, glutation S-transferase dan protein Z)
 Proses 2 arah, trgantung dari konsentrasi & afinitas
albumin plasma dan ligandin.
 Di hepatosit bilirubin akan dikonjugasi eksresi
ke empedu
 Pd bbrp keadaan: fenobarbital mempertinggi
konsentrasi ligandin dan meningkatkan afinitas
Konjugasi bilirubin
 Dlm sel hepar, bil dikonjugasi bilirubin glukoronid
 enzim yang berperan : UDPG-T (uridin difosfat
glukoronid transferase) dan glukoronil tansferase
 UDPG-t mengkatalisis pembentukan bilirubin
monoglukoronide
 Bil monoglukoronidebil diglukorinide oleh enzim
glukoronil tranferase
 Bilirubin diglukoronide berupa isomer yg dpt
membentuk ikatan hidrogen dan dpt dieksresi ke
dalam empedu (bilirubin direk yang larut
air/bilirubin terkonjugasi)
Eksresi bilirubin
 Sesudah konjugasi bilirubin menjadi bil direk
larut air dpt dieksresi cepat ke empedu ke
usus
 Di usus bil direk tidak diabsorpsi, namun akan
dikeluarkan melalui feses (menjadi sterkobilin)
dan urin (urobilinogen)
 sebagian kecil akan di hidrolisis menjadi bilirubin
indirek dan direabsorpsi (siklus ini disebut siklus
enterohepatik) yg diperantarai oleh enzim β-
glukoronidase It is the end product of haem breakdown.
 Enzim ini meningkat pd neonatus
Metabolisme Bilirubin
 Bone marrow

RETICULOENDOTHELIAL
SYSTEM (RES) SHUNT PATHWAY
RBCs
Hgb Hgb Fe
heme Heme precursors
Globin
oxygenase Myoglobulin
Globin
+
Biliverdin Non-hgb heme proteins
Heme Biliverdin
reductase

Fe
Bilirubin Kidney
+
Porphogens
Bilirubin-Albumin Complex

Liver uptake ENTEROHEPATIC CIRC

Cytoplasmic
protein
binding Urine
Smooth urobilinogen
endoplasmic Conjugated excretion
reticulum bilirubin
Hydrolysis Intestine
Bilirubin

Urobilinogen

Stercobilin
Prevalensi Jaundice
 65% of term newborns develop clinical
jaundice in first week

 80% of preterm infants

Etiologi
1.Produksi yg berlebihan
melebihi kemampuan bayi u/ mengeluarkan. Pd
keadaan hemolisis (akibat inkopatibilitas Rh, ABO, def
enzim G-6PD, perdarahan dan sepsis.
2. Gangguan transportasi, uptake
akibat albumin <<<, efek obat yg mengganggu afinitas
albumin (salisilat, sulfafurazole). Sehingga bilirubin indirek
bebas>>> dan akan melekat ke otak.

3. Gangguan dlm proses ‘uptake’ dan konjugasi

Akibat imaturitas hepar, prot ligandin <<, gangguan fungsi
hepar (asidosis, hipoksia, infeksi, enzim glukoronil
transperase <<, def protein Y.
4. Gangguan eksresi.
Krn obstruksi dlm hepar/diluar hepar (biasanya kelainan
bawaan), atau obstruksi didlm hepar krn infeksi atau
kerusakan hepar.
Jenis Hiperbilirubinemia
 Physiologic
 Pathologic
 Hemolytic Disease
 RhesusIncompatibilities
 ABO Incompatibilities

 Neonatal Sepsis
 “Breast Milk” Jaundice
Klasifikasi
 Ikterus dalam 24 jam pertama
 Ikterus dalam 24-72 jam sesudah lahir
 Ikterus > 72 jam pertama – 1 minggu
 Ikterus > 1 minggu pertama
Ikterus dlm 24 jam pertama
 Biasanya ikterus patologis
 Penyebab:
 Inkompatibilitas ABO, Rh
 Infeksi intrauterin (TORCH)
 Defisiensi enzim G-6-PD
 Infeksi kongenital
Pemeriksaan yg perlu dilakukan:
- Kadar bilirubin berkala
- Darah tepi lengkap
- Gol darah ibu & bayi
- Uji coombs
- Px enzim G-6PD, biakan darah atau biopsi hepar
bila perlu.
Ikterus dlm 24-72 jam
 Biasanya ikterus fisiologis
 Masih ada kemungkinan hemolisis inkopatibilitas darah (jika
kadar bil > 5gr% dlm 24 jam)
 Mungkin def enzim G-6PD
 Polisitemia
 Hemolisi krn perdarahan tertutup (subaponeurosis,
perdarahan hepar dll)
 Hipoksia
 Dehidrasi, asidosis
 Def enzim eritrosit

Pemeriksaan yg perlu dilakukan:

- Pd keadaan bayi baik dan peningkatan ikterus tdk cepat,
dpt dilakukan pemeriksaan : Kadar bilirubin berkala, Darah
tepi lengkap, Gol darah ibu & bayi, Uji coombs
- Px enzim G-6PD, biakan darah atau biopsi hepar bila perlu.
 Physiological jaundice
• Physiological jaundice is jaundice that is present
between day 2 and day 10
Physiological jaundice
• Physiological jaundice is due to:
- High bilirubin production (fetal Hb,
high Hb)
- Reduced bilirubin excretion
(UDPGT concentrations at term are
1% of adult concentrations)
Ikterus dlm 72 jam – 1minggu
 Biasanya krn infeksi
 Asidosis
 Mungkin def enzim G-6PD
 Pengaruh obat
 Sindrom criggler-najjar (kurang enzim glukoronil
transferase)
Ikterus > 1 minggu pertama
 Biasanya krn obstruksi
 Hipotiroidism
 ‘breast milk jaundice’
 Infeksi
 Neonatal hepatitis
Pemeriksaan yg dilakukan
- Px bilirubin berkala
Px darah tepi
Px G-6PD
Biakan darah
Breasfeeding associate
jaundice (early onset)
 Breastfeeding associate jaundice (early-onset)
mulai trjadi pada 2-4 hari pertama, trjadi pd 12-35%
breasfed newborn (Blackburn, 2007).
 Hal ini terjadi krn proses breasfeeding dan mungkin
akibat penurunan kalori dan intake cairan oleh
bayi sebelum milk supply adekuat. Hal ini
dikarenakan fasting diasosiasikan dgn penurunan
hepatic clearance of bilirubin (porter & Dennis,
2002). Penurunan intake cairan jg menyebabkan
dehidrasi, sehingga konsentrasi bilirubin dlm darah
semakin meningkat.
Intervensi
 Berikan ASI on demand (10-12x/hari)
 Hindari pemberian suplemen seperti air, dextrose
water, formula.
 Evaluasi BAB berkala
 Berikan fototerai jika bilirubin meningkat signifikan
 Bantu ibu untuk memjaga supplai ASI dan
pengeluaran ASI
Breast milk jaundice
 Late onset (mulai hari ke 5-7, terjadi ada 2-4%
breasfed infant.
 Terjadi peningkatan bilirubin dlm 1-2 minggu dan
selanjutnya akan menurun.
 Peningkatan mungkin trjadi selama 3-12 minggu,
namun bayi menunjukkan kondisi yg baik & stabil
 Jaundice ini mungkin diakibatkan faktor dlm ASI
(pregnandiol, fatty acid, dan β-glukoronidase) yg
semua faktor tersebut menurukan konjugasi dan
eksresi bilirubin. Anak juga mungkin BAB lebih
jarang (less frequent).
Intervensi
Tingkatkan frekuensi ASI, jangan gunakan
supmelen
Pantau kadar: G-6PD, bilirubin direk &
indirek, riwayat keluarga
Lakukan fototerapi jika ada indikasi
Tetap berikan ASI
What are the factors that
exacerbate ‘physiological
jaundice’?
Factors that can increase the
severity of physiological jaundice
 Prematurity
 Sepsis
 Polycythaemia
 Delayed passage of meconium
 Breast feeding (early onset) breastmilk
jaundice (late onset)
 Certain ethnic groups, esp Chinese
Ikterus yg kemungkinan
patologis
 Ikterus dlm 24 jam pertama
 Ikterus dg kadar bilirubin melebihi 12,5 mg% pd
NCB dan 10% pada NKB
 Ikterus dg peningkatan bilirubin > 5mg%/hari
 Ikterus menetap sesudah 2 minggu
 Ikterus mempunyai hubungan dg proses hemolitik,
infeksi dan keadaan patologis lain
 Kadar bilirubin direk > 1 mg%
 Kernicterus
 Juga disebut bilirubin encephalopathy

 Sindrom Neurological syndrome akibat efek neurotoksik

bilirubin yang unconjugated/indirect pada basal
ganglia dan nukleus brainstem

 Diakibatkan oleh bilirubin indirek yang bebas (tdk terikat

albumin) dan menempel pd basal ganglia otak, corpus
stiatum dan nukleun brainstem/batang otak.
 Though infrequent, has at least 10% mortality and 70%
morbidity
Mechanism of neurotoxicity in
kernicterus
 Unbound (unconjugated) bilirubin is:
 neurotoxic at high levels
 lipophilic and can cross the blood-brain-barrier

Bilirubin accumulates at nerve terminals

Binds to cell components

Impairs mitochondrial functions

neurotransmitter synthesis

Dysfunction and death of neurons

Bilirubin staining of affected areas

Long term clinical sequelae

Kernicterus: signs and symptoms
(first 24 hours)
 Phase 1:
 Poor suck, hypotonia and lethargy

 Phase 2:
 Hypertonia and opisthotonos

 Phase 3:
 Less hypertonia, high pitched cry, hearing and visual
loss, poor feeding.
Kernicterus: signs and symptoms
(long term)
 Choreoathetoid cerebral palsy
 Sensorineural hearing loss
 Intellectual delay
Treatment
 Treatment of Neonatal Jaundice
 Depends on the cause and level and type of
bilirubin
 Unconjugated hyperbilirubinaemia:
 Ensure adequate fluid intake
 Phototherapy
 IV immunoglobulin
 Exchange transfusion

 Conjugated hyperbilirubinaemia:
 Ensure adequate nutrition
 Treat underlying problem
Treatment
 Mempercepat proses konjugasi, dahulu diberikan fenobarbital, krn
sifatnya “enzim inducer’. Promotes: hepatic glucoronil transferase
(meningkatkan konjugasi bilirubin dan hepatic clearance); meningatkan
sintesis protein, albumin (bilirubin binding sites).
 Mencegah hemoksidase dgn metalloporhirin: menurunkan destruksi
heme.
 Memberikan substrat untuk transportasi / konjugasi. Contohnya
pemberian albumin untuk mengikat bilirubin. Albumin jg diberikan
sebelum transfusi tukar, krn albumin jg akan memperepat keluarnya
bilirubin dari Ektravaskuler ke vaskular sehingga bilirubin yg diikat akan
lebih mudah dikeluarkan saat transfusi tukar. Glukosa jg penting untuk
konjugasi hepar (energi).
 Dekomposisi bilirubin dg fototerapi.
 Trasnfusi tukar, dgn indikasi:
- Jika kadar bilirubin indirek < 20 mg%
- Kenaikan bilirubin indirek cepat, yakni 0,3-1 mg%/jam
- Anemia berat pd neonatus dg gagal jantung
- Bayi dg kadar Hb talipusat < 14mg% dan uji coombs
direk (+)
 Inisiasi ASI, meningkatkan: intesinal motility, menurunkan enterohepatic
shunting, memelihara flora normal intestine.
feeding
Early feeding: berguna untuk
1). Menstimulasi peristaltik dan memproduksi
lebih cepat pasase mekonium. Serta
meminimalkan reabsorpsi bilirubin indirek.
2). Memasukkan bakteri/flora normal untuk
memantu perubahan bilirubin menjadi
urobilinogen dan sterkobilin
Kolostrum juga mrpkan katarsis natural untuk
memfasilitasi evakuasi mekonium.
 Treatment

 Tujuan
 Mencegah kernikterus
 Treatment of underlying conditions
 Maintenance of hydration and nutrition
 Interventions
 IntensivePhototherapy
 Adjuct therapies
 Albumin
 Hydration
 Other Medications
 Exchange transfusion
phototherapy
Introduction
 Phototherapy is a primary treatment for
reducing bilirubin levels that cause
jaundice in premature and newborn
babies

 Mekanismenya: fotooksidasi dan

isomerisasi
Mechanism of phototherapy
 Absorbtion of light by dermal and subcutaneous
bilirubin
 Fotooksidasi dari bilirubin indirek indirek yg
mudah larut dlm plasma, dan lebih mudah
terikat albumin, sehingga akan mudah
diekresikan oleh hati ke dalam saluran empedu.
 Fotoisomerisasi: Phototherapy converts bilirubin
that is present in the superficial capillaries and
interstitial spaces of the skin and subcutaneous
tissue to water-soluble isomers that are
excretable without further metabolism by the
liver
Mechanism of Phototherapy
 The bilirubin relatively quick photocemical
reaction (configurational isomerization,
structural isomerization, and
photooxidation) to form non toxic
excretable isomers.
 These bilirubin isomers are more polar,
and can be excreted from the liver into
the bile without undergoing conjugation
or requiring special transport for their
excretion
Mechanism of phototherapy
 The photoisomerization of bilirubin begins
almost instantneously when the skin is
exposed to light. Unlike unconjugated
bilirubin,the photoproducts of these
process are not neurotoxic.
PHOTOCHEMICAL
REACTIONS
LIGHTBILIRUBIN ABSORBS PHOTON
‘ EXCITED’ BILIRUBIN ↓
↓ ↓ ↓
PHOTO-OXIDATION
↓
STRUCTURAL ISOMEZARATION
(LUMIRUBIN) ↓
CONFIGURATIONAL
ISOMERIZATION
( 4E,15Z,4Z,15E AND 4E,15E
PHOTOISOMERES)
Phototherapy
Ultraviolet light Phototherapy is NOT:
Infrared light
(10 – 400 nm) • Ultraviolet light
(400 – 700 nm)
• Infrared light

Spectrum of light
Blue is most effective (460 - 490 nm)

Bilirubin absorbance

Bilirubin absorbance and transmittance

Maisels MJ et al. N Engl J Med 2008;358:920-8

PHOTO-CHEMICAL REACTION &
ELIMINATION OF BILIRUBIN
When is phototherapy
prescribed ?
 Preterm infants --- prophylactically
 Late-preterm and full-term infants --- at
theurapeutic dose
 > 36 weeks: 14,6 mg/dl
 > 32 weeks: 8,8 mg/dl
 > 28 wks: 5,8 mg/dl
 > 24 wks: 4,7 mg/dl
When to start phototherapy?

Decision is based on:

1. Level of bilirubin
2. Rate of rise of bilirubin
3. Gestational age
4. Chronological age
5. Wellness of the baby
When to start phototherapy?
 Phototherapy
 Indication for early phototherapy
 Bilirubin rising faster than 0.5mg/dL/hr or 5mg/dL/d
 Persistent, severe metabolic or respiratory acidosis
 Sepsis
 Sick VLBW infants
 Indication for photherapy in infants >35 weeks gestation

AAP: Clinical Practice

Guideline:
Management of
Hyperbilirubinemia in
the Newborn Infant 35
or More Weeks
Gestation, July 2004
When to start phototherapy?
FACTORS AFFECTING EFFICACY OF
PHOTOTHERY
 DEPENDENT ON

 TYPE OF LIGHT USED

 LIGHT INTENSITY

 SURFACE AREA OF SKIN EXPOSED TO LIGHT

 DISTANCE FROM LIGHT TO BABY

 Factors that affect phototherapy:
 The factors that affect the dose of phototherapy include the irradiance
of light used, the distance from the light source, and the amount of skin
exposed.
 Standard phototherapy is provided at an irradiance of 8-10 microwatts
per square centimeter per nanometer (mW/cm2 per nm).
 Intensive phototherapy is provided at an irradiance of 30 mW/cm2 per
nm or more (430–490 nm). For intensive phototherapy, an auxiliary light
source should be placed under the infant. The auxiliary light source
could include a fiber-optic pad, a light-emitting diode (LED) mattress, or
a bank of special blue fluorescent tubes.
 Term and near-term infants should receive phototherapy in a bassinet
and the light source should be brought as close as possible to the
infant, typically within 10-15 cm.
 However, if halogen or tungsten lights are used, providers should follow
the manufacturer recommendation on the distance of the light from
the infant to avoid overheating.
 Preterm infant can be treated in an incubator, but the light rays from
the phototherapy device should be perpendicular to the surface of the
incubator to minimize light reflectance. Adapted from Maisel MJ,
McDonagh AD.
 Phototherapy for Neonatal Jaundice. N Engl J Med. 2008;358:920-928.
 Phototherapy

 Mechanism of action
 Skin exposure to lights causing geometric photoisomerization and
bilirubin photooxidation allowing diffusion and albumin binding
 Not useful in neonates with elevated conjugated bilirubin
 Technique
 Light source
 banks, spotlights, fiber optic blankets, LED
 white, blue, green
 wave length: 420-500nm
 irradiance > 5 uW/sq cm/nm or change bulbs every 2000 hours
 Positioned 45-50 cm above infant
 Largest surface area possible exposed
 Intermittent vs. Continuous: current evidence does not allow
recommendations
TYPES OF PHOTOTHERAPY
DEVICE

 FLUORESCENT TUBES
 DAYLIGHT(WHITE)
 BLUE
 GREEN

 HALOGEN LAMPS
 FIBEROPTIC SYSTEM
 GALLIUM NITRIDE LIGHT EMITTING
DIODES (L.E.D)
Spectral Qualities
 Wavelength 400 to 520 nm, with peak of
460 ± 10 nm
 Blue, green and turquois are considered
the most effective
COMPARISON OF
DIFFERENT LIGHTS
% REDUCTION IN SERUM BILIRUBIN
40

30 P<0.05

20

10

0
SPECIAL BLUE GREEN DAYLIGHT

TAN KL ET AL: PEDIATRICS,114:132,1989

Irradiance
= the light intensity – number of photons
delivered per square centimeter of
exposed body surface
 The delivered irradiance determines the
effectiveness of phototherapy
 Measured by spectral radiometer sensitive
 Intensive phototherapy requires a spectral
irradiance of 30 W/cm2/nm
Distance from light
A simple way to increase irradiance is to
move the light closer to the infant
 Effective: 45-50 cm
Exposed body surface area
 The greater the body surface area
exposed to light, the faster the decline in
serum bilirubin
 At least 80 % body surface
 Positioning
COMPARING AND CONTRASTING
PHOTOTHERAPY DELIVERY
SYSTEMS
 Combinationphototherapy is to use an
overhead unit above the infant :
⁻ Fluorescent bank light
⁻ Gallium nitride light-emitting
diode (LED)
⁻ Halogen lamp
and a fiberoptic mattress underneath the
infant
LED
 LED phototherapy systems, which use gallium nitride LEDs,
are the newest devices used to provide phototherapy.
 Gallium nitride LEDs emit high-intensity light in the blue-green
portion of the spectrum within a narrow wavelength (460-
485 nm).[14]
 LEDs offer some advantages to other phototherapy sources.
Their narrow wavelength of emission is close to the
wavelength at which light is maximally absorbed by bilirubin.
 Additionally, the spectral quality of the LED device can be
customized by the use of varying proportions of blue, blue-
green, and green LEDs.
 Also, LEDs generate less heat than either halogen or
fluorescent lamps, and can thus be positioned very close to
the skin without significant risk of overheating or burns.
 Prior studies have shown that using an array of 600, 3-mm
blue LEDs, at a short distance from an infant can achieve an
irradiance of more than 200 mW/cm2 per nm.[14]
 Specially designed LED systems, such as the neoBLUE LED
Phototherapy system (Natus Inc; San Carlos, CA), are
recommended by the American Academy of Pediatrics for
use during intensive phototherapy.[
Light-emitting Diodes (LED)
 One of the most recent innovation in
phototherapy
 High irradiance in the blue to blue-green
spectrum without excessive heat
generation
 Efficient, long lasting and cost-effective
 Counteract the “blue hue” effect that
can irritate caregivers
LED
LED : one-dual surface
Halogen spotlight
 Halogen lamp using 1 or more quartz
halogen bulbs
 Device designed with a single lamp
produce a circle of light with high
irradiance only the center
 Generating significant amount heat
 Manufacturer’s recommendation for safe
maximal distance should be followed
HALOGEN LAMPS
 Halogen-based phototherapy lamps, or spotlights, use a
commercially available tungsten- halogen light bulb and
direct a strong beam of white/yellow light towards the infant.
These devices are typically free-standing on a pole, or
available as part of a radiant warmer. Halogen-based spot
lights are the most heat producing of all the available
phototherapy lights. Care must be taken not to place the
devices closer to the infant than recommended by the
manufacturer to avoid overheating the infant. Additionally,
due to the associated heat output, halogen lights may result
in increased insensible water loss in infants receiving
phototherapy.
 See the image below.
Fluorescent tube
 Not all fluorescent tubes are the same
 Different exist – different type
 One system contains 6 blue tubes and 2
white tubes
 Caregivers are often bothered by the
blue-hue effect
 Can impair assesment of infant skin color
fiberoptics
 Fiberoptic phototherapy devices deliver light form a high
intensity lamp to a fiberoptic blanket.
 These BiliBlanket devices are typically used in
conjunction with overhead halogen, fluorescent, or LED
systems.
 These devices are also commonly used to provide home
phototherapy.
 A disadvantage of using fiberoptic pads is that they
cover a fairly small surface area. Therefore, 2-3 pads
may be needed to provide effective phototherapy.[13]
This is one reason why home phototherapy is reserved
only for use in low-risk infants with total bilirubin levels 2-3
mg/dL lower than that recommended for intensive
phototherapy.
 Fiberoptic blankets
 It contain a tungsten-halogen bulb that delivers
light via a cable into a plastic pad containing
fiberoptic fibers

 The pad remain cool and can be placed directly

under an infant’s midsection to provide
phototherapy while the infant is being held
Biliblanket/wallaby blanket
DIFFERENT MODES

OF

PHOTOTHERAPY
CONTINUOUS VS INTERMITTENT
PHOTO-THERAPY
PERCENT REDUCTION IN SERUM BILIRUBIN

24
23
22 ------N.S.-------

21
20 N=69 N=47
19
18
CONT INTERMIT
CALDERA,R ET AL ANN PEDIAT 1984
CONTINUOUS VS INTERMITTENT
PHOTO-THERAPY-2
RATE OF DECLINE IN SERUM BILIRUBIN
M/L/HR

3 N=10
2.5 N=13 N=10 N=12
2
-N.S.-
1.5
RUBALTELI
1
0.5 LAU
0
CONT INTERM
SINGLE VS. DOUBLE
PHOTOTHERAPY
DECLINE IN SERUM BILIRUBIN
(M/L/HR)
5
P<0.01 0<0.05 P<0.01
4

2 SINGLE

1 DOUBLE
0
SRIVASTAVAS SHARMA HOLTROP
 Phototherapy Precautions
 Ensure patent airway
 Maintain constant body temperature by using incubator and Neutral Thermal
Environment. Assess temperature every 4-8 hours
 Maintain fluid balance by increasing intake and minimizing loss (insensible,
respiratory, GI)
 Cover eyes and genitalia
 Assure skin integrity
 frequent diaper changes
 water baths
 no lotions or oils on skin
 position to avoid skin irritation
 Careful technique when repeatedly drawing labs
 Consider use of automatic lancet
 Warm foot before procedure
 Avoid areas of previous puncture
 Provide comfort measures before and during procedure (swaddling, sucrose)
Side effect
 Loose stools, greenish stools perianal rash 
keep skin clean and dry
 Transient skin rash
 Hipertermia
 Increased metabolic rate
 Dehydration (increased insensible water loss & intestinal
water loss)
 Dry skin exoriasi and breakdown (prevent uses
of oily lubricant/lotion frying effect)
 Electrolit disturbance (Oxidize essential fatty acids,
decreases vitamins and calcium in premature infants
hipoklasemia)
 Retinal injury
Nursing problems
 Risk for impaired parent-infant
attachment
 Interupted breasfeeding
 Risk for deficient fluid volume
 Risk for impaired skin integrity
 Interupted family process
Nursing care
 Ensure effective irradiance
 Provide eye protection
 Asses skin exposure
 Proper positioning
 Assess and adjust thermoregulation
devices
 Promoting elimination and skin integrity

 Hydration

 Promoting parent-infant interactions

 Monitoring billirubin levels

Make an accurate charting
 Times that fhototherapy is started & stopped
 Proper shielding of the eyes
 Type of fluoresenc lamp
 Number of lamps
 Distance between surface and infant (not less
18 inches)
 Use of phototherapy combination with
incubator/bassinet
 Photometer measurement
 Occurrence side effect
Family support
 Parents need reassuring concerning infant progress
 Explain the risk & benefit for each therapy
 Reassure that naked infant under phototherapy is
warm & comfortable
 Eye shield are removed when parents visiting infant
to facilitate attachment
 Give auditory & tactile stimulation
 Informed consent
 Home Phototherapy

AAP Guidelines

 Healthy full term infant

 Greater than 48 hrs. old
 TSB between 14 and 20mg/dL
 No direct hyperbilirubinemia.
 No history or signs of hemolysis
 Rate of bili increase <1mg/dL in 3-4hrs
 Pharmacologic Treatments

 Phenobarbital
 Accelerates metabolic pathways for bilirubin clearance
 Tin-mesoporphyrin
 inhibits heme oxygenase
 IV gamma globulin
 inhibits hemolysis
 Act. Charcoal
 binds bili in the intestine
 Exchange Transfusion

 Procedure
 Transfer care to Neonatologist and NICU
 Complications
 Thrombocytopenia
 Portal vein thrombosis/perforation
 Necrotizing Enterocolitis
 Cardiac arrythmias
 Hypo- Calcemia, magnesemia, glycemia
 Respiratory & metabolic accidosis
 HIV, Hepatitis B & C infection
 Exchange Transfusion

 Indication in infants 35 weeks gestation or more

AAP: Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn

Infant 35 or More Weeks Gestation, July 2004
 Future Issues and Therapies

 Predicting Hyperbilirubinemia using

transcutaneous bilimeters, ETCO (exhales carbon
monoxide)
 Registry to report cases of excessive hyperbilirubinemia (
20mg/dL) and poor neurologic outcome
 Metalloporphyrin for high producers
 Gene therapy for conjugation defect
Follow-up Care
 Follow-up Care

 Plan based on
 Age in hours at discharge
 Risk of excessive hyperbilirubinemia
 Availability and reliability of follow-up
 Components
 Written discharge instructions regarding
hyperbilirubinemia, breastfeeding, dehydration
 Time specific appointment based on age in hours at
discharge and risk factors
 Infant < 24 hours old: should be seen by 72 hours of age
 Infant between 24-47.9 hours old: seen at 96 hours of age
 Infant between 48-72 hours old: seen at 120 hours of age
 Infant >72 hours old at discharge: physician’s discretion
 Follow-up resources for lactation support
Systematic Prevention
 Overview

 System failures associated with identifying and treating

severe hyperbilirubinemia
 Root causes related to four patient care processes:
 Patient Assessment
 Continuum of Care
 Patient & Family Education
 Treatment
 Root Causes Identified
 Patient Care Related
 The unreliability of the visual assessment of jaundice in newborns with dark
skin.
 Failure to recognize jaundice in the infant –or its severity– based on visual
assessment, and measure a bilirubin level before the infant’s discharge from
the hospital or during a follow-up visit.
 Failure to measure the bilirubin level in an infant who is jaundiced in the first
24 hours.
 Continuum of Care
 Early discharge (<48 hours) with no follow-up within one to two days of
discharge.
 Failure to provide early follow-up with physical assessment for infants who
are jaundiced before discharge.
 Failure to provide ongoing lactation support to ensure adequacy of intake for
breast-fed newborns.
 Patient Education
 Failure to provide appropriate information to parents about jaundice and
failure to respond appropriately to parental concerns about a jaundiced
newborn, poor feeding, lactation difficulties and change in newborn behavior
and activity.

Sentinel Alerts 18/31, JCAHO, 2001