HYPERBILIRUBINEMIA

By
Sheela
MMM college of nursing
 HYPERBILIRUBINEMIA
It is an excessive level of accumulated bilirubin in the
blood, causing jaundice/icterus a yellowish
discoloration of skin, sclera and nails.

in conjugated(direct) and unconjugated(indirect) bilirubin

When it is visible?
• Adult sclera > 2mg / dl
• New born skin > 5 mg / dl

Incidence of neonatal jaundice

Term : Occurs in 60%
Preterm : 80% of preterm neonates

Jaundice is the most common condition that requires

medical attention in newborns.
 TYPES OF BILIRUBIN
Unconjugated bilirubin Conjugated bilirubin
(Indirect ) (Direct )
• Bind to albumin • Conjugated with
• Fat soluble glucuronic acid
• Can cross blood brain • Water soluble
barrier • Excreted in urine and
• Toxic in high level to stool
brain • Not toxic
 • Appears after 24 hours
• Total bilirubin rises by less than 5 mg/dl per
Physiological day
• Maximum intensity by 4th-5th day in term &

Jaundice 7th day in preterm

• Serum level less than 15 mg / dl

• Appears age Appears within 24 hours of age

• Increase of bilirubin > 5 mg / dl / day
Pathological • Serum bilirubin > 15 mg / dl
• Jaundice persisting after 14 days
jaundice • Stool clay / white colored and urine staining
yellow staining clothes
• Direct bilirubin > 2 mg / dl
 BREAST FEEDING ASSOCIATED JAUNDICE

Begins at 2-4 days of age

Decreased breast feeding increases enterohepatic circulation of

bilirubin

Reduced fluid intake dehydration concentrate bilirubin

in blood
 BREAST MILK JAUNDICE
• Begins at 5-7 days of age
• Despite persistent high bilirubin level for 3-12 weeks, these infants do
well
• Caused by factors in breast milk (pregnanediol, fatty acid & glucuronidase)

Inhibits the conjugation decrease the excretion of bilirubin

PHOTOTHERAPY
 PHOTOTHERAPY
• Phototherapy - mainstay of treatment unconjugated
Hyperbilirubinemia.

• PT is effective in reducing excessive unconjugated

Hyperbilirubinemia.

• Phototherapy should be regarded as a drug, with an appropriate dose

and duration
The initiation and duration of PT is decided by baby’s age and level of
bilirubin
MECHANISM OF PHOTOTHERAPY
 Efficacy of phototherapy depends on..
• First, wavelength must be • Second, amount of irradiation
considered. and reduction in serum bilirubin
• Bilirubin absorbs light primarily up to an irradiation level of 30-
around 450-460 nm. 40 µW/cm2/nm.
• the ability of light to penetrate • Many older phototherapy units
skin is also important; longer deliver much less energy, 6
wavelengths penetrate better. µW/cm2/nm.
• On the other hand, newer
phototherapy units, deliver light
energy above 40 µW/cm2/nm.
• Third, distance between the
infant and the light source.
• This distance should not be greater
than 50 cm (20 in) and can be less
(down to 10 cm) provided the
infant's temperature is monitored.
• Fourth, skin surface
• Irradiating a large skin surface
area is more efficient than
irradiating a small area.

• Fifth, the nature and character of the light.

• Irradiation levels using quartz halide spotlights are maximal at the
center of the circle, Large infants and infants who can move away
from the circle's center may receive less efficient phototherapy.
What happens if you follow this properly…?!

• The clinical impact of phototherapy should

be evident within 4 to 6 hours
• Decrease of more than 2 mg/dL in serum
bilirubin concentration.
 MINOR SIDE EFFECTS OF
PHOTOTHERAPY
• Loose, greenish stools
• Transient Skin rashes (lasting for short period)
• Hyperthermia
• Increased metabolic rate
• Dehydration
• Electrolyte disturbance
• Priapism - prolonged and persistent penile erection
 BRONZE BABY SYNDROME
 Dark grey-brown pigmentation of skin, mucous membrane
and urine following phototherapy.
 Hepatic dysfunction has to be there for this condition to be
present.
 Lesions spread over the abdomen, chest, back and both
upper and lower limb after receiving phototherapy.
 It is assumed that abnormal accumulation of photo isomer
of bilirubin is the cause of this condition.
 The second cause is abnormal hepatic function leading to
copper-porpyhrin complex which is photo destroyed leading
to brown pigmentation.
 The third explanation is accumulation of biliverdin leading
to pigmentation.
 MANAGING MINOR EFFECTS

• The temperature is monitored to detect early signs of hypothermia or

hyperthermia

• The skin is observed for evidence of dehydration and drying, which can lead to
excoriation and breakdown.

• May require additional fluid volume to compensate for insensible and intestinal
fluid loss.
• Breastfeeding or bottle feeding by the mother every 2 hours

• Frequent stooling can cause perianal irritation; meticulous skin care is essential.
 CARE FOR NEWBORN
• Perform hand wash
• Place baby half naked – eye shield and diaper
• Fix eye shield – appropriate size to avoid nares block and retinal damage
• Keep baby at least 45 cm from lights
• Frequent extra breast feeding every 2 hourly
• Turn baby after each feed or every 2 hourly
• Temperature should be recorded 2 to 4 hourly
• Weight record- daily
• Monitor urine frequency
• Monitor bilirubin level – 6-12 hours
Lets find out…what is this…?!
TRANSCUTANEOUS BILIRUBINOMETER

Non invasive
Measures the bilirubin level
Read at the level of chest and forehead
 BILIBLANKET
• Biliblanket is a portable phototherapy device
used to treat neonatal jaundice.
• The name "biliblanket" combines the words 
bilirubin and blanket.
 RETROCOLLIS AND OPISTHOTONOS
• Advanced stage of acute bilirubin
encephalopathy.
• Retrocollis – cervical dystonia causes
repetitive muscle contraction that results in
neck extension
• Opisthotonos – spasm of muscles causing
backward arching of head, neck and spine.
THANK YOU!