Now, let's talk about the
next newborn complication.
First, I want you to say that three times fast.
Okay now I'll tell you what it is.
Hyperbilirubinemia is the buildup of
excess biulirubin in the baby's blood.
Let's talk about the physiology.
So in the case of
hyperbilirubinemia, what's going on
is that red blood cells have to be broken down.
Where do all these extra red
blood cells come from?
Here's a list.
First of all, any type of birth
trauma that might lead to bruising.
So perhaps there was an instrument
delivery or some other traumatic event.
We talked about cephalohematoma
in our lecture on newborn assessment.
Remember, there's a buildup of blood.
Extra red blood cells.
There can also be physiologic
destruction of RBCs that happen just
as a part of normal transition.
We can also have pathologic destruction,
meaning that something has gone wrong,
In this case of sensitization, or blood
incompatibilities might be a number one cause.
Either way, any of these conditions can lead to the
need for a breakdown of excessive red blood cells.
In order for all of those extra red
blood cells to be excreted from the body,
it has to be conjugated bilirubin.
So let's talk about how we get there.
So from hemolysis of the RBCs,
we get unconjugated bilirubin.
And that unconjugated
bilirubin has to be conjugated.
It has to be bound in order to leave the body.
So at the serum albumin binding sites, the
unconjugated bilirubin can bind to the albumin.
However, in order for all those
RBCs to be excreted from the body,
it has to leave the body as conjugated bilirubin.
So let's talk about how we get there.
As the red blood cells are broken down, they
are broken down into unconjugated bilirubin.
That's allowed to float freely in the bloodstream.
Now, there are serum albumin sites.
And in the serum albumin sites, the
unconjugated bilirubin can be bound.
However, if there are more RBCs
than there are albumin binding sites,
there's going to be an excessive amount of
bilirubin allowed to float into the bloodstream.
When that happens, we get staining of the skin.
The cutaneous tissue, which
gives us that yellow jaundice color.
Over time, in an excessive amount of
bilirubin, we can also have staining of brain tissue
that can lead to kernicterus and brain damage.
The bilirubin that's bound to the albumin is then
transferred to the liver where it is conjugated.
It becomes conjugated bilirubin.
And the bile helps to transport that
conjugated bilirubin to the intestines,
and it's able to be excreted
both in the stool and in the urine.
And that's how we get rid of all those
extra broken down red blood cells.
That's the physiology of hyperbilirubinemia.
Now, let's talk about the risk
factors for hyperbilirubinemia.
Interestingly, we have a mnemonic for this.
So risk factors include: Jaundice
within the first 24 hours after birth.
This would coincide with
Sometimes after 24 hours, especially
with babies that are breastfed,
they may experience physiologic
jaundice, which is not as problematic.
But jaundice within the first 24 hours is always
pathologic and will always need further workup.
A - A sibling who was jaundiced as a neonate.
So a family history of hyperbilirubinemia.
U - Unrecognized hemolysis
such as ABO incompatibility.
Remember my chart across the top.
N - Nonoptimal sucking or nursing.
So in this case, think about anything that's
going to get in the way of excreting the bilirubin.
So if you're not getting enough in, then
you're not going to have anything coming out.
D - A deficiency in glucose-6
- phosphate dehydrogenase.
This is a genetic disorder.
And infection. Remember one
system off another system off.
C - Cephalohematoma or bruising.
Chart across the top as a
cause for extra RBC production.
Or E - East Asian or Mediterranean descent.
Just because there may be an
increased risk for any type of anemia,
and that can cause a need for an
increased amount of red blood cells.
So there's your mnemonic for your
risk factors for hyperbilirubinemia.
Let's talk about treatment for hyperbilirubinemia.
Now you might notice this baby is
under some pretty cool blue lights.
This is not a special effect.
These are Bili lights also known as phototherapy.
This is going to help increase
the binding of that bilirubin.
So one of the things we want to notice is
that the baby's not really wearing any clothes.
Well, that's to allow more of the
light to come in contact with the skin,
which is what we want.
But we also want to make sure the
baby doesn't get too cold or too hot.
So depending how the phototherapy
is delivered, whether it's in an isolette or
over a radiant warmer, or maybe a blanket
will determine, what other things we need to do
to make sure the baby maintains temperature,
So remember, it could be too
hot or too cold, so check both.
I and O is going to be super important for
babies that are experiencing hyperbilirubinemia.
Remember, the way we excrete the conjugated
bilirubin is through the stool and the urine.
So it's important that the baby eats.
Well, because that's how they drink too.
Also making sure the baby's
eyes are protected from the lights.
We don't want to cause eye
damage from phototherapy.
So the cool sunglasses are not
just cool, they're actually functional.
And finally, remember, thinking
about how this bilirubin is excreted -
through the urine and through
the feces, and we want more of it.
So we want to make sure that the baby stays
dry and that our skin integrity remains intact
throughout this entire process.
When we talk about preventing
hyperbilirubinemia, we want to go back to the things
we've already been talking about.
Maintaining a thermoneutral environment.
So watching out for those four
ways that the baby can lose heat
and making sure that their temperature remains
normal is one way we can prevent hyperbilirubinemia.
Also making sure the baby stays well fed.
So early and frequent feedings
regardless of the method.
Checking input and output for any
baby is going to be really important.
But this is definitely effective
for preventing hyperbilirubinemia.
Also a skin into a skin assessment.
Making sure that we notice any signs of jaundice.
Remember, if the jaundice happens within
the first 24 hours, that's pathologic jaundice.
If it happens after 24 hours, it
may be physiologic jaundice.
To provide a more objective
measurement of the bilirubin levels,
we can use what's called
a transcutaneous bilimeter.
Once we have that value, then we can
use that information to determine whether
feeding is appropriate,
bili lights are appropriate,
or whether we have to have an
exchange of the red blood cells.