Why is it important for the nurse to know the infants gestational age?

Note: This guideline is currently under review. 

Introduction

Aim

Definition of Terms

Assessment

Managment

Potiential Complications

Discharge Planning

Family Centered Care

Special Considerations

Companion Documents

Links

Evidence Table

References

Introduction

This guideline applies to neonates within the first two weeks of life.

Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. Approximately 60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which classically becomes visible on day 3, peaks days 5-7 and resolves by 14 days of age in a term infant and by 21 days in the preterm infant. Treatment with phototherapy is implemented in order to prevent the neurotoxic effects of high serum unconjugated bilirubin. Phototherapy is a safe, effective method for decreasing or preventing the rise of serum unconjugated bilirubin levels and reduces the need for exchange transfusion in neonates.

Aim

This guideline provides health care providers with information to understand the causes of neonatal jaundice, the rationale for the use of phototherapy and outlines the care of neonates receiving phototherapy in order to enhance effective phototherapy delivery and minimise complications of phototherapy.

Definition of Terms

• Jaundice: the yellow appearance of the skin that occurs with the deposition of bilirubin in the dermal and subcutaneous tissues and the sclera.
• Bilirubin: the orange-yellow pigment of bile, formed principally by the breakdown of haemoglobin in red blood cells at the end of their normal life-span. Neonate’s bilirubin production rate is double that of adults and their clearance of bilirubin is reduced, hence the importance of monitoring levels and detecting jaundice in this early post-natal period. 
• Bilirubinaemia: the presence of bilirubin in the blood.
• Hyperbilirubinaemia: the excess of bilirubin in the blood. Types of Neonatal Hyperbilirubinaemia:
  • Unconjugated: most common form of neonatal hyperbilirubinaemia. The bilirubin has not been metabolised and hence cannot be excreted via the normal pathways in the urine and bowel. Unconjugated bilirubin binds with lipids and albumin, and results in the yellow appearance of the skin and sclera. Unconjugated bilirubin can cross the blood-brain barrier and cause neurotoxic effects.
  • Conjugated: less common in neonates. The bilirubin has been metabolised and is water soluble, but accumulates in the blood usually due to hepatic dysfunction. Conjugated bilirubin does not cross the blood-brain barrier. 
• Serum Bilirubin [SBR]: reports the unconjugated and conjugated bilirubin levels. This is the usual specimen requested by Medical staff on the pathology slip at RCH. Hyperlink to RCH Specimen Collection handbook.
• Total serum bilirubin levels [TSB]: measure used when charting serum bilirubin results onto Phototherapy and/or Exchange transfusion charts. TSB is the sum of unconjugated + conjugated serum bilirubin. A TSB can be requested on the pathology slip at RCH, but only the total combined conjugated and unconjugated bilirubin level is reported.
• Breast milk jaundice: develops within 2-4 days of birth, is most likely related to limited fluid intake as breast milk supply is established, may peak at 7-15 days of age and may persist for weeks.
• Phototherapy: a treatment for jaundice where the exposure of skin to a light source converts unconjugated bilirubin molecules into water soluble isomers that can be excreted by the usual pathways. Blue-green light is most effective for phototherapy as it both penetrates the skin and is absorbed by bilirubin to have the photochemical effect. 
• Bilirubin encephalopathy: the acute manifestations of bilirubin toxicity seen in the first few weeks after birth. Signs include lethargy, hypotonia and poor suck progressing to hypertonia, opisthotonos, high-pitched cry and eventually to seizures and coma.
• Kernicterus: the pathogenic diagnosis characterised by bilirubin staining of the brain stem and cerebellum. Also the term used to refer to chronic bilirubin encephalopathy. Clinical findings include cerebral palsy, developmental and intellectual delay, hearing deficit, dental dysplasia and oculomotor disturbances.
• Single Light: One neoBLUE LED phototherapy unit [mini or standard]
  
• Double Lights: Two neoBLUE LED phototherapy unit’s [mini or standard] or One neoBLUE LED phototherapy unit [mini or standard] + One biliblanket
• Triple Lights: Three neoBLUE LED phototherapy unit’s [mini or standard] or Two neoBLUE LED phototherapy unit [mini or standard] + One biliblanket 
  

**All phototherapy units are to be set on high intensity at all times, regardless of the amount of units in use. This ensures delivery of adequate amounts of blue light via light emitting diodes [LEDs]. Therefore, a single unit is classified as a single light and single, double or triple lights refers to the amount of units not the intensity setting. 
 
**As per Natus neoBLUE LED phototherapy in-service guide [available on the intranet], mini neoBlue LED phototherapy units deliver the same intensity as the standard unit set on high intensity; the only difference is in the surface area coverage.

Assessment

Please note that when charting the TSB level onto the Phototherapy or Exchange Transfusion charts, in the presence of risk factors [sepsis, haemolysis, acidosis, asphyxia, hypoalbuminaemia] TSB values should be plotted on the range 1 lower than the neonate’s gestational age/weight. This is because the risk of developing kernicterus increases in the presence of the above risk factors.
The Phototherapy and Exchange Transfusion charts onto which total SBR is plotted are for the first 7.5 and 5 days of life respectively. After the first 5-7 days continue utilising these charts, as levels plateau and can continue to be documented.

• Assess general skin colour whenever measuring and recording vital signs. Ensure the Phototherapy tick box in the EMR Flowsheets is activated and document time of commencement and cessation.Obtain blood sample to measure total serum bilirubin levels [either venous, arterial or capillary]
• Document hourly the type and number of light banks and the presence of eye protection.
• Obtain blood sample to measure total serum bilirubin levels [either venous, arterial or capillary] Hyperlink to RCH Specimen Collection handbook] Ensure the lights are turned off during sampling so accuracy of current blood levels can be attained.  Initially SBR levels may need to be assessed every 4-6 hours until reduction.  Follow medical advice and ordering of SBR levels according to acuity of levels and plot on appropriate line of the chart. Observe for signs of lethargy and poor feeding [insert link to assessing for Jaundice]
  
• Observe for signs of lethargy and poor feeding [insert link to assessing for Jaundice]

During phototherapy neonates require ongoing monitoring of:

• adequacy of hydration [urine output] and nutrition[weight gain] 
• temperature
• clinical improvement in jaundice
• TSB or SBR levels
• potential signs of bilirubin encephalopathy

Investigations

• Initial TSB/SBR measurement should be requested based on clinical observation and the following factors:
  • any neonate