HYPERBILIRUBINEMIA

Hyperbilirubinemia is caused by the accumulation of excess bilirubin in the blood serum.

The skin and the sclera of the eyes begin to appear yellow on the second or third day of life.

There are two main types of hyperbilirubinemia:

Unconjugated / indirect hyperbilirubinemia

- The unconjugated bilirubin is then sent to the liver, which conjugates the bilirubin
with glucuronic acid, making it soluble in water.
- Bilirubin that is attached to a protein is called indirect or unconjugated bilirubin.
Conjugated / direct hyperbilirubinemia
- Bilirubin that moves freely in the blood is called direct or conjugated bilirubin.

Bilirubin is a bile pigment that is formed from the breakdown of heme, mainly as a
product of red blood cell degradation. Unconjugated bilirubin is not very soluble in aqueous
solution, and therefore needs to be bound to albumin in the blood. The conjugation process takes
place in the liver, and produces a water-soluble conjugated bilirubin, which is ready to be
excreted from the body. If there are lots of bilirubin around and it is mostly unconjugated, it
means that it hasnt been through the liver yet so either theres a ton of heme being broken
down (and its exceeding the pace of liver conjugation), or theres something wrong with the
conjugating capacity of the liver (like a congenital disorder where youre missing an enzyme
necessary for conjugation for example, Gilbert syndrome). If there are lots of bilirubin around
and its mostly conjugated, it means that it has been through the conjugation process in the liver
but theres something preventing the secretion of bilirubin into the bile (like hepatitis, or biliary
obstruction), and the bilirubin is backing up into the blood.

RISK FACTORS

Infants who are prone to extensive bruising (Large, breech or preterm babies)
- Bruising leads to hemorrhage of blood into the subcutaneous tissue or skin.
Cephalhematoma collection of blood under the periosteum of the skull bone caused by
pressure at birth
- As the RBC in this are hemolyzed, additional indirect bilirubin is also released and so
can cause jaundice. (Nelson, Doering, Anderson, et al., 2012)
Intestinal obstruction
- Stool cannot be evacuated. Intestinal flora in the bowel breaks down bile into its basic
components, one of which is indirect bilirubin.
Breastfed babies
- They may have more difficulty converting indirect bilirubin to direct bilirubin
because breastmilk contains pregnanediol (a metabolite of progesterone), which
depresses the action of glucuronyl transferase.
Premature birth
 - A baby born before 38 weeks may not be able to process bilirubin as quickly as full-
term babies do.

MANIFESTATIONS

Yellow discoloration of the skin and sclera

COMPLICATIONS

Kernicterus
- is the yellow staining of specific areas of brain tissue in the neonate secondary to
accumulation of unconjugated bilirubin.

Manifestations:

Involuntary and uncontrolled movements

Permanent upward gaze
Hearing loss
Bilirubin Encephalopathy
- syndrome of severe brain damage from the deposition of bilirubin in the brain cells, it
is caused by kernicterus.

Manifestations:

Listlessness or difficulty waking

High-pitched crying
Poor sucking or feeding
Backward arching of the neck and body
Fever
Vomiting

MEDICAL MANAGEMENT

Phototherapy
- Exposure of the infant to light to initiate maturation of the liver enzymes. Light waves
of a very specific frequency work to convert the bilirubin in the in the babys skin.
- Phototherapy employs blue wavelengths of light to alter unconjugated bilirubin in the
skin. The bilirubin is converted to less toxic water-soluble photoisomers that are
excreted in the bile and urine without conjugation.
- In this setting, phototherapy may cause a dark grayish-brown discoloration of the skin
(bronze baby syndrome).
- In phototherapy, blue light is typically used because it is more effective at breaking
down bilirubin (Amato, Inaebnit, 1991).

Types of Phototherapy
 a. Conventional

These devices typically use one or more tungsten halogen bulb, a metal halide gas
discharge tube, long or compact (or folded) fluorescent lamps, or most recently, light
emitting diodes (LEDs). The light source is positioned above or below the baby and the
irradiance is dependent on the distance between the baby and the lights.

b. Fiberoptic blanket

These devices use a standard light source, usually a quartz halogen bulb. The light from
the bulb may then be passed through a filter before being channeled down a fibreoptic bundle
into a pad of woven optic fibers. The pad can then be placed next to the neonates skin.

Exchange transfusion
- Alternate giving and withdrawing blood in small amounts through artery/vein.
- The main purpose of the exchange transfusion is to prevent toxic effects of bilirubin
by removing it from the body. It is indicated for high levels of bilirubin and/or high
rates of rise of bilirubin.
- The procedure removes partially hemolyzed and antibody-coated erythrocytes and
replaces them with uncoated donor red blood cells that lack the sensitizing antigen.
Pharmaceutical therapy
- Inhibition of bilirubin production through blockage of heme oxygenase. Achieved
through the use of metal mesoporphyrins and protoporphyrins.

DIAGNOSTIC PROCEDURES AND LABORATORY EXAMINATIONS

Laboratory test of a sample of the infants blood

- A bilirubin test is a diagnostic blood test performed to measure levels of bile pigment
in an individual's blood serum and to help evaluate liver function.
Skin test with a device called transcutaneous bilirubinometer, which measures the
reflection of a special light shone through the skin.

Diagnostic tests for hyperbilirubinemia may include:

Direct and indirect bilirubin levels. These reflect whether the bilirubin is bound with
other substances by the liver so that it can be excreted (direct), or is circulating in the
blood circulation (indirect).
Red blood cell counts
Blood type and testing for Rh incompatibility (Coomb's test)

PHARMACOLOGIC MANAGEMENT
 Intravenous immunoglobulin (IVIG) at 500 mg/kg has shown to significantly reduce the
need for exchange transfusions in infants with isoimmune hemolytic disease.

NURSING CARE

1. Monitor the presence of jaundice.

2. Prepare for phototherapy and monitor during treatment.
American Academy of Family Physicians (2002). Hyperbilirubinemia in the Term Newborn.
Retrieved from http://www.aafp.org/afp/2002/0215/p599.html

Juadwarto, W. (2009). Clinical Pediatric Hepatology. Retrieved from

https://pediatrichepatology.wordpress.com/2009/06/03/treatment-of-neonatal-jaundice/

http://www.neonatal-nursing.co.uk/pdf/inf_001_tll.pdf