This activity is designed to increase the knowledge
level and therefore the quality of care for infants at risk
pathophysiology of hyperbilirubinemia in the newborn
the risk factors currently recognized with positive predictive
value for hyperbilirubinemia.
the process of evaluation of risk for hyperbilirubinemia
in the term newborn
in the newborn: $10,000,000 settlement against nurses
review the facts.
in this case are plaintiff son Nathaniel, a newborn male infant
now age four, plaintiff mother Jodie, a 38-year-old homemaker,
and plaintiff father Douglas, a 37-year-old attorney. Plaintiff
son was born at SJMC in Tacoma (owned by defendant). He was
essentially a healthy newborn and was discharged the following
day. He developed jaundice over the next several days. There
were a variety of contacts between the parents, doctors and
May 20, 1997, plaintiff mother called defendant lactation
consultant for advice on what she believed was a breast-feeding
problem, as the infant was not feeding well. The lactation
nurse who took the telephone call recorded that the baby was
"really jaundiced, lethargic, and fading fast."
The nurse did not call the doctor or advise the mother about
what she admitted at trial was a potential medical emergency.
Instead, the nurse testified that she told plaintiff mother
to call the doctor and report the symptoms, and arranged for
a lactation consultation with another of defendant's lactation
nurses, which took place in Federal Way, Washington (also
owned by defendant).
second nurse testified that this was the most jaundiced baby
she had ever seen. She also knew this was a potential medical
emergency. However, the nurse did not direct the parents
to the emergency room (one floor below), and did not call
the baby's doctor to report her assessment or concerns. Nor
did the nurse tell the parents that their baby was in jeopardy.
The nurse assumed that the mother was going to follow up with
the pediatrician later that day. The nurse did not plan to
see the pediatrician until the following day.
routine bilirubin blood test (TSB) done earlier that morning
(for review by the pediatrician the following day) was reported
by page to the pediatrician as 29.2 mg/dL (extremely high).
The pediatrician suspected laboratory error because the baby's
clinical picture seemed inconsistent with the laboratory result.
The pediatrician had not been advised of the lactation nurse's
assessment and therefore arranged for a home health nurse
to go out to the baby's home and get another blood draw and
second blood result was about 32 mg/dL. The doctor told the
parents to take the baby to MB Children's Hospital emergency
department in Tacoma. After they arrived and while the arrangements
were being made for an exchange of blood transfusion, the
baby suffered severe brain injury.
alleged that the nurses were negligent in failing to call
the baby's doctor failing to direct the parents and baby to
the emergency room; failing to tell the parents that their
baby was in jeopardy; and failing to properly respond to what
they knew was a potential medical emergency. In addition,
plaintiffs alleged the hospital was corporately negligent
in failing to develop and implement policies and procedures
for handling newborn jaundice. Finally, plaintiffs alleged
that under these extraordinary circumstances, the hospital
failed to obtain informed consent.
denied liability, asserting that its nurses met the standard
of care as they told the parents to call or see the pediatrician.
Defendant denied any obligation to call the pediatrician directly
or to send the baby to the emergency room. It asserted the
pediatrician, not the emergency room doctor, was the proper
person to handle this problem and that it would have made
no difference if the pediatrician or emergency room doctor
had been called because nothing would have been done until
the blood tests came back. Plaintiffs called pediatric experts
who testified the delay in communication and treatment caused
the brain injury. Defendant also alleged the parents were
contributorily negligent for not following advice to call
or see the pediatrician.
sustained kernicterus with athetoid cerebral palsy and severe
motor impairment. He is believed to be cognitively normal.
He also has a non-related kidney disorder that will necessitate
transplant (congenital nephrotic syndrome). The defense initially
argued that this condition was a contributing factor to kernicterus
but abandoned this theory at trial.
Litigation and Arbitration Reports: The jury, after four days
of deliberation, found that the hospital was negligent. It
awarded damages of over $10,000,000 to the minor boy, and
$665,000 to the parents. As to the parents'; contributory
negligence, the jury found the hospital to be 80% at fault
and the parents to be 20% at fault (for a net verdict of $532,000
in favor of the parents).
were the breakdowns in process here? Does our culture, here
at Mother Frances, leave us at risk for just such a case?
Perhaps not, but we need to review.
do we know about kernicterus?
a serious - but preventable - neurological syndrome, can strike
otherwise healthy newborns with jaundice or high bilirubin
concentrations. It is a lifelong brain syndrome that can include
cerebral palsy, mental retardation, and hearing loss, caused
by severe and untreated elevations of the bilirubin in the
newborns develop jaundice and never have a problem.
Why the sudden concern?
jaundice affects over half of all newborns in the US. It usually
appears within the first few days of life and may resolve
on its own. Without treatment, some infants develop
very high levels of bilirubin, which may lead to brain damage
or hearing impairment. Kernicterus had become a rare occurrence
in the US when babies stayed in the hospital for several days.
The jaundice, usually visible within 72 hours, was identified
and treated while the infant was still an inpatient. Because
most healthy newborns are now released from the hospital within
no more that 48 hours of birth, and may not be closely followed,
jaundice may go unnoticed. In recent years, complications
of jaundice have reappeared. Better monitoring, parent education
and follow-up are vital.
occurs when an infant becomes jaundiced?
breakdown of a red blood cell (RBC) releases hemoglobin and
produces bilirubin. The rate of bilirubin production in the
newborn is two to three times that of an adult. There are
fetus has more RBC's per KG of body weight, due to the environment
of reduced oxygen supply. At birth, respiration is established
in an oxygen-rich environment and the surplus of RBC's is
no longer needed. They are then metabolized.
RBC's have an average life span of 70-90 days compared to
that of an adult 120 days.
an essential molecule in oxygen-dependent metabolism and
a potential source of bilirubin, is increased in the neonate.
shunting is often increased in the neonate.
newborn gut lacks bacterial floras needed to convert bilirubin
to a form that cannot be reabsorbed and thus excreted. The
newborn bowel contains 10X the adult concentration of the
intestinal enzyme beta-glucuronidase, which readily hydrolyzes
conjugated back into the unconjugated form. The unconjugated
form is absorbed across the intestinal mucosa and returns
to the liver via the enterohepatic circulation.
can see this repeats the whole process and adds to the bili
does the bilirubin end up in the skin and sclera... even worse
old erythrocytes (RBC's) are removed from the circulation
they break down into heme, globin and iron. Heme is converted
to biliverdin, which is transformed rapidly into the unconjugated
form of bilirubin and released into the plasma (Halamek &
bilirubin is bound to albumin in the plasma until there are
insufficient sites or unless the bilirubin has decreased affinity
for the albumin. Unbound bilirubin has potential for
movement into tissues (skin, sclera, across the blood-brain
bilirubin cannot be excreted. Conjugation is accomplished
in the liver with the aid of hepatic ligands, which aid in
transport from the albumin across the cell membrane. As
luck would have it, hepatic ligands are decreased in the neonate
and do not reach adult levels until about 5 days of life.
Conjugation also requires oxygen and glucose - no wonder that
we see higher bili levels in newborns that have trouble maintaining
oxygen and glucose levels. Once conjugation occurs the
bilirubin is water soluble and excreted into the intestine
in the stool as stercobilin, a small amount will be excreted
as urobilinogen by the kidneys. When any part of this
process suffers we develop the potential for higher and higher
there factors that predispose an infant to Hyperbilirubinemia/kernicterus?
risk factors are well known and appear to have played a role
in the recent cases.
appearing in the first 24 hours after birth
nutrition/hydration through suboptimal breast-feeding
newborns at 35, 36, and 37 weeks of gestation, particularly
if they are breast-fed.
and cephalohematomas (increase the production of bilirubin)
hemolysis, such as ABO incompatibility
dehydrogenase (G6PD) deficiency
or ethnic risk factors include siblings with jaundice, East-Asian
or Mediterranean descent.
The root causes have been identified, also.
unreliability of the visual assessment of jaundice in newborns
with dark skin
to recognize jaundice in an 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
to measure the bilirubin level in an infant who is jaundiced
in the first 24 hours.
discharge (before 48 hours) with no follow-up within one
to two days of discharge. Particularly important for infants
less than 38 weeks gestation.
to provide early follow-up with physical assessment for
infants who were jaundiced before discharge.
to provide ongoing lactation support to ensure adequacy
of intake for breast-fed newborns.
and family education
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.
(JCAHO/Sentinel alert news, 2002)
to recognize, address or treat rapidly rising bilirubin.
to aggressively treat severe Hyperbilirubinemia in a timely
manner with intensive phototherapy or exchange transfusion.
can we detect pathologic levels of bilirubin? When does
jaundice become serious?
you want the AWHONN version or the American Academy of Pediatrics
version? Actually they agree and AAP goes (as you can
imagine) a step further.
prenatal testing should include ABO and Rh(D) typing and
a serum screen for isoimmune antibodies.
direct Coombs' test, a blood type, and an Rh(D) type on
the infant's cord blood are recommended.
are encouraged to save cord blood for future testing, particularly
when the mother's blood type is group O (most common for
family history, ethnic or geographic origin, or the timing
of the appearance of jaundice suggests the possibility of
glucose-6-phosphate dehydrogenase deficiency or some other
cause of hemolytic disease, appropriate laboratory assessment
of the infant should be performed.
TSB level needs to be determined in infants noted to be
jaundiced in the first 24 hours of life.
newborn infants, jaundice can be detected by blanching the
skin with digital pressure, revealing the underlying color
of the skin and subcutaneous tissue. The clinical assessment
of jaundice must be done in a well-lighted room. (If you
can't picture this and have never done it, seek a demo from
a "nursery" nurse.) Dermal icterus is seen first
in the face and progresses caudally to the trunk and extremities.
As the TSB level rises, the extent of cephalocaudad progression
may be helpful in quantifying the degree of jaundice; use
of an icterometer or transcutaneous jaundice meter may also
be helpful. Special care must be taken in evaluation of
dark-skinned infants as the jaundice may be masked by skin
color. Observe the sclera carefully and watch for behavior
of newborn infants who develop abnormal signs such as feeding
difficulty, behavior changes (irritable, fussy, lethargic),
apnea, or temperature instability is recommended - regardless
of whether jaundice has been detected - to rule out underlying
should be provided to all neonates discharged less than
48 hours after birth by a health care professional in an
office, clinic, or at home within 2 to 3 days of discharge
one third of healthy breast-fed infants have persistent
jaundice after 2 weeks of age. A report of dark urine or
light stools should prompt a measurement of direct serum
bilirubin. If the history (particularly the appearance of
the urine and stool) and physical examination results are
normal, continued observation is appropriate. If jaundice
persists beyond 3 weeks, a urine sample should be tested
for bilirubin, and a measurement of total and direct serum
a mother nurses a newborn, it takes at least 2-3 days for
the breast to start making enough milk. If the baby goes home
at 36 hours and is not nursing well, there is a chance that
the baby will not get adequate nutrition. When this happens,
jaundice is much more likely to occur.
In every study of jaundiced infants, most cases of severe
jaundice have occurred in breast fed infants. However, it
is VERY IMPORTANT TO EMPHASIZE THAT ALMOST ALL OF THESE CASES
HAVE OCCURRED IN INFANTS IN WHOM BREAST-FEEDING HAS BEEN INADEQUATELY
OR POORLY MANAGED. THIS IS ABSOLUTELY NOT A REASON
TO DISCOURAGE BREAST FEEDING. BREAST FEEDING IS, WITHOUT
QUESTION, THE BEST WAY TO FEED A BABY.
To prevent jaundice, strategies to promote early effective
breastfeeding are important. Breastfeeding should be started
early-at birth or soon after - and separation of the newborn
and mother avoided barring maternal or neonatal complications.
The AAP (1997) recommends early and frequent breastfeeding
without water, other fluids or glucose supplementation unless
medically indicated. Early frequent feedings can ensure an
adequate volume of colostrum and milk in the intestine to
encourage peristalsis and passage of meconium and provide
adequate caloric needs (Sater, 1995).
AAP discourages the interruption of breast-feeding in healthy
term newborns and encourages continued and frequent breast-feeding
(at least eight to ten times every 24 hours). Supplementing
nursing with water or dextrose water does not lower the bilirubin
level in jaundiced, healthy, breast-feeding infants. Depending
on the mother's preference and the physician's judgment, however,
a variety of options are presented for possible implementation
beyond observation, including supplementation of breast-feeding
with formula or the temporary interruption of breast-feeding
and substitution with formula, either of which can be accompanied
Options for Jaundiced Breast-fed Infants
Breast-feeding; administer phototherapy
breast-feeding with formula with or without phototherapy
breast-feeding; substitute formula
breast-feeding; substitute formula; administer phototherapy
treatment can we expect?
<24 hours old are excluded, because jaundice occurring
before age 24 hours is generally considered "pathologic"
and requires further evaluation. Although some healthy infants
appear slightly jaundiced by 24 hours, the presence of jaundice
before 24 hours requires (at least) a serum bilirubin measurement
and, if indicated, further evaluation for possible hemolytic
disease or other diagnoses. Phototherapy and/or exchange
transfusion may be indicated for rapidly rising TSB levels
in the first 24 hours of life.
the treatment of 25-48 hour old infant, phototherapy may
be considered when TSB level is >12 mg/dL. Phototherapy
should be implemented when TSB level is >15mg/dL.
If intensive phototherapy fails to lower a TSB level of
>20mg/dL, exchange transfusion is recommended.
If the TSB level is >25mg/dL when the infant is
first seen, intensive phototherapy is recommended while
preparations are made for an exchange transfusion. If intensive
phototherapy fails to lower the TSB level, exchange transfusion
is recommended. The higher TSB levels in a 25-48 hour old
infant suggest that the infant may not be healthy and indicate
the need for investigation into the cause of hyperbilirubinemia,
such as hemolytic disease.
may be considered for the 49-72 hour old jaundiced infant
when the TSB level is >15mg/dL. Phototherapy is
recommended when the TSB level reaches 18mg/dL. If intensive
phototherapy fails to lower the TSB level when it reaches
or is predicted to reach 25 mg/dL, an exchange transfusion
is recommended. If the TSB level is >30 mg/dL
when the infant is first seen, intensive phototherapy is
recommended while preparations are made for exchange transfusion.
If intensive phototherapy fails to lower the TSB level,
and exchange transfusion is recommended.
the infant >72 hours old, phototherapy may be considered
if the TSB level reaches 17 mg/dL. Phototherapy needs to
be implemented at a TSB level of >20mg/dL. If
intensive phototherapy fails to lower a TSB level of >25mg/dL,
exchange transfusion is recommended. If the TSB level is
>30mg/dL when the infant is first seen, intensive
phototherapy is recommended while preparations are made
for an exchange transfusion. If intensive phototherapy fails
to lower the TSB level, an exchange transfusion is recommended.
of Hyperbilirubinemia in the Healthy Term Newborn
Transfusion if Intensive Phototherapy Fails
Transfusion and Intensive Phototherapy
discharge early. Is it up to the parents to follow up?
The most important outcome of parental education is ensuring
that the parent understands the importance of and adherence
with the infant's follow-up care plan. Lack of follow up has
been one of the greatest challenges faced by practioners following
the AAP Practice Parameter guidelines for early discharge
(Brown et al., 1999; Seidman et al., 1995). Health care providers
should remember that 10% or more of parents may not seek follow-up
care for their infants at the recommended time even when they
have agreed to do so or have a scheduled appointment for their
child (Seidman et al., 1995).
Breastfeeding should be evaluated carefully before discharge
by a professional qualified to assess latch, suck and the
mother's perception of feeding. Mothers should voice their
understanding of and agreement with the definition of "frequent"
Parents should be instructed to recognize a difference in
the infant's color appearance, behavior or feeding and to
seek professional care if concerns arise. Understand that
it is difficult for parents to recognize jaundice and relying
on their observation for jaundice cannot be considered adequate
light of the serious nature of this condition the nurse cannot
over assess. The key to risk reduction is:
early and often. Report any jaundice or abnormal behavior
to the provider.
parents and family to the signs and symptoms of hyperbilirubinemia.
Stress the importance of follow-up, following the recommended
the latch and suck of breast-feeding infants. Learn the
signs of a good latch and suck/swallow indicators.
Document. Documentation of assessments, teaching, consultations
with the provider and lactation consultant is defensive
your unit policy for hyperbilirubinemia and bilirubin protocol.
Notify the provider of any abnormal values and findings.
hospitals are taking steps to develop a process for thorough
screening of all infants for risk of hyperbilirubinemia
prior to discharge
nomogram is useful to decide which babies may need more follow-up
and can be used with TcB or TSB.
following guideline is useful in the determination of which
infants should receive phototherapy. Following the graph is
an example of the clinical pathway recommended by the American
Academy of Pediatrics.
Practice Guideline. (2004). Management of hyperbilirubinemia
in the newborn infant 35 or more weeks of gestation. Pediatrics
S. S. (2005). Managing jaundice in full-term infants.
The Nurse Practitioner 30, (1).
Commission on Accreditation of Healthcare Organizations.
(2001). Kernicterus threatens healthy newborns. Sentinel
Event Alert, 18.
September 2002 Legal Case Study. Failure to timely diagnose
and treat jaundice-kernicterus brain injury with athetoid
cerebral palsy and severe motor impairment of a newborn boy.
Accessed at: http://www.nso.com
12 November 2002.
D. (2001). Hyperbilirubinemia: identification and management
in healthy term and near term newborns. Association of Women's
Health, Obstetric and Neonatal Nurses.