Neonatal Hyperbilirubinemia and Jaundice Nursing Guide

Hyperbilirubinemia, a condition in which the total serum bilirubin level is above the normal threshold for age in hours, is one of the most common conditions requiring medical evaluation and treatment in newborns. It occurs when there is an imbalance between bilirubin production and elimination. In the neonatal period, this condition is often associated with liver immaturity, increased red blood cell turnover, or underlying medical conditions that impair bilirubin conjugation or excretion.

One common symptom of hyperbilirubinemia is neonatal jaundice. Neonatal jaundice describes the visible manifestation of hyperbilirubinemia, where it presents as yellow discoloration of the skin and/or sclera. 

This symptom is extremely common, affecting approximately 60% of term and 80% of preterm infants within the first week of life. While most cases are transient and benign, failure to identify and manage elevated bilirubin levels can result in serious neurotoxic outcomes, such as acute bilirubin encephalopathy or kernicterus (a form of brain damage caused by excessive bilirubin crossing the blood-brain barrier).

Nurses play a pivotal role in early recognition, ongoing monitoring, and coordinated care of jaundiced neonates, ensuring timely treatment and prevention.

Etiology and epidemiology

In neonates, jaundice typically arises due to increased bilirubin production and immature hepatic pathways for conjugation and excretion. The etiology can be categorized as physiologic or pathologic:

• Physiologic jaundice: Appears after 24 hours of life, peaks between days three and five, and usually resolves by day 14 in term infants. It results from immature liver enzymes and increased bilirubin load from fetal hemoglobin breakdown.
• Pathologic jaundice: Appears within the first 24 hours and persists beyond two weeks (in term infants) or has a rapid rise in serum bilirubin. Common causes of pathologic jaundice include:
  • Hemolytic disease (ABO or Rh incompatibility)
  • Neonatal sepsis
  • Congenital hypothyroidism

While jaundice is the hallmark sign of hyperbilirubinemia, additional clinical symptoms may occur, particularly when bilirubin levels rise to dangerous levels. These may include:

• Lethargy or difficulty waking for feeds
• Poor feeding or weak suck
• Hypotonia (decreased muscle tone)
• High-pitched or inconsolable crying
• Arching of the back or neck
• Irritability or changes in responsiveness

These signs may indicate the early stages of acute bilirubin encephalopathy and require immediate medical attention. Ongoing monitoring for these symptoms is essential in at-risk neonates to prevent progression to kernicterus.

ICD-10 code

• P59.0–P59.9 — Neonatal jaundice (with subtypes for cause, e.g., from hemolysis or prematurity)

Nursing care plan

Nursing care for neonates with jaundice revolves around consistent monitoring, support for feeding and hydration, and ensuring effective phototherapy. The plan should be individualized based on bilirubin levels, gestational age, and comorbid conditions.

Nursing considerations

• Observe for jaundice starting at the head and progressing caudally (cephalocaudal progression).
• Monitor feeding frequency, volume, and voiding/stooling patterns.
• Educate parents on phototherapy, feeding, and signs of worsening jaundice.
• Maintain skin integrity during phototherapy by repositioning frequently.
• Document Total Serum Bilirubin (TSB) levels and response to treatment.

Assessment

• Skin and scleral appearance: Monitor for yellow discoloration.
• Urine and stool: Assess for dark urine and pale stools, which may indicate cholestasis.
• Feeding adequacy: Poor feeding can exacerbate jaundice due to decreased bilirubin excretion.
• Neurological status: Watch for lethargy, high-pitched crying, hypotonia, or poor suck, early signs of acute bilirubin encephalopathy.
• Bilirubin trends: Identify and track risk level(s) using nomograms (e.g., the Bhutani nomogram) and the BiliTool™.

Nursing diagnoses

• Risk for neonatal hyperbilirubinemia related to immature hepatic function and increased RBC turnover.
• Risk for impaired parenting related to anxiety about phototherapy and newborn illness.
• Risk for impaired skin integrity related to frequent phototherapy positioning and device use.
• Risk for imbalanced nutrition — less than body requirements related to ineffective breastfeeding.
• Risk for developmental delay related to potential bilirubin neurotoxicity if untreated.

Interventions

Once hyperbilirubinemia risk has been evaluated by the provider and a plan of care has been developed, the nurse can anticipate performing interventions aimed at both treatment and family-centered support.

Initial clinical actions may include:

• Initiate phototherapy as ordered, ensuring proper, consistent eye protection and thermoregulation. It is important to note the number of lights ordered by the provider, as this coincides with the level of risk that critical bilirubin levels may be reached.
• Encourage frequent breast or formula feeding to enhance bilirubin excretion.
• Monitor bilirubin levels per hospital protocol. Once phototherapy is initiated, monitoring is commonly done via timed blood draws (every 6-12 hours) to review serum bilirubin levels for a downward trend.
• Promote bonding by encouraging kangaroo care when phototherapy is paused. In facilities that have bili blankets, this option allows bonding and treatment to continue simultaneously. The blanket enables mobility of the infant, whereas traditional phototherapy involves overhead lights and a bassinet, where the infant must remain.
• Provide education on breastfeeding techniques and signs of worsening jaundice. It is important to note that the risk level decreases as the infant gets older (in days). This often provides assurance for the parents when preparing to be discharged.
• Offer the parent(s) emotional support, addressing concerns and explaining treatment rationale.
• Record input/output to track hydration and feeding efficiency.

In more persistent cases, additional interventions may be warranted:

• Phototherapy: This is a primary treatment. It converts bilirubin into a water-soluble form excreted in urine/stool. Intensity, duration, and distance from the infant must follow strict protocols based on bilirubin levels and age.
• Exchange transfusion: This is performed in cases where TSB exceeds treatment thresholds or signs of bilirubin encephalopathy are present. This is a rare but urgent intervention.
• Hydration and feeding: Breastfed babies may require supplementation if intake is poor. Adequate hydration promotes bilirubin excretion.
• Treating underlying causes:
  • ABO/Rh incompatibility: This may require IVIG or exchange transfusion.
  • Infections: Treat sepsis with appropriate antibiotics.
  • Hypothyroidism or metabolic disease: Initiate endocrine referral and appropriate therapy.

Educating and preparing the family is a vital component of nursing care:

• Explain the difference between physiologic and pathologic jaundice.
• Teach parents and family members how to monitor for jaundice at home, especially in the sclera and chest.
• Review feeding frequency and the importance of hydration.
• Discuss safe phototherapy use at home (if discharged with a phototherapy unit).
• Provide written instructions for follow-up bilirubin testing and appointments.

Expected outcomes

• Bilirubin levels decrease to within normal range (<12 mg/dL by day seven in term infants).
• The neonate feeds at least eight to 12 times per 24 hours with adequate weight gain.
• Parents demonstrate understanding of home care and phototherapy instructions.
• Skin remains intact, and no signs of bilirubin encephalopathy develop.

Examination and testing

• History: Birth history, maternal blood type (and antibody screen), timing of jaundice onset, feeding patterns, and family history of hemolytic disorders.
• Physical exam: Evaluate the extent of jaundice, neurologic tone, feeding, and behavior.
• Risk factors: Assess for maternal and neonatal risk factors, such as low gestational age, hemolysis from any cause, and scalp hematoma or significant bruising. 

Laboratory tests

• Total and direct bilirubin (TSB and conjugated bilirubin): This is a primary tool to determine severity.
• Blood type and Coombs test: This is used to evaluate for ABO/Rh incompatibility.
• Hemoglobin and hematocrit: This may show anemia in hemolysis.
• Reticulocyte count: This will be elevated in hemolytic conditions.
• G6PD screening: This is used in high-risk populations.
• Thyroid function tests: This is used for prolonged jaundice.
• Liver function tests: This is used if cholestasis is suspected

Imaging

Imaging is typically not required in cases of physiologic jaundice; however, it may be ordered in pathologic cases, which include the following:

• Abdominal ultrasound: This is used for suspected biliary atresia or liver structural abnormalities.
• Hepatobiliary scintigraphy (HIDA scan): This confirms biliary patency in prolonged jaundice

Through evidence-based care, comprehensive parent education, and interdisciplinary collaboration, nurses play a vital role in promoting safe outcomes for newborns affected by jaundice.

Additional resources

• American Academy of Family Physicians
• American Academy of Pediatrics (AAP)
• HealthyChildren.org
• La Leche League International