Question concerning neonatal hyperbilirubinemia

  1. Hi all. I had a neonate the other day (thurs) who was slightly jaundiced and 2 days postpartum. I had a total bilirubin drawn and received a call later on telling me it was 13 (elevated). Unfortunately the delivery labs were not in our system and the person who retrieves them was unable to get them. I talked with more seasoned PAs and NPs at the clinic who all said they look at the trends and make a determination of photo therapy off that. Without the trends, I contacted the mother and told her I would contact in the morning to get an idea of how the baby looked. Mother was somewhat unfazed as a previous child went through the same thing.

    The next day (friday), instead of getting new labs drawn, the mother chose to go to the ED. They drew labs and found the TB up to 13.4 and direct bili 0.5. They decided not to treat and suggested to follow up with us the next day (today), but we aren't open on weekends. As I am somewhat concerned, I naturally kept an eye on the chart and that's the only way I knew the outcome of the ED visit. I am wondering if I should be proactive and order the mother a biliblanket now, or hold off until Monday and have her redraw the labs when we are open? On the peds side of the house, this is kind of new territory for me. Just getting some experienced ideas. Thanks!

    Edit to add...mom is not breastfeeding.
    Last edit by djmatte on Mar 17
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    About djmatte, MSN, APRN

    Joined: Jan '08; Posts: 304; Likes: 401

    16 Comments

  3. by   Pattoncy
    At 3 days post partum, a result of 13.4 is not concerning. Especially when the day before it was 13. So in 24 hours it only increased by 0.4.
  4. by   babyNP.
    Have you not heard of bilitool.org ?

    This is kind of basic newborn stuff, to be frank. What sort of NP are you and did you not have newborn training? I would try to educate yourself on the topic a bit more.

    To answer your question, again, frankly, you should not be asking internet strangers on how to manage a patient. Do you have an attending physician? They would be much more suitable to answer your questions. I couldn't without knowing more of the infant's history such as mom/baby's blood type, ethnicity, gestational age, bili levels drawn at which hour life, etc etc. I don't mean to be harsh, but not knowing how to treat a newborn with hyperbili could result in kernicterus, which is a "never" event in medicine and highly litigious, not to mention severe life altering for the patient and their family.
  5. by   djmatte
    Quote from babyNP.
    Have you not heard of bilitool.org ?

    This is kind of basic newborn stuff, to be frank. What sort of NP are you and did you not have newborn training? I would try to educate yourself on the topic a bit more.

    To answer your question, again, frankly, you should not be asking internet strangers on how to manage a patient. Do you have an attending physician? They would be much more suitable to answer your questions. I couldn't without knowing more of the infant's history such as mom/baby's blood type, ethnicity, gestational age, bili levels drawn at which hour life, etc etc. I don't mean to be harsh, but not knowing how to treat a newborn with hyperbili could result in kernicterus, which is a "never" event in medicine and highly litigious, not to mention severe life altering for the patient and their family.

    Just getting insight. I'm a new FNP and this was my first experience with it. Last I checked, this is a place where people come to ask questions. Mine were fairly simple and something that I would know more with a little experience with the topic which I clearly stated I didn't. That website is new to me, but other tools and information I was reading said otherwise. I'll remember next time to keep my practice questions to myself. Thanks for a boatload of nothing.
  6. by   babyNP.
    Quote from djmatte
    Just getting insight. I'm a new FNP and this was my first experience with it. Last I checked, this is a place where people come to ask questions. Mine were fairly simple and something that I would know more with a little experience with the topic which I clearly stated I didn't. That website is new to me, but other tools and information I was reading said otherwise. I'll remember next time to keep my practice questions to myself. Thanks for a boatload of nothing.
    Asking questions about how to manage a specific patient's circumstances that could result in permanent brain damage is very different from asking general questions about management. And actually, it might be against TOS here, I think.

    I guess I don't know how to make you understand- but this is newborn care 101. I don't know much about adults, but maybe something like, "my patient has a high blood pressure of 160/90, but I told him just to watch it." It's not safe to provide care if you don't know the basics and asking internet strangers on how to do so isn't appropriate. Why don't you ask your attending physician if you have one? If you're afraid of looking stupid, it's part of the job. I've felt and been stupid many times as a NP and will continue to do so in my career, albeit less often. But I still asked the question to appropriate people with more knowledge than myself...
  7. by   djmatte
    Quote from babyNP.
    Asking questions about how to manage a specific patient's circumstances that could result in permanent brain damage is very different from asking general questions about management. And actually, it might be against TOS here, I think.

    I guess I don't know how to make you understand- but this is newborn care 101. I don't know much about adults, but maybe something like, "my patient has a high blood pressure of 160/90, but I told him just to watch it." It's not safe to provide care if you don't know the basics and asking internet strangers on how to do so isn't appropriate. Why don't you ask your attending physician if you have one? If you're afraid of looking stupid, it's part of the job. I've felt and been stupid many times as a NP and will continue to do so in my career, albeit less often. But I still asked the question to appropriate people with more knowledge than myself...
    Don't worry. I've asked the questions to the right people. Just getting other perspectives. Clearly some don't have an interest in helping out clinically. No worries and noted for the future.
  8. by   chare
    Quote from djmatte
    Don't worry. I've asked the questions to the right people. Just getting other perspectives. Clearly some don't have an interest in helping out clinically. No worries and noted for the future.
    Then perhaps you could have included what you had already learned in your initially post. In addition to demonstrating that you have researched on your own, showing what you have learned already provides a starting point to base further discussion on. Also, and it now appears that I misread it, your original post did seem to be asking for information in developing your management plan.

    If you have access, you might find the following helpful:

    Bhutani, V. K. (2011). Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks gestation. Pediatrics, 128, e1046-e1052. Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation | From the American Academy of Pediatrics | Pediatrics

    Lauer, B. J. & Spector, N. D. (2011). Hyperbilirubinemia in the newborn. Pediatrics in Review, 32, 341-349. http://dx.doi.org/10.1542/pir.32-8-341

    Kaplan, M., Wong, R. J., Sibley, E., & Stevenson, D. K. (2015). Neonatal jaundice and liver disease. In R. J. Martin, A. A. Fanaroff, & M. C. Walsh (Eds).Fanaroff and Martin's neonatal-perinatal medicine: Diseases of the fetus and infant (pp.1616-1673)

    Newman, T. B. (2009). Universal bilirubin screening, guidelines, and evidence. Pediatrics, 124, 1199-1202

    Pan, D. H & Rivas, Y. (2017). Jaundice: Newborn to age 2 months. Pediatrics in Review, 38, 499-210. http://dx.doi.org/10.1542/pir.2015-0132

    Wong, R. J. & Bhutani, V. K. (2017a). Clinical manifestations of unconjugated hyperbilirubinemia in term and late preterm infants. In S. A. Abrams (Ed.) UpToDate

    Wong, R. J. & Bhutani, V. K. (2017b). Evaluation of unconjugated hyperbilirubinemia in term and late preterm infants. In S. A. Abrams (Ed.) UpToDate

    Wong, R. J. & Bhutani, V. K. (2017c). Treatment of unconjugated hyperbilirubinemia in term and late preterm infants. In S. A. Abrams (Ed.) UpToDate
  9. by   gatherswool
    Aaaaaaand here we see the fundamental difference between family and pedi people. Family people know that most babies are totally fine and do best with a little too little intervention rather than too much. Pedi people have actually cared for that one baby out of a few hundred thousand who had a bili of 13 at 36 hours, but oh, hey, also has g6pd and did I mention mom is O- and missed the rhogam appointment? So yeah, crap, that bili is the one the lab left sitting in the window for an hour and when it's redrawn in the ED at 72 hours it's 35.

    That obviously wasn't the case here. But I think most pedi people would say that if newborns don't terrify you, you shouldn't be treating them. Most family folks will tell you terrorizing parents is bad for bonding and for the like 90% of babies who are fine. Personally I try to act like Family and think like Pedi, but I will admit that I exclusively take my own kids to Pedi people.

    You've doubtless already heard this, but the perennial cause of ANYTHING in the first two weeks is sepsis, so even though a mild hyperbilirubinemia is demonstrably good for babies, I'd recommend a quick once-over for mom's GBS status and rupture time, then document reviewing s/sx infection with the responsible guardian. And bili tool of course, remembering to assess the appropriate risk level based on gestational age. Personally I treat all ABO setups as "HDN" since the Coombs is a crap test on neonatal hemoglobin. And make sure baby actually had a newborn screen done - you'd be amazed how many fall through the cracks.

    Good luck with the newborns - and us Pedi people! Remember, we're the way we are because kids (and especially babies) almost never go bad - but when they do, damn they go bad quick, and hard, and ugly. And you'd best believe that someone's going to come looking for a scapegoat, reasonably or not.
  10. by   APRNSRTHEBEST
    The md i work for uses bilitool.org to determine complication risk. You put in bili level and hours old and it works it out for you
  11. by   GoodNP
    Wow, this thread is a case study is nurses eating their own, even at this level. smh
  12. by   Dodongo
    Quote from GoodNP
    Wow, this thread is a case study is nurses eating their own, even at this level. smh
    I don't know if this is the case. Have you ever seen a resident not know something with an attending in a teaching institution. Especially if it's straight forward, "easy" diagnosis or management. They dont beat around the bush. They say, "you should know this, there's no excuse for not knowing it, go research it, and then come back and present it to me." The MDs who precepted me were incredibly difficult and expected SO much. No excuses. Sometimes hand holding is not helpful. Sometimes, you should just know something. Especially if it's bread and butter for the specialty you're attempting to practice in.
  13. by   djmatte
    Quote from Dodongo
    I don't know if this is the case. Have you ever seen a resident not know something with an attending in a teaching institution. Especially if it's straight forward, "easy" diagnosis or management. They dont beat around the bush. They say, "you should know this, there's no excuse for not knowing it, go research it, and then come back and present it to me." The MDs who precepted me were incredibly difficult and expected SO much. No excuses. Sometimes hand holding is not helpful. Sometimes, you should just know something. Especially if it's bread and butter for the specialty you're attempting to practice in.
    I can assure you I was actively researching the topic and asking my fellow providers well before I posted here. But some of my source material was a little different and I felt inclined to ask here where I mistakenly presumed people had some modicum of professionalism. What you consider "bread and butter" I have never encountered in clinical practice. I recognized the problem, I made textbook calls on assessing and diagnosing. But the management is where I was unsure. I asked here for simple understanding... Not a reprimand of a knowledge deficit or to be treated like I was somehow deficient because I was unaware of an online tool that states in its disclaimer that it doesn't make up for clinical judgement. Point made...allnurses isn't the place for actual discourse of professionals regarding performing in their roles. They're more interested in threads like "should I be an fnp or whatever", or "why are we losing wages".
  14. by   yogagal
    I remember when I was new and panicking about stuff like this after hours and over the weekend. I know you were just coming here for reassurance and insight. I am however concerned that none of the numerous other providers you asked about this taught you how to use bilitool and how to use those results combined with the clinical presentation to guide your plan. It seems they all see newborns as well and none of them use it either? Or if they do, they didn't advise you to use it also? If you as a new FNP came to me with this question, the first question I would ask you would be "what is the risk level?" Once you told me you didn't know, I would realized that I need to teach you how to use bilitool, I would have you input the data and come back to me with the result so we could discuss what to do. I fear that you are seeing newborns (and patients in general) in an environment where the more seasoned providers aren't interested in teaching you even when you ask. I'm and FNP and see peds as well and agree that it is super important to have a peds provider to go to with questions, eight years out and there are some days when I'm going down the hall to one of my pediatricians 3-4 times a day to ask them to double check a kid for me. Little ones can be tricky! Just be safe, both for the sake of your patients and your license.

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