Question concerning neonatal hyperbilirubinemia

Pattoncy · Mar 19, 2018

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.

babyNP., APRN · Mar 19, 2018

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.

djmatte, ADN, MSN, RN, NP · Mar 19, 2018

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.

babyNP., APRN · Mar 19, 2018

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...

djmatte, ADN, MSN, RN, NP · Mar 19, 2018

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.

chare · Mar 19, 2018

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

gatherswool · Mar 19, 2018

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.

APRNSRTHEBEST · Mar 20, 2018

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

GoodNP · Mar 20, 2018

Wow, this thread is a case study is nurses eating their own, even at this level. smh

Dodongo, APRN, NP · Mar 21, 2018

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.

djmatte, ADN, MSN, RN, NP · Mar 21, 2018

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".