Pediatric Primary Care Case Studies (133 page)

Laboratory studies are needed to confirm the diagnosis, and to monitor the degree of hyperbilirubinemia and the response to treatment. According to the AAP, bilirubin levels should be obtained within the first 24 hours of life, then repeat the test based on identified risk factors from every 4 hours to every 24 hours. When suspecting hyperbilirubinemia, a total serum bilirubin level should be obtained for baseline diagnosis. It is generally accepted that a rise of greater than 5 mg/dL per day of life is concerning. And any level greater than 15 mg/dL requires further investigation and possible intervention (AAP, 2004a). If elevated, but within normal limits for age/gestation, a follow-up level should be obtained the next day. Depending on the severity of hyperbilirubinemia, levels may need to be obtained as frequently as every 4 hours, in which case an infant would need to be hospitalized for the frequent lab draws and management such as phototherapy. Generally, a daily total serum bilirubin level is adequate to monitor the low-risk infant. In addition, a set of electrolytes would be warranted in this infant due to the dehydration. The fractionated bilirubin test is helpful to rule out any other issues that could cause a cholestatic hyperbilirubinemia; however, current guidelines suggest evaluation only if the jaundice persists beyond the normal physiologic period (2 weeks) in newborns. Also, if it had not been obtained in the newborn nursery or neonatal intensive care unit, a direct Coombs test would be necessary to rule out Rh hemolytic disease (Moerschel et al., 2008).

You order the following tests:

   Neonatal bilirubin

   Complete blood count with differential

The indirect bilirubin level comes back at 15 mg/dL on day 6 of life, and the CBC is within normal limits. Fortunately, the mother had a discharge summary from the birth hospital, and the direct Coombs test is negative. With the information that Bobby has had only three wet diapers in the last 24 hours, is not taking adequate amounts of fluids, and has had an excessive weight loss (approximately 11%) within the first few days of life, in combination with the elevated bilirubin level, you decide that this infant’s hyperbilirubinemia is exaggerated by poor feeding and mild dehydration with no other signs of sepsis.

Management

How do you plan to treat the hyperbilirubinemia and dehydration? What specifically will you do to bring the bilirubin level to within acceptable range?

The most important therapy to initiate after making the diagnosis will be one that increases bilirubin excretion and includes improved hydration and stooling. Increasing the number of feedings per day will be necessary with possible supplemental breastmilk or formula, usually adding about one additional ounce of formula or breastmilk to each feeding as tolerated. Some infants may even “request” more, and as long as the infant does not have emesis, choking, or overt resistance, he or she can be fed with an ad lib volume. Breastfed infants should continue to be breastfed, optimally 8–12 times per day, 10–15 minutes on each breast. If there is difficulty with breastfeeding, a lactation consult may be initiated. Water or dextrose water supplementation is not recommended (Moerschel et al., 2008). If the mother is still having trouble breastfeeding or her milk production seems low, encourage her to stay hydrated herself and to eat healthy meals. Many new mothers feel that once the baby is born it is a good time to go on a diet, but this is not appropriate for breastfeeding mothers. Also, support her if she chooses not to breastfeed. There is a lot of pressure from society to breastfeed, and many new mothers feel like failures if they are unsuccessful or overwhelmed with the difficulties and frequency of feeding necessary with a poor feeder.

In extreme cases of hyperbilirubinemia or dehydration, hospitalization will be required for intravenous fluid therapy and aggressive monitoring of total serum bilirubin levels. A minimum of daily total serum bilirubin levels is recommended. Home phototherapy could be considered if the infant is close to requiring intensive phototherapy. You will need to order the phototherapy equipment for the mother from a local home healthcare equipment vendor if you decide to use it. The old wives’ tale of placing a jaundiced infant near the sunlight still holds true to a certain extent to help assist with mild jaundice. However, issues such as “heat, excessive water loss and dehydration, and unnecessary exposure to ultraviolet light (prevented by window glass) need to be considered” (Polin & Spitzer, 2001, pp. 196–197).

Patient Education

The goals of patient education should be holistic and include addressing the socioeconomic factors/home stresses as well as the infant’s medical condition. They are as follows:

1.
Feeding:
The most important thing for this infant’s hyperbilirubinemia and mild dehydration is to increase the feedings/intake. The mother is young and is probably lacking support at home in caring for the infant. A lactation consultant should be included if the mother wishes to continue breastfeeding successfully. Sandra should be taught that the infant needs to be fed every 3 hours and to supplement with extra breastmilk or formula as needed due to the hyperbilirubinemia. The mother should contact the healthcare provider if the infant is refusing feedings. Tell her that she
should observe improvement in intake in the next 12 hours. If not, Bobby must be seen immediately for the first morning appointment or taken to the emergency department if he is listless or she is concerned about his general well-being. Instruct the mother to keep a journal to log feeding times, volume and length of feedings, and the number of wet diapers and bowel movements each day.

2.
Jaundice:
Sandra needs to be taught what jaundice/hyperbilirubinemia is and the potential risks of elevated bilirubin levels, such as kernicterus. She should be taught to call the healthcare provider immediately if Bobby shows signs of increased irritability, hypertonia alternating with lethargy, arching, fever, and high-pitched cry (Moerschel et al., 2008).

3.
Infection/thermoregulation:
Instruct the mother that often newborns do not have fevers when they become ill, and may actually have a low temperature. Instruct the mother in how to take the infant’s temperature if she has not been taught, good handwashing techniques, and to keep the infant away from ill contacts. Regarding temperature, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) recommends that a good rule of thumb is to dress the infant in one more layer than the mother is wearing (AWHONN, 2007).

4.
Sleeping:
Most infants sleep 18–20 hours per day in the newborn period, and it is not uncommon for infants to sleep through feedings. For newborns, the typical length of sleep between feedings is 2–4 hours, then usually a 30-minute feeding, then back to sleep. Most healthcare providers do not recommend sleeping longer than 4 hours without a feeding, and not exceeding 30 minutes for a feeding. Encourage the mother to wake the infant up for feedings and teach her to always place the infant on his back to sleep.

5.
Referrals:
Due to the mother’s young age, it is important to get her the appropriate referrals such as WIC (Women, Infants, and Children) programs, lactation consultants, referral to a teen mom clinic if you have one in your practice setting, and any community organizations (such as the YWCA or YMCA) that help young mothers. Encouraging her to network with other mothers and even other teen mothers is important because her resources may be limited. Web sites such as
http://www.youngmommies.com
,
http://www.teenmotherchoices.org
, and
http://www.mops.org
all offer resources to teenage parents. She should be provided phone numbers for questions and for poison control, and told in case of emergency to call 911. AWHONN has a worksheet for parents on its Web site that helps parents keep information organized for doctor visits (
http://www.awhonn.org
).

6.
Immunization:
Bobby received his first hepatitis B immunization at birth. You will emphasize Sandra’s role in having her son receive all recommended childhood vaccinations on schedule. Tell her that immunization is
the most effective way to avoid vaccine-preventable diseases and to protect her child’s health. The AAP and the Centers for Disease Control and Prevention have excellent immunization information for parents. Their Web sites are
http://www.aap.org
and
http://www.cdc.gov
, respectively.

You discuss each of these six major areas of patient education with Sandra and provide pamphlets or written information regarding the key points outlined under each patient education point.

When do you want to see Sandra and Bobby back again?

You want to see Bobby the next day for a follow-up total serum bilirubin level and to evaluate feedings and stooling. Encourage Sandra to bring her journal with her to the appointment to help quantify this information and include both José and his mother at the appointments, if possible, for additional support to Sandra. Including the grandmother at the appointments and translating information into Spanish for her may improve stress encountered at home from different ideas on how to care for Bobby.

Sandra and her baby return the next day for the follow-up appointment and the total serum bilirubin level is 13 mg/dL. She brings her journal with her with detailed entries on feeding times, volume, and intake/output and has done a good job in increasing the feedings. She quietly tells you that when she left the hospital she did not know she was supposed to wake the baby up to feed and before yesterday’s visit had been supplementing formula in between breastfeedings. She also tells you that the lactation consultant is coming over to her house today to help assist with breastfeeding, because she “isn’t very good at it,” and hopes this will help. You congratulate her on a job well done and encourage her and José to continue doing a great job. You decide to see Bobby again tomorrow to check another bilirubin level and tell Sandra to continue with current management of increased volume intake. At that time you will also expand on your anticipatory guidance discussions, including appropriate car seat positioning and size for a preterm infant, placing Bobby on his back to sleep, and making sure they have a crib that meets current safety standards, among other newborn safety issues.