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      <h1 id="top">7.2 Hypoglycemia; Jaundice</h1>
      <div class="section" id="Pathologic_Neonatal_Hypoglycemia"><h2>Pathologic Neonatal Hypoglycemia</h2>
    <div class="section" id="Physiology"><h3>Physiology</h3>
      <div>The term <span class="term"> hypoglycemia </span> refers to low blood glucose concentration. The body, and particularly the brain, requires a source of energy to function. Glucose is an important source of energy. <br /> <br /> There are two times of crisis in the neonates life regarding energy (glucose) needs. Both crises are managed by <span style="font-weight: bold;">normal metabolic adaptation</span> which provides alternative fuel sources for the neonate. <br /> <ol><li> The first crisis occurs when the cord is cut and the maternal supply of glucose to the newborn is abruptly discontinued.<sup><a href="#note1">1</a>,</sup><sup><a href="#note2">2</a></sup> <br /> <ul><li> blood glucose concentration reaches its nadir in the first 1 - 2 hours <br /> </li><li> blood glucose concentration then rises to a steady state within 2 - 3 hours </li><li> feeding the infant may cause small transient rises in blood glucose concentration, but it is not feeding that maintains euglycemia </li></ul> </li><li> The second crisis will occur if lactation is delayed.<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup><br /><ul><li>Fat breakdown occurs, releasing ketone bodies that provide glucose-sparing fuel to the neonatal brain, protecting neurologic function.</li></ul></li></ol></div>
      <blockquote>
        <div>Transient hypoglycemia in the early neonatal period is a common adaptive phenomenon as the newborn changes from the fetal state of continuous transplacental glucose consumption to intermittent nutrient supply following cessation of maternal nutrition at birth. <br />Research has demonstrated that in the term, healthy newborn, this dynamic process is self-limiting and is not considered pathologic.<sup><a href="#note6">6</a></sup></div>
      </blockquote>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Do not screen normal, full term neonates.</h3>
        <div>
          <p><br />Clinically significant (ie pathologic) hypoglycemia does NOT occur in well, full term babies. The baby's physiology protects him against this by using metabolic processes to maintain steady-state glucose concentration. <sup><a href="#note2">2</a></sup></p>
          <p> Unnecessary routine screening results in the <span style="font-weight: bold;">misidentification</span> of neonates captured while experiencing the normal, self-correcting physiologic blood glucose nadir, who are then diagnosed with pathologic neonatal hypoglycemia. <br />Subsequent to this misdiagnosis, further surveillance and unnecessary, aggressive treatment interventions will follow that are potentially harmful to the successful establishment of positive maternal-infant interactions and the breastfeeding experience. </p>
          <p> Research studies indicate that routine hypoglycemia screens, treatments, and interventions in the healthy infant are not evidence-based and result in a serious disruption of the initiation process and duration patterns of lactation.<sup><a href="#note6">6</a></sup> </p>
        </div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div class="section" id="Diagnosing_pathologic_neonatal_hypoglycemia"><h3>Diagnosing pathologic neonatal hypoglycemia</h3>
      <div>Prolonged hypoglycaemia, sufficiently severe to cause neurological signs, is called pathologic neonatal hypoglycemia.<br />Diagnosis is made when <br /><ul><li>neurological signs are present, and <br /></li><li>blood glucose concentration is low.<sup><a href="#note7">7</a></sup> </li></ul></div>
      <div class="section" id="Clinical_signs_to_observe_for_"><h4>Clinical signs to observe for:</h4>
        <div>
          <p> The first observation to make, and the most important, is the infant's <span style="font-weight: bold;"> level of consciousness</span>. Pick up the infant, talk to him, wake him up. A limp infant you cannot wake is a bad sign. </p>
          <p class="listTitle"> Other clinical manifestations </p>
          <ul>
            <li> irritability, tremors, jitters </li>
            <li> exaggerated Moro reflex </li>
            <li> high-pitched cry </li>
            <li> lethargy, limpness, hypotonia </li>
            <li> apnea or irregular breathing </li>
            <li> cyanosis </li>
            <li> hypothermia, temperature instability </li>
            <li> poor or inadequate sucking reflex </li>
            <li> vasomotor instability </li>
            <li> seizures </li>
          </ul>
        </div>
      </div>
      <div class="section" id="Which_infants_are_at_risk_"><h4>Which infants are at risk?</h4>
        <div>Think about which infant's may have metabolic stressor's or immaturity that could affect the normal release of glucose in the first hours following birth, or ketone body metabolism later.<br /><br />Infants at risk of symptomatic hypoglycemia include:<sup><a href="#note8">8</a></sup><br /><ol><li>Infants of diabetic mothers - hyperinsulinemia as a result of poor maternal control during pregnancy will cause hypoglycemia until stabilised.</li><li>Infants who are preterm or late preterm with metabolic immaturity.</li><li>Infants who have few fat reserves, eg small for gestational age infants</li></ol>Infants in these categories require frequent observation for neurological signs and blood screening for glucose concentration at intervals according to evidence-based medical policies.<br /></div>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 7.3</h3><p>Complete Activity 7.3 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div class="section" id="Preventing_pathologic_hypoglycemia"><h3>Preventing pathologic hypoglycemia</h3>
      <div><ul> </ul>Placing <span style="font-weight: bold;">ALL</span> newborns in skin-to-skin care with their mother from immediately after birth, and for as long as possible, preferably at least the first day of life, will:<br /><ul><li>stabilise the infant's temperature (no requirement to burn fat for heat)<br /></li><li>stabilise the infant's cardio-respiratory system<br /></li><li>stimulate metabolic adaptation</li><li>initiate the first phase of the enteric nervous system (facilitating intestinal function)<br /></li><li>reduce stress (release of cortisol initially causes a surge in blood glucose concentration, then a fall)</li><li>facilitate early and frequent breastfeeding, preventing a delay in lactation</li><li>and prevent other factors, such as nosocomial infections and hypothermia that cause hypoglycemia.<br /></li></ul></div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>This is really important!</h3>
        <div>It's worthwhile repeating: The <span style="font-weight: bold;"> BEST </span> way for you to prevent hypoglycaemia in the infants you care for is by placing baby in skin-to-skin contact with his mother immediately after birth, and for as long as possible. <br /> <p> Share your thoughts in the forum about how this simple, no-cost practice helps prevent hypoglycemia. <br /> </p></div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
      <div class="section" id="What_about_early_feeding_"><h4>What about early feeding?</h4>
        <div>Facilitation of early and frequent breastfeeding is strongly encouraged. However, sources of exogenous glucose, such as from colostrum, are not essential to maintain <span style="font-weight: bold;">normal glucose concentration</span> in the first 24 hours. <p> Healthy, full-term infants do not develop symptomatic hypoglycemia in the first 24 hours simply as a result of underfeeding.<sup><a href="#note9">9</a></sup> </p>Frequent, effective breastfeeding will, however, be protective after the first 24 hours. Beginning breastfeeding soon after birthing will ensure the infant is breastfeeding well and maternal lactation is becoming established by the time the infant is dependent on this source of energy.<br /><br /></div>
      </div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 7.4</h3><p>Complete Activity 7.4 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div class="section" id="Clinical_management_of_pathologic_hypoglycaemia"><h3>Clinical management of pathologic hypoglycaemia</h3>
      <div>
        <p> Inadequately treated symptomatic hypoglycemia has such a serious outcome that pediatricians agree that <br /> &ldquo;<q> the clinician <span style="font-weight: bold;">should not rely on oral feeding</span> (eg breastmilk or infant formula) for the correction of symptomatic hypoglycemia </q>&rdquo; <sup><a href="#note9">9</a></sup> and &ldquo;<q> symptomatic hypoglycemia should <span style="font-weight: bold;">always be treated with a continuous infusion of parenteral dextrose</span>. </q>&rdquo; <sup><a href="#note8">8</a></sup> <br /> </p>
        <p>However, during this medical management, breastfeeding should continue uninterrupted. The goal is to have an infant who suckles effectively at the breast and a mother's milk supply that is able to meet his needs when IV therapy is discontinued. <br /></p>
        <ul>
          <li> continue breastfeeding, and skin-to-skin contact during treatment<br /></li>
          <li><span style="font-weight: bold;"> do not give </span> water, glucose water or formula to the breastfed infant </li>
          <li> continue breastfeeding while weaning baby from IV glucose, monitoring carefully </li>
        </ul>
      </div>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/article.png" class="icon" alt="" /><h3>Extend your knowledge</h3>
      <div>Go to the <img alt="PDF" src="design/page_white_acrobat.png" /><a href="http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf">Academy of Breastfeeding Medicine</a> and read this protocol on Hypoglycemia. File it in your workbook.<br /></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Unit Activity</h3>
      <div>Access your Unit policy on the management of hypoglycemia. Compare it to the literature published in peer-reviewed journals. Is it up-to-date and evidence-based? If not, form a working group to review it, present it at a Unit meeting and implement it.</div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div class="section" id="What_should_I_remember_"><h3>What should I remember?</h3>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
        <div>
          <ul>
            <li>How euglycemia is maintained, regardless of oral intake.<br /></li>
            <li>The effect of unnecessary blood glucose monitoring on the full-term infant.</li>
            <li>The infants who are 'at-risk' of pathologic neonatal hypoglycemia.</li>
            <li>How to recognise signs of pathologic hypoglycemia.</li>
            <li>The best practice management to prevent symptomatic hypoglycemia for all infants.</li>
            <li>How to support breastfeeding during medical management of pathologic hypoglycemia.<br /></li>
          </ul>
        </div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div class="section" id="Self-test_quiz"><h3>Self-test quiz</h3>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
        <div></div><div class="activity" id="activity_ry">
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	{ c : 'Baby Freddy was born at 38 weeks 6 days gestation weighing 2.6kg (5lb 11oz). Following an examination by the pediatrician at which time he was noted to be healthy, he was transferred to the postnatal ward with his mother.<br/><br/>A junior nurse/midwife is assigned to care for mother and baby. She has asked you if there is any additional care or considerations in their postnatal recovery.<br/><br/>Discuss the important issues you\'d discuss with the nurse.<br/><br/>', r : 'Compare your response to these sample points:<br/><br/><ul><li>Gestation. Not really significant as infant is quite close to term. Feeding ability should be unaffected.</li><li>Weight. This is significant. Plot the weight on a weight percentile. This infant falls in the small-for-gestational-age range.<br/>Discuss the possibility of pathologic hypoglycemia developing. Is it likely to occur in the first few hours? Why not?</li></ul>Due to low fat reserves baby Freddy is at most risk if he needs to burn fat for energy. To ensure this isn\'t necessary he should be cared for in skin-to-skin contact with his mother (or father or grandmother when mother showering, etc). The infant will be physiologically stabilised rapidly, stress reduced, temperature maintained and breastfeeding established early. <br/><br/>Due to his weight the doctor may have requested a blood screen for hypoglycemia. However, of more importance is regular observations for the signs associated with hypoglycemia. A symptomatic infant requires immediate medical attention.<br/><br/>If baby Freddy is not breastfeeding regularly, assist his mother to hand express her colostrum. The goal being to ensure an early, problem-free establishment of lactogenesis. The colostrum can be fed to baby Freddy, though this won\'t prevent hypoglycemia, but could encourage him to breastfeed.<br/><br/>Provide support for the mother and a safe sleeping environment for her and her baby.<br/>Offer frequent drinks and nutritious foods to the mother.<br/><br/>' }
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      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
  </div>
      <div class="section" id="Jaundice"><h2>Jaundice</h2>
    <div>
      <p>
		The most common paediatric condition encountered in the first week is hyperbilirubinaemia. It is so common that it is termed "Physiological Jaundice" and reflects the normal physiological changes that occur as the neonate adapts to extrauterine life.
	</p>
    </div>
    <div class="section" id="Normal_serum_bilirubin_levels"><h3>Normal serum bilirubin levels</h3>
      <div>
        <p class="listTitle">The neonate is more susceptible to high serum bilirubin levels because</p>
        <ol>
          <li>there is increased breakdown of fetal erythrocytes. This is the result of the shortened lifespan of fetal erythrocytes and the greater number of erythrocytes in neonates.</li>
          <li>liver excretory ability is low because of the relative immaturity of the liver.</li>
        </ol>
        <p> </p>
        <p>At birth neonates have a low serum bilirubin. The normal pattern is for a rise to a peak by the third day of life, followed by a plateau and drop in levels, or, for ⅔ of babies, a gradual rise to another peak on about the 10th day. After this the levels gradually drop until about the third week of life. (An exception to this is found in babies of Asian origin whose Day 3 levels peak nearly twice as high as found in non-Asian babies). </p>
        <p> In some mothers, unidentified factors present in her breastmilk may contribute to increased enterohepatic circulation of bilirubin with harmless jaundice persisting for many weeks. This is an extension of physiologic jaundice known as breastmilk jaundice. No special treatment is required and continued breastfeeding is recommended.<sup><a href="#note10">10</a></sup> </p>
        <br />
      </div>
      <div class="captionBox"><img width="475" height="342" src="images/se_bilirubin_graph.gif" alt="" /><p> <br />Diagram &copy;  Health e-Learning</p></div>
      <div>
        <p>
			An explanation of why newborns have elevated bilirubin levels could be that the antioxidant effects of bilirubin compensate for the relative deficiency of endogenous antioxidants in newborns. It is another protective effect denied the artificially fed infant.
		</p>
      </div>
    </div>
    <div class="section" id="Causes_of_abnormal_bilirubin_levels"><h3>Causes of abnormal bilirubin levels</h3>
      <div>
        <ul>
          <li><span style="font-weight: bold;"> Abnormal weight loss </span> : A weight loss of more than 7% in both artificially fed and breastfed infants is associated with higher serum bilirubin concentrations. Inadequate intake causes <br /> <ul><li> retention of meconium and reabsorption of previously excreted bilirubin back into the blood stream. </li></ul> The cycle is then likely to continue as raised serum bilirubin causes sleepiness and poor feeding, decreased intake and further reabsorption of bilirubin. </li>
          <br />
          <li><span style="font-weight: bold;"> Hemolytic processes </span> : Blood group incompatibilities (Rh, ABO, and others) may increase bilirubin production through increased haemolysis. Nonimmune haemolytic disorders (spherocytosis, G-6-PD deficiency) also may cause increased jaundice through increased haemolysis. </li>
          <br />
          <li><span style="font-weight: bold;"> Non-hemolytic processes </span> : A number of other nonhaemolytic processes can increase serum bilirubin levels. Accumulation of blood in extravascular compartments (cephalhaematomas, bruising, occult bleeding) may increase bilirubin production as the blood is absorbed and degraded. Increased bilirubin production also is seen in infants with polycythemia and in infants of mothers with diabetes. Increased reabsorption of bilirubin from the bowel leading to elevated bilirubin levels is seen in infants with bowel obstruction or ileus. </li>
        </ul>
      </div>
    </div>
    <div class="section" id="Physical_appearance"><h3>Physical appearance</h3>
      <div>
        <p> Jaundice has a cephalocaudal (or cephalopedal) <span class="aside"> ie head to toe </span> progression; it is evident first in the face, gradually becoming visible on the trunk. Jaundice seen below the level of the umbilicus and on the extremities reflects increasingly higher serum bilirubin levels. Jaundice disappears in the opposite direction. <br /> Daylight on a clear day provides the best lighting for evaluation. Pressure applied on the skin using the finger pad will blanch the skin revealing the underlying colour. <br /> </p>
        <p> Non-invasive transcutaneous measurement of bilirubin is a reliable screening method for identifying infants who need additional work-up.<sup><a href="#note11">11</a></sup> Laboratory measurement of bilirubin is indicated if jaundice involves the lower body and extremities.<sup><a href="#note10">10</a></sup> </p>
      </div>
    </div>
    <div class="section" id="Management_of_hyperbilirubinemia"><h3>Management of hyperbilirubinemia</h3>
      <div><p><span style="font-weight: bold;"> Prevention </span> of hyperbilirubinemia due to inadequate intake involves early recognition of risk factors, good teaching and supervision of breastfeeding, and mothers who are able to recognize that good transfer of breastmilk to the infant is occurring. </p><p class="listTitle"> Low serum bilirubin concentrations in the first 5 days are characterised by optimal breastfeeding behaviours: <sup><a href="#note10">10</a></sup> </p><ul><li> initiation of breastfeeding in the first hour after birth </li><li> continuous rooming-in with unlimited access to the breast </li><li> a breastfeeding frequency of 10 to 12 times per day </li><li> prompt responses to early hunger cues, and </li><li> absence of all supplementation. </li></ul><p><span style="font-weight: bold;"> Ensure adequate intake for the infant: </span></p><ul><li> assess breastfeeding effectiveness </li><li> stimulate and support an adequate milk supply </li><li> frequent breastfeeds; 8-12 per 24 hrs </li><li> offer supplemental feeds of expressed breastmilk </li><li> artificial infant formula is given only in the absence of adequate breastmilk volumes </li></ul> Phototherapy treatment may be required to heighten elimination of bilirubin. If the infant is under phototherapy lights: <br /> <ul><li> continue all of the above </li><li> offer emotional support to the mother while her baby is receiving treatment </li><li> Contraindicated: water supplementation </li></ul></div>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 7.5</h3><p>Complete Activity 7.5 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/article.png" class="icon" alt="" /><h3>Extend your knowledge</h3>
      <div>
        <p>Read and print the <img alt="External" src="design/external.gif" /><a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297" title="External link" target="_blank">AAP Clinical Practice Guidelines for the management of hyperbilirubinemia</a>. Note the recommendations regarding breastfeeding and supplements. </p>
        <p class="listTitle">Note that the first two recommendations are to:</p>
        <ol>
          <li>promote and support successful breastfeeding, and</li>
          <li>harm is associated with supplementing breastfed infants with water or dextrose water.</li>
        </ol>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Unit activity</h3>
      <div>
        <p>
			What is your Unit's policy on recognition, prevention and management of jaundice? Discuss the Unit policy with your colleagues, comparing it to the AAP recommendations and other evidence-based articles. Would the algorithm in the AAP guidelines be useful to reproduce for your Unit?
		</p>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div class="section" id="What_should_I_remember_"><h3>What should I remember?</h3>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
        <div>
          <ul>
            <li>Jaundice is a normal physiological process in the well full-term baby (physiological jaundice)</li>
            <li>The potential risk factors for problematic jaundice</li>
            <li>The optimal management that prevents an abnormal pattern of jaundice</li>
          </ul>
        </div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div class="section" id="Self-test_quiz"><h3>Self-test quiz</h3>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
        <div></div><div class="activity" id="activity_rz">
<p class="instructions">Click and drag the missing words below into their correct place</p><p class="missingWords">The missing words are: <strong>breastfeeding</strong> <strong>breastmilk</strong> <strong>physiological</strong> <strong>supplementation</strong> <strong>tenth</strong> <strong>third</strong></p><span value="physiological" class="dropper">__________</span> jaundice is normal in most newborns. Bilirubin rises to a peak on the <span value="third" class="dropper">__________</span> day of life, followed by a further rise until the <span value="tenth" class="dropper">__________</span> day for most breastfed infants. A harmless form of jaundice that persists for many weeks is termed <span value="breastmilk" class="dropper">__________</span> jaundice.<br />Prevention of hyperbilirubinemia is focused on frequent, effective <span value="breastfeeding" class="dropper">__________</span> and the absence of all <span value="supplementation" class="dropper">__________</span>.<br /><script type="text/javascript">initCloze('activity_rz');</script></div>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#hawd10" title="See full details">#</a> Hawdon JM (2010) Best practice guidelines: Neonatal hypoglycaemia.</li>
          <li id="note2"><a href="references.html#corn00" title="See full details">#</a> Cornblath M et al. (2000) Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds</li>
          <li id="note3"><a href="references.html#hawd92" title="See full details">#</a> Hawdon JM et al. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week.</li>
          <li id="note4"><a href="references.html#edmo85" title="See full details">#</a> Edmond J et al. (1985) Ketone body metabolism in the neonate: development and the effect of diet.</li>
          <li id="note5"><a href="references.html#cott11" title="See full details">#</a> Cotter DG et al. (2011) Obligate role for ketone body oxidation in neonatal metabolic homeostasis.</li>
          <li id="note6"><a href="references.html#hani01" title="See full details">#</a> Haninger NC et al. (2001) Screening for hypoglycemia in healthy term neonates: effects on breastfeeding</li>
          <li id="note7"><a href="references.html#hawd99" title="See full details">#</a> Hawdon JM (1999) Hypoglycaemia and the neonatal brain.</li>
          <li id="note8"><a href="references.html#jain10" title="See full details">#</a> Jain A et al. (2010) Hypoglycemia in the newborn.</li>
          <li id="note9"><a href="references.html#eide01" title="See full details">#</a> Eidelman AI (2001) Hypoglycemia and the breastfed neonate</li>
          <li id="note10"><a href="references.html#gart01" title="See full details">#</a> Gartner LM (2001) Breastfeeding and jaundice</li>
          <li id="note11"><a href="references.html#panb10" title="See full details">#</a> Panburana J et al. (2010) Accuracy of transcutaneous bilirubinometry compare to total serum bilirubin measurement.</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li class="current">7.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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