Trisha Williams (Host 1): Hi, guys. Welcome to the Advanced Practice Perspectives Podcast. I'm Trisha Williams.

Tobie O’Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look at the various advanced practice roles at Children's Mercy.

Host 1: Today, we are pleased to have Cristy Toburen with us. She is a newborn hospitalist who provides care for infants born and delivered at an affiliated hospital with Children's Mercy. Welcome to the podcast, Cristy.

Cristy Toburen: Thanks for having me.

Host 1: You are so welcome. Can you tell us a little bit about yourself?

Cristy Toburen: So, I have been a nurse practitioner since 2005. I started my career in a private practice where I worked for the first 10 years. And then, I transitioned back to Children's Mercy and to the primary care clinic in 2015. And there, I spent about half my time in the primary care clinic and half my time at the newborn nursery. And then, within this last year or so, I've converted to being full time in just the newborn nursery.

Host 2: Well, that's exciting. We've had a NICU nurse practitioner with us, but we haven't had a nurse practitioner that has worked in the newborn nursery on the podcast yet. So, we are excited to have you. Thank you for joining us today.

Cristy Toburen: Yeah, I'm excited to be here.

Host 2: We really wanted to hit a topic that had been requested by our peers to talk about hyperbilirubinemia in the newborn NIC time. And so, we are hoping you can kind of refresh our memories on newborn babies and how and why they're at risk for high bilirubin.

Cristy Toburen: Yeah. So, newborns are born with high levels of fetal hemoglobin. And when those cells are breaking down, one of the byproducts of that is bilirubin. And so, that's what puts newborns at increased risk of developing jaundice in the first few weeks of life. They also have kind of an immature liver in the first several days of life as well, so it can have a hard time keeping up with the rapid red blood cell breakdown that takes place.

Host 1: Now, are there certain patients, either ethnicity, gender-based genetic components that make them at a higher risk for high bilirubin?

Cristy Toburen: Yeah. So, there are risk factors, things that put them more at risk. So, things like exclusive breastfeeding, if you've had a sibling or a parent with a history of jaundice that also required treatment or big babies that are born to diabetic mothers are also at increased risk. Additionally, there's neurotoxicity risk factors, which are a little bit different than just the regular hyperbilirubinemia risk factors. And those neurotoxicity risk factors are definitely a little bit more serious. And those are things that are like gestational age less than 38 weeks, signs of sepsis, or any clinical instability in the previous 24 hours, so things like birth asphyxia or hypoglycemia, hypothermia, those all put babies at increased risk. And then, definitely things like isoimmune hemolytic disease. And then also, having a low albumin is another neurotoxicity risk factor that puts babies at increased risk of developing higher levels of jaundice.

Host 1: Now, is there a certain time frame that you're more concerned about the risk for hyperbilirubinemia from like newborn to two days of life, you know, 72 hours of life? Like what's the window?

Cristy Toburen: So, definitely, any newborn who's developing jaundice in the first 24 hours of life are going to be the ones that we kind of worry about the most. There's several different causes of jaundice and that kind of affects when we expect the levels to be more elevated and how much we get concerned about them.

Host 2: I see. And most babies now, I mean, I've heard some moms go home pretty soon, especially if it's like their second or third baby, but what is the typical length of time that you like to see them and watch them before, that's in that critical window you said 24 hours?

Cristy Toburen: So, it sort of depends on their risk factor. So certainly, some babies, their parents want to take them home sooner. So with a baby without major risk factors of neurotoxicity, then we usually just check a bilirubin around 24 hours of life, which is around the same time that we do the newborn screen. And then, if they're still in the hospital, then we'll repeat that level again at 36 hours of life. Babies who are at increased risk, so babies that have risk factors for like isoimmune hemolytic disease or babies that are usually like DAT positive, those babies, we start checking their levels much sooner. So, we'll start checking them at like four hours of life with transcutaneous and repeating that at 8 and 12 hours. And then, we check that 24-hour total serum bili. And then again, with another TCB at 36 hours if those levels are still staying okay. And if obviously any the levels are elevated, then we may need to escalate the care.

Host 2: Cristy, how does breastfeeding versus formula feeding affect bilirubin levels?

Cristy Toburen: So as I mentioned earlier, another known risk factor for developing hyperbilirubinemia is exclusive breastfeeding. So, breastfeeding jaundice is really known as inadequate milk intake, now labeled in the new guidelines as suboptimal intake hyperbilirubinemia. So breastfeeding fewer than eight times per day has been associated with increasing total serum bili concentrations. So, low milk intake contributes to decreased stooling, which then leads to increased intrahepatic circulation of bilirubin. This same phenomenon can happen to formula-fed babies as well, which is why the new guidelines have changed it from just breastfeeding jaundice to suboptimal intake hyperbilirubinemia, because this is not only just associated with just breastfeeding. So, the main treatment for this type of jaundice is going to be just feeding the infant.

Host 2: I see. So it doesn't necessarily matter that it's breastfeeding or formula, but it's more that it's just like the suboptimal amount of formula.

Host 1: And that makes sense with the breastfeeding moms, right? Because sometimes the milk doesn't come in until 24 hours after birth. And so, they're getting that colostrum, but not the adequate intake that they need for sustainability.

Cristy Toburen: Correct. Yes, it can take several days, especially with moms with C-sections for their milk to be fully established. And so, a lot of the jaundice that we sometimes see in the first couple of days of life are just related to an adequate intake.

Host 1: Interesting. It's a very complex situation. And I understand that there's a lot of long term sequelae that can happen from hyperbilirubinemia. As our listeners know, Toby and I work in ENT. So, the one thing that I for is sensorineural hearing loss on my side, working in otology. But can you kind of shed some light on what of some of those other long-term sequelae are if left unmanaged?

Cristy Toburen: Yeah. So, the whole point of us really checking these levels is to make sure that the levels aren't getting so high where they can pass the blood-brain barrier. And so when the levels are getting really elevated up there, then they can cause permanent neurological damage, caused by what's called kernicterus.

Host 2: Cristy, can you tell us more about the new hyperbilirubinemia guidelines that there are for newborns?

Cristy Toburen: Yeah. So, most recently in August of 2022, they did a total overhaul of the original guidelines that were published back in 2004. And they made several changes that assist providers in not only the evaluation and treatment of hyperbilirubinemia, but they also provided more specific information in regards to followup.

So, they offer specific time frames for newborn bilirubin levels to be reassessed based on the discharge bilirubin levels in relation to their gestational age and their risk factors. And since we now have more specific curves that individualize the risk factors for certain newborn age groups, such as infants, with and without neurotoxicity risk factors, as well as the specific curves now that delineate between the gestational ages for the infants between 35 and 40 weeks. It allows us to provide more individualized care.

Host 1: That sounds like an amazing guideline to be able to provide very succinct, direct care to our newborns. Is there anything else that can like help guide primary care providers or newborn hospitalists such as yourself with these guidelines?

Cristy Toburen: So, another big takeaway from the guidelines, generally speaking, that we are going to be much more conservative with our recommendations to treat with phototherapy as the new thresholds for infants, especially without neurotoxicity risk factors, is 1-2 mg/dL higher than the previous recommendations. So, generally speaking, we should be doing a lot less phototherapy, especially in the well baby nursery with the new recommendations.

Host 1: Very good. Now, when I first started out in nursing, blood exchange transfusions were like the new hype with high bilirubin, depending on certain numbers. Is that still a recommendation based on what those levels of bilirubin are?

Cristy Toburen: Yeah. So, that is actually something that is new to the guidelines, is this kind of escalation of care that is recommending when you get within 2 mg/dL below the exchange transfusion threshold, there are some pretty specific recommendations as to additional lab work that you should be getting. Definitely when we're getting to this level of care though, this is where we need to be consulting with our neonatology specialists and babies usually are going to be managed more in the NICU setting at this point.

Host 2: And what do the new guidelines have to say about the transcutaneous tool?

Cristy Toburen: So, the use of the transcutaneous tools are discussed in the new guidelines and they support the use when available to people to use. The only caveat that they recommend is that when you are reaching the phototherapy thresholds, that you base your treatment decisions off of the gold standard, the total serum bilirubin.

So, the guidelines do discuss the margin of error of the transcutaneous tool being approximately 3 mg/dL of the serum value, which is helpful to allow nurse-driven protocols. If the level is reaching within that 3 mg/dL of the phototherapy threshold, infants need to have the serum level checked. And then, the guidelines also discuss the use of the transcutaneous devices after phototherapy, whereas previously we had been instructed that we really can't use transcutaneous devices after an infant has received phototherapy. But the new guidelines are stating that we can use them at least 24 hours after phototherapy has been discontinued.

And one last thing to mention about use of transcutaneous is that if the TCB level is showing that it's 15 milligrams per deciliter or higher, then you really should confirm that with a serum level.

Host 1: That's some really great information and you're very knowledgeable about the new hyperbilirubinemia guidelines and kind of what it means for hyperbilirubin babies. I kind of want to switch direction now and I'm really, really curious about your role as a newborn hospitalist. I think that at Children's Mercy, we didn't know that that position existed. And I know that we staff some local newborn nurseries for those that do not have primary care. So, I'm just really interested in what that role looks like and how do you help patients establish primary care providers and how do you collaborate and coordinate care with those community providers.

Cristy Toburen: Yeah. So, I think the newborn hospitalist role for nurse practitioners in our institution especially has grown tremendously over the last, three to five years. We continue to collaborate with new hospitals and we definitely have increased our staffing quite a bit over the last several years. We admit babies to several affiliated hospitals with Children's Mercy shortly after birth. And then, we manage their care daily until discharge day and then we do all their discharge teaching and things like that as well. During the hospitalization, we help families decide on where would be an appropriate place for their newborn to be followed up. And then, we have a discharge planner that helps make that first appointment for them so that every newborn leaves the nursery with an appointment with an appropriate PCP. And then, because especially related to bilirubin, it's very important to often have these levels to be continued to be checked once the baby is discharged. So, all of our discharge notes are then immediately directed to the PCP so that they have documentation of the baby's history and what the levels were looking like during the hospitalization.

Host 2: That sounds like that's a great rule and probably really enjoyable. I mean, I think it'd be so fun to be able to have that first contact with those new babies and get them established where they need to go. So, I'm so glad to hear that we have this role. And do you know how many of you guys there are?

Cristy Toburen: So, I think that we have eight nurse practitioners currently on staff.

Host 1: Wow. That's amazing. Because then, you know, in that newborn period, it's so critical to catch those congenital heart defects that aren't caught during intrauterine ultrasounds and all of those different types of diagnoses that can present themselves. And so to have that expertise from hospitalists, newborn nursery hospitalists, from Children's Mercy is a huge contribution to our community. So, I'm very proud to be a part of Children's Mercy with that work. So, you guys are doing amazing things.

Cristy Toburen: Yeah. It's definitely exciting to be a part of and definitely the role is definitely expanding in the community, because I think of the great outcomes that we have been able to provide for babies that are born on our service.

Host 1: Before we kind of lay on the plane and close things out today, is there any certain recommendations you have for tools and guidelines for our community providers if they wanted to look anything up in regards to what we talked about today?

Cristy Toburen: Yeah. I mean, I think that, you know, definitely reviewing the new guidelines is going to be super important. There are several key action statements that we all need to be aware of. Definitely, all babies need to be having a bilirubin checked within the first 24 to 48 hours of life. Even if they're born outside the hospital, we need to make sure that babies are getting that bilirubin level checked.

 The use of like the bilitool.org or PDTool are both great resources where you can just plug the numbers in and it really helps just spit out the new guidelines in a very simplistic form that lets you know what next steps should be, when we should repeat the next level and it's super helpful. It makes it much easier than the previous recommendations from the old Bhutani nomograms.

Host 1: Perfect. We all love a good tool to use. So, those are excellent recommendations. Thank you so much for that.

Host 2: Well, we really appreciate you coming on here. You really do have a wealth of knowledge and so thank you for sharing that with us and with our guests that listen to this podcast. We always end each episode with a question for our guests. And so, what we want to know from you is what would your younger self high five you for now?

Cristy Toburen: Yeah. So, I think it's doing things like this, is definitely something that I'm proud of. So, one of the reasons that I came back to, you know, academic medicine at Children's Mercy was to have more opportunities to do education and research and having that APRN3 role that really motivates you and kind of pushes you outside your clinical box to do things that may not be in your comfort zone initially. I have just really enjoyed these different opportunities to participate in research and QI and education.

Host 1: We are so glad that you love those opportunities, because sharing your knowledge with our community in regards to these new guidelines and stuff is extremely important and motivating for all of us.

Host 2: Yeah. And Cristy, thanks again so much for coming on the podcast. We really do appreciate all of your time that you spent with us today.

Cristy Toburen: Thanks for having me, guys. It's been fun.

Host 1: It's been great. Thanks, Cristy.

(Outro): If you have a topic that you would like to hear about, or you're interested in being a guest, you can email us at tdobrien@cmh.edu or twilliams@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives podcast.