JAUNDICE IN THE NEWBORN

Dr. V.I. Joel-Medewase
(Consultant Neonatologist)

INTRODUCTION

In Nigeria, neonatal morbidity and mortality due to jaundice remains unacceptably high despite increase in knowledge of the causes of jaundice. Increase in knowledge of preventive measures in tertiary centres have no positive impact in the communities, primary and secondary health facilities where majority of these babies are born and are dying. Wrong and dangerous practices continue, e.g.

  • Umbilical cords still being dressed with menthol-containing agents like mentholatum, “Robb” and Dusting powder, 
  • Ampicilin/Ampclox drops, phenobabitone or multivitamins are ignorantly supplied to mothers for treatment of jaundice. 
  • Wrong counseling given to mothers, and mothers are wrongly assured.
  • Late presentation of Jaundiced babies to the hospital

All these have made brain damage from severe jaundice to persist. This must change! Correct information must be passed to communities and stake holders of health facilities.

WHAT IS JAUNDICE?

Jaundice is the yellowish discolouration of the sclera, skin and mucous membrane as a result of accumulation of bilirubin (a yellowish-red pigment compound) in the blood. Sixty per cent of term and 80% of preterm newborns have jaundice.

Jaundice in the baby appears first in the eyes, then the face, upper parts of the body, and this progresses downwards towards the toes.

Jaundice becomes clinically visible at serum bilirubin levels of 4 – 7 mg/dl.

A rough guide: Face = 5 mg/dl, mid-abdomen = 15 mg/dl, soles of feet = 20 mg/dl.

WHAT CAUSES JAUNDICE? 

Jaundice is caused by the presence of excessive amount of bilirubin in the blood. Bilirubin is formed from breakdown or destruction of red blood cells. Normally, small amounts of bilirubin found in everyone’s blood. When there is excessive amount of bilirubin in the baby’s skin, the baby’s colour also appears yellowish. The baby in the womb have many red blood cells for oxygen carriage to its tissues.

When the baby is born and now have access to the free air (oxygen), some of the red blood cells will no longer be needed and are destroyed, releasing the bilirubin into the blood. This bilirubin causes the eyes and skin to take on a yellow colour.

Meconium (a dark greenish stool passed by a newborn in the first few days after birth) also contains bilirubin which can be released to the blood. One gram of meconium contains about  35mg of bilirubin.

Babies who cannot pass meconium because of intestinal obstruction may increase blood level of bilirubin and become jaundiced. Early breastfeeding may help baby to pass meconium and prevent high level of bilirubin (jaundice).

WHY THE CONCERN ABOUT JAUNDICE IN THE NEWBORN?

BILIRUBIN IS DANGEROUS! Bilirubin (the cause of jaundice) is toxic (poisonous) to all cells of the body, but the toxicity to the brain is what we are most afraid of. Excessive free bilirubin (unconjugated bilirubin) in the blood crosses to the brain and damages the brain of a newborn if not appropriately treated. The baby may grow up with very slow development,  mental retardation, deafness and with failure to achieve his potentials in life. However, this severe jaundice is preventable and easily treatable if identified before the damage is done to the brain of the baby.

Jaundice can also be a possible manifestation of serious diseases which must be detected and treated to prevent severe damage to the liver, brain and eyes.

TYPES OF JAUNDICE 

Jaundice can be classified in different ways:

  • Based on the need for treatment
  • Based on the time of outset or when the jaundice is noticed.
  • Based on time of clearance or disappearance.
 
Based on the need for treatment

Physiological: When the jaundice is as a result of the natural process of red blood cell breakdown only.

Pathological: When disease conditions are causing the destruction of red blood cells. This type is almost always dangerous.

 

Based on the time of outset or when the jaundice is noticed.

Early outset (when the jaundice is noticed in the baby within the first 36 hours of birth). It is almost always pathological and very dangerous type of jaundice.

Late outset (when the jaundice occurs after 5th to 7th days of life). This is the time when physiological jaundice is almost completely resolved or has resolved.

Based on time of clearance or disappearance

Early resolution: When the jaundice resolves within the first 10 to 12 days as in full term babies and within 14 days as in preterm babies.

Prolonged: This is jaundice that is still noticed to be more than mild after 2 weeks of life and confirmed by serum (blood) bilirubin to be above 2mg/dl (34μmol/l).

 

FACTORS RESPONSIBLE FOR PHYSIOLOGICAL JAUNDICE IN NEWBORN 

The factors include:

  • Increase in bilirubin load to the liver because of relatively high red blood cell mass. PCV 45% – 65%
  • Short red blood cell life span: 30 – 90 days
  • Increased bilirubin production from badly formed red blood cells or inefficient red blood cell formation in the newborn. The normal newborn infant produces 6-8mg of bilirubin per kg of body weight per 24 hours which is 2.5 times the rate of bilirubin production in adults.
  • Reduced newborn liver uptake due to reduced liver protein (i.e. reduced Y-protein).
  • Reduced conjugation from reduced liver enzyme activity
  • Reduced liver bilirubin excretion to the bile ducts.
  • Reduced liver circulation and hence reduced bilirubin transportation
  • Reduced blood flow to the liver immediately after birth and following clamping of the umbilical cord.
  • Shunting of blood through the patent/persistent ductus venosus postnatally from the liver thereby impairing the clearance of bilirubin by the liver.

Jaundice should not be considered physiological under the following circumstances:

  • Jaundice appearing in the first 24 hrs of life
  • Rapidly rising jaundice (TSB > 5mg/day or >0.5mg/hr) TSB > 15mg/dl by 48 hrs, > 16mg/dl by 72 hrs or > 17mg/dl by 96 hrs
  • Jaundice in any sick newborn
  • Conjugated hyperbilirubinaemia

PATHOLOGICAL JAUNDICE

This is jaundice that is often associated with high or severe bilirubin level. It may be due to disease conditions that provoke destruction of the newborn’s red blood cells (rbcs) beyond the physiological level. 

It may also be due to a disease that makes the liver unable to perform its functions in processing bilirubin or that obstructs the pathway of the circulation of bilirubin. It almost always lead to severe damage

Features of Pathological Jaundice

Jaundice in 1st 24-36 hrs; that is jaundice occurring too early! 

Rapidly rising TSB (> 5 mg/dL (85μmol/l) per day).  

TSB > 17 mg/dL (289μmol/l). Jaundice noticeable below the trunk or in the feet or hand 

Persistent jaundice (beyond the first week of life in the full term infant or second week in the preterm infant). Jaundice too late to disappear. 

Jaundice in a baby who is sick (fever, vomiting, poor sucking, excessive cry, sleeplessness etc) 

Jaundice with brownish or deeply yellow urine and/or ‘pale’ stool.

ASSESSMENT AND TREATMENT OF JAUNDICE IN THE NEWBORN 

HOW DO YOU ASSESS A BABY WITH JAUNDICE?

TAKE A HISTORY (Ask the mother for the) :

Age of the baby (from date of birth)

History of outset, progression and associated problems suggestive of illness in the baby.

Take family history of jaundice in the previous siblings.

Find out the blood group of parents if they know (ABO and Rhesus blood groups).

Find out problems related to pregnancy, labour (pitocin induction) and activity of baby at birth.

LOOK AND CHECK (EXAMINE THE BABY)

Check for the following:

Note colour of the skin, size, maturity, weight and degree of jaundice, fever, activity, poor feeding, hydration, bruising, pallor.

Check for enlarged liver, spleen, abnormal cry and muscle tone.

NOTE

When the baby passes dark brown urine and/or light coloured stool, it is suggestive of obstruction to the flow of conjugated bilirubin.

The jaundice in this condition may also be deep and persist beyond 2-3wks 

 

INVESTIGATIONS

Blood Tests:

Bilirubin levels (Conjugated and unconjugated): Serial (repeated) tests to know rate of   rise

Mother’s and baby’s blood groups: ABO and Rh type, antibody (Coomb’s test).

Umbilical cord blood of the baby must be taken immediately after birth for full blood count, reticulocyte count, bilirubin level if mother is Rh negative, and Coomb’s test.

If necessary: Full blood count, screening for infection (including urine).

TREATMENT OF UNCONJUGATED SEVERE JAUNDICE 

Phototherapy if indicated (charts may be used to guide decisions).

Exchange Blood Transfusion (EBT)

Other specific treatments for the cause of jaundice

Drugs

Note: Treatment should only be done in hospitals that are well equipped, including personnel who can perform EBT and PHOTOTHERAPY

Phototherapy also called light treatment is the process of using light to eliminate bilirubin in the blood. It is the use of concentrated light rays in the treatment of jaundice. The baby’s skin and blood absorb these light waves and change bilirubin into products (photoisomers) which can pass through and be eliminated from the body through the excretory systems. It was originally developed following the observation that lowering of serum bilirubin levels occurred in infants exposed to direct sunlight and concentrated fluorescent lights. (430-490nm)

Phototherapy shows a clear dose – response, that is, the more light the baby is exposed to, the lower the bilirubin. The closer the baby to the light, the lower the bilirubin. 

The efficacy of phototherapy depends on the rate of formation of bilirubin, the potency of the light source, the distance of the baby to the light source, the surface area of the baby exposed to the light and the duration of exposure of the baby.

ANY BABY WITH JAUNDICE MAY NEED EBT URGENTLY!!!

If phototherapy does not adequately reduce the bilirubin level, exchange blood transfusion (EBT) is done as adjunct while the phototherapy is continued.

NOTE: FOR EBT TO BE DONE, PARENTAL CONSENT IS NECESSARY AFTER EXPLANATION OF THE INDICATIONS.

EXCHANGE BLOOD TRANSFUSION (EBT)

This is a modality of treatment for severe jaundice in the newborn using compatible blood.

EBT is done when there is urgent need to rapidly lower the level of bilirubin and to possibly prevent its further rise.

EBT helps to remove bilirubin and antibodies from circulation.

It is most beneficial to infants with on-going hemolysis.

It is often used after intensive phototherapy has failed to adequately lower the serum  bilirubin.

It is done by gradually withdrawing the baby’s blood and replacing it with equal volume of compatible fresh donor blood. Volumes of 5, 10 or 20mls may be withdrawn at a time and replaced depending on the size of the baby. This is done slowly.

COMPLICATIONS OF EXCHANGE BLOOD TRANSFUSION

EBT is a relatively safe procedure but some complications are possible. These complications could occur during, shortly after, or much later after the procedure.

Some immediate complications are:

Haematologic: Blood incompatibility crises, anaemia, polycythaemia, volume overload and congestive heart failure

Metabolic: Hyperkalaemia, acidosis, hypocalcaemea, hyperglycaemia, hypoglycaemia.

Complications associated with cannulation: Thrombo-embolism and air embolism, haemorrhage, necrotizing  enterocolitis (NEC), mechanical damage to umbilical vessels.

Temperature instability: Hypothermia, hyperthermia (If procedure is done under a warmer).

Infections: Malaria, bacterial, viral

OTHER SUPPORTIVE / SPECIFIC CARE

Apart from phototherapy and/or exchanged blood transfusion, one should treat any treatable identifiable cause of the jaundice and in all cases, ensure continuous breastfeeding and hydration (except where baby is too ill to feed and intravenous line is in place).

Babies with infections would need intravenous antibiotics.

Babies with hypothyroidism would need thyroxin drug urgently.

Babies with galactosaemia will need feed manipulations.

Babies with biliary atresia will need surgery before 60th day of life etc.

AVOIDING BRAIN DAMAGE FROM BILIRUBIN TOXICITY AND OTHER PREVENTIVE MEASURES

To prevent kernicterus, all health care providers should –

Recognize the common clinical risk factors for severe jaundice

Recognize the factors that can increase bilirubin toxicity

Do day-3 pre-discharge serum bilirubin

Carefully monitor babies in whom any of the factors is present in order to avoid brain damage by means of prompt diagnosis and correct management.

 

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