JAUNDICE IN THE NEWBORN

Jaundice is defined as a yellowish discoloration of the sclerae and/or the skin due to high levels of bilirubin in the blood.

Pathophysiology:

Bilirubin is a yellow pigment that is created in the body during the normal recycling of old red blood cells. The liver helps break down bilirubin so that it can be removed from the body in the stool. Before birth, the placenta, the organ that nourishes the developing baby, removes the bilirubin from the infant so that it can be processed by the mother's liver. Immediately after birth, the baby's own liver begins to take over the job, but this can take time. Therefore, bilirubin levels in an infant are normally a little higher after birth.

Causes of jaundice in the Newborn:

Physiologic jaundice usually appears after 24 hours of life and peaks between the third and fourth day of life and disappears after 2 weeks. It usually happens during the breakdown of fetal red blood cells at birth that are not adequately handled by the liver of the newborn resulting in a higher bilirubin level but causes no problems.

Breast milk jaundice occurs when a metabolite in breastmilk (3-alpha-20-beta-pregnanediol) inhibits an enzyme (USPGA glucoronyl transferase) which is responsible for the conjugation and excretion of bilirubin. This usually happens in some healthy, breastfed babies after one week of life, and usually peaks during the second and third week of life. It may last at low levels for a month or more.

Breastfeeding jaundice is seen in breastfed babies in the first 3-7 days of life when baby does not get enough breastmilk and is dehydrated and has infrequent bowel movement. Without bowel movement, bilirubin is not excreted.

Conditions that increase the number of red blood cells that need to be broken down, and can cause more severe newborn jaundice:

1. Abnormal blood cell shapes
2. Blood type incompatibility between the mother and the baby
3. Cephalohematoma (bleeding underneath the scalp) due to a difficult delivery
4. Deficiency or lack of certain important enzymes
5. Higher levels of red blood cells, which is more common in small-for-gestational-age babies and some twins
6. Infection

Conditions that make it harder for the baby's body to remove bilirubin may also lead to more severe jaundice:

1. Certain medications
2. Congenital infections, such as rubella, syphilis, and others
3. Diseases that affect the liver or biliary tract, such as cystic fibrosis or hepatitis
4. Hypoxia
5. Infections (such as sepsis)
6. Many different genetic or inherited disorders

Symptoms

The earliest indication of jaundice is yellowish discoloration of the sclerae. The main symptom is a yellow color of the skin. The yellow color is best seen right after gently pressing a finger onto the skin. The color sometimes begins on the face and then moves down to the chest, abdomen, legs, and soles of the feet. Sometimes, babies with significant jaundice have poor activity and poor suck.

Signs and tests

Any infant who appears jaundiced especially in less than 24 hours of life should be worked up right away. The tests include the following:

 Complete blood count
 Coomb's test
 Reticulocyte count
 Bilirubin levels, (direct, indirect and total)

Doctors, nurses, and family members will watch for signs of jaundice at the hospital. Some hospitals use probes that can estimate the bilirubin level just by touching the skin. High readings need to be confirmed with blood tests.

After discharge, the parents are advised to monitor for signs of jaundice. If significant jaundice is observed after 24 hours, more so if accompanied by other signs and symptoms like vomiting, poor suck or poor activity, the infant should be brought back to the hospital right away and be tested.

Treatment

Treatment depends on the cause, age of the baby, day of life of occurrence, level of bilirubin and how fast the level is rising so a serial monitoring may be needed. Physiologic or normal causes of jaundice usually need no treatment but only reassurance. However, a baby who was born prematurely even with low levels of bilirubin, or a term neonate with a very high level of bilirubin or with a level that rises rapidly may require hospitalization and treatment.

Treatment regimen may entail use of phototherapy and in severe case of jaundice, it may require an exchange transfusion and giving of intravenous immunoglobulin.