NEONATAL JAUNDICE

What is neonatal jaundice and how common it is? 

  • Jaundice is a yellowish appearance of the skin and the eyes and is very common in newborns.
  • Roughly 60% of term and 80% of preterm babies develop jaundice within the first two or three days of birth and reach a peak at about the 4th day of life. Then gradually disappears in most babies by the time they are 2 weeks of age. 
  • Rarely it can occur within the first 24 hours of life (which points to a more serious condition). 
NEONATAL JAUNDICE

Why do babies become jaundiced? 

  • Jaundice is caused by the accumulation of bilirubin which is a breakdown product of old RBCs. In our body, old RBCs break down and new RBCs are formed. In adults, the RBC life span is nearly 120 days but in newborns, it is less and neonates also have a higher number of RBCs which break down more quickly and results in more bilirubin production. 

Physiological jaundice

  • Appears after 24 hours of birth with maximum intensity by 4th-5th day in term & 7th day in preterm and serum level <15 mg/dl.
  • Disappears without any treatment and is undetectable after 14 days.
  • The baby should be observed for worsening jaundice.

Pathological jaundice

  • Appears within 24 hours of life with an increase of bilirubin > 5 mg/dl/day.
  • Serum bilirubin > 15 mg/dl.
  • Jaundice persisting after 14 days.
  • Stool clay/white-colored and urine staining clothes yellow.
  • Direct bilirubin > 2 mg/dl.

Clinical presentation

  • Yellowish discoloration of skin starting from the face(whites of eyes) and progresses downwards. Babies with very high bilirubin levels may be sleepy, fussy, floppy, or poor feeding, poor suck, abnormal shrill cry, abnormal body movements.
  • Adequacy and assessment of feeding( breastfeeding, spoon-feeds ), urine and stool outputs.
  • Discharge weight(excessive weight loss, as per the day of life) should be checked. Acceptable weight loss-1-1.5 % per day in term babies and 1.5-2% per day in preterm babies)

Babies with risk factors are more likely to get severe jaundice: Prematurity, low birth weight, jaundice in the first 24 hours of life, Mother’s blood group O or Rh negative, Glucose-6-phosphate dehydrogenase (G6PD) deficient, Rapid rise of total serum bilirubin (>5mg/day), infection, cephalohematoma or bruises or polycythemia (more RBCs), babies of diabetic mothers, history blood transfusion, anemia, gall bladder stones in the family (Hemolytic anemia), history of severe NNJ in siblings, inadequate feeding. 

  • Inadequate breastfeeding- can lead to jaundice (called breastfeeding jaundice), it’s best to feed more often. Breastfeeding (lactation) consultant can help.

embolism, or genes.

NEONATAL JAUNDICE

How to measure bilirubin? 

Can be done with a machine (Transcutaneous bilirubin meter) which is placed on the baby’s skin, if this recording is high it is confirmed with a more accurate blood sample, the total serum bilirubin level (TSB), and show whether the jaundice level requires treatment or not.

TSB (Total serum Bilirubin) to be done 

  • If icteric within 24 hrs of life.
  • At any time, soles and palms are yellow.
  • If TcB > ≥12 mg/dl

Tcb (Transcutaneous bilirubin)to be done  

  • Icteric after 24 hrs of life (Pre discharge and in follow up in OPD).
  • TcB usually corresponds(+/- 2 mg/dl) of TSB
  • Mean differences between TcB measurements and TSB level are large when the bilirubin levels exceed 205 μmol/L (12 mg/dL).
  • Tcb is not reliable-< 24 hrs of life,< 35 weeks of gestation, already in phototherapy. 
  • Phototherapy to started as per AAP charts for jaundice for (≥ 35 weeks gestation babies). And NICE guidelines (For babies < 35 weeks)

OTHER LAB STUDIES THAT MAY BE INDICATED:

  • CBC, reticulocyte count, G6PD level, PBF for hemolysis.Urine for reducing substances (r/o galactosemia), electrolytes (to assess dehydration), thyroid studies, complete LFT
NEONATAL JAUNDICE

Treatment for jaundice 

  • The normal treatment is phototherapy(blue light) to reduce the bilirubin level. It depends on the cause of jaundice, the bilirubin levels, and a baby’s age. The baby will be placed naked, except for a nappy and eye band, in a cot under a special blue light (Phototherapy). Phototherapy converts bilirubin to a more easily removable form that is excreted in urine and stools. Bilirubin values are rechecked after 4-6 hours of starting and can be stopped when the bilirubin level is out of the phototherapy range. Phototherapy is discontinued, when TSB 2mg/dl below for the infant’s postmenstrual age.

For more serious cases of jaundice(jaundice levels very high, with risk factors, having neurological symptoms babies apart from getting intensive phototherapy may require:

  • Fluids.
  • Exchange blood transfusion. This emergency procedure is done if very high bilirubin levels do not come down with phototherapy. The baby’s blood is replaced with blood from a donor to quickly lower bilirubin levels.
  • Intravenous immunoglobulin (IVIg). Given to babies with blood type incompatibilities. 

How to care for a baby receiving phototherapy? 

Feed your baby at regular intervals. Staff will monitor your baby’s vitals, urine output, and stool output, and weight at regular intervals. The baby may experience loose green stools and blotchy rashes, which are temporary and will resolve when treatment is stopped. 

Will jaundice harm my baby? 

In most cases, jaundice is not usually dangerous. But if risk factors are present, and effective treatment is not provided to the baby according to guidelines it can cause neurological damage.

What if my baby remains jaundiced? 

Jaundice normally clears by the time your baby is two weeks old. However, if jaundice continues beyond 14 days of age in a full-term baby or 21 days in a premature baby it is called prolonged jaundice. Your baby will be examined and blood tests will be taken to ensure your baby is well. If your baby’s stools and urine are not a normal color at any time this should be investigated. These include infections, and problems with the liver or bile system, metabolism, or genes.

By Dr. Bijay Laxmi Behera ( Consultant Neonatology)