Newborn Jaundice – A complete guide

What is jaundice?

Jaundice is caused by increased bilirubin in blood. When the red blood cells are broken down, the byproducts are metabolized by liver and removed. Liver also detoxifies toxins in body and secretes it into the intestine called bile.

Why do we get jaundice?

When there is excessive breaking of red blood cells are problem in liver in secreting bile the bilirubin in blood increases. This increased bilirubin causes yellowish discoloration of skin and eyes. Jaundice is not a disease, but rather a sign of an elevated blood bilirubin level.

Why newborn babies get Jaundice?

Newborn babies are born with high hemoglobin (16 to 18 gms/dl) due to low oxygen in mothers blood. When they are exposed to normal air after birth there is increased breakdown of red blood cells so that the haemoglobin comes down to normal values ( around 12 -13 gm/dl). This increased breakdown is the cause of jaundice in newborn babies.

What is physiological jaundice and pathological jaundice in newborn?

All Newborn babies get jaundice, which usually peaks 3 days after birth. This clears 7 days after birth in term babies and within 14 days in preterm babies. This is called physiological jaundice. It is a natural phenomenon that happens in all newborn babies.

But, in certain conditions the level of bilirubin shoots up requiring some form of treatment. This is called pathological as there would be some underlying problem causing it. Some of the causes of infant jaundice are:

1. Babies born preterm (before 37 weeks)
2. Babies bruised during birth
3. Babies with a brother or sister who had newborn jaundice
4. Babies whose mothers are Rh negative and/or have type O blood
5. If a mother and baby’s blood group and type are different (or “incompatible”); the mother’s immune system may damage the baby’s red blood cells
6. Babies with Middle Eastern, East Asian, or Mediterranean ethnicity
7. Overall, bilirubin is also more slowly removed in the newborn compared to adults because a baby’s liver and intestines are not fully functional. In Asian babies, the ability to remove bilirubin takes longer to develop.

What You Should Know About Jaundice Management?

Any baby can get jaundice, but, severe jaundice that is not treated can cause brain damage. Your baby

should be checked for jaundice in the hospital and again within 48 hours after leaving the hospital. Ask your doctor or nurse about a jaundice bilirubin test.

How can I tell if my baby has jaundice?

Ask about a bilirubin test before you leave the hospital. The best way to measure bilirubin is by having a sample of your baby’s blood taken. Your doctor or nurse will compare results from your baby’s jaundice bilirubin test to what is normal for a baby the same age (in hours).

Are there any signs of jaundice that I can see?

Some babies with jaundice might look yellow or even orange, but it is not possible to notice jaundice in all babies, especially those with darker skin color. Talk to your doctor or nurse immediately if your baby:

● Has fewer than 4 wet or dirty diapers in 24 hours

● Has trouble nursing or sucking from a bottle

● Is very sleepy and hard to wake, even to feed

● Cannot be comforted, has a shrill and high­pitched cry, or both

● Is limp or floppy

How is jaundice treated?

Your baby might be put under special blue lights (phototherapy) to lower the bilirubin level. You should not put your baby in direct sunlight; this is not a safe treatment for jaundice and could cause

sunburn. Very high bilirubin level might need a blood transfusion in the hospital to get rid of jaundice in the new born.

What else can I do to keep my jaundiced baby healthy?

Take jaundice seriously and stick to the follow­up plan for appointments and recommended care. Make sure your baby is getting enough to eat. The process of removing waste also removes bilirubin in your baby’s blood. If you are breastfeeding, you should nurse the baby at least 8 to 12 times a day for the first few days. This will help you make enough milk for the baby and will help keep the baby’s bilirubin level down. If you are having trouble breastfeeding, ask your doctor or nurse for help.

Fast Facts

● Untreated jaundice can cause brain damage.

● Newborns should be checked for jaundice before leaving the hospital and again within 48 hours after hospital discharge.

● Jaundice is the number one reason babies are readmitted to the hospital.

● 1 in 10 babies has jaundice that may require treatment.

What are the complications of jaundice?

In babies whose blood bilirubin levels reach harmful levels, bilirubin may get into the brain and cause reversible damage (called acute bilirubin encephalopathy) or permanent damage (called kernicterus or chronic bilirubin encephalopathy). Frequent monitoring and urgent, early treatment of babies at high risk for jaundice helps to prevent severe hyperbilirubinemia.

What is kernicterus?

Kernicterus is a type of brain damage that can result when jaundice is not treated properly. A child with kernicterus can have cerebral palsy, hearing loss, problems with vision and teeth, and sometimes mental retardation. Kernicterus can be prevented if jaundice is properly treated.

JAUNDICE TREATMENT

The goal of treating jaundice is to efficiently and safely reduce the level of bilirubin. Babies with mild hyperbilirubinemia may need no treatment at all. Babies with higher bilirubin levels will need brief treatment, which is described below.

Jaundice is common in premature babies (those born before 38 weeks). Premature babies are more vulnerable to hyperbilirubinemia because brain toxicity occurs at lower levels of bilirubin than in term babies. As a result, premature babies are treated at lower levels of bilirubin but with the same treatments discussed below.

Frequent feeding — Providing adequate breast milk is an important part of preventing and treating jaundice because it helps in the elimination of bilirubin in stools and urine. If your baby is not getting enough through breastfeeding, your doctor can talk to you about options such as supplementing with formula or donor breast milk. You will know that your baby is getting enough milk if s/he has at least six wet diapers per day, the color of their stools will change from dark green to yellow, and s/he seems satisfied after feeding.

Phototherapy — Phototherapy (“light” therapy) is the most common medical treatment for hyperbilirubinemia in babies. In most cases, phototherapy is the only treatment required. The baby’s skin surface is exposed to special blue light, which breaks bilirubin into compounds that are easier to eliminate in the stool and urine. Treatment with phototherapy is successful for almost all babies.

Phototherapy is usually given in the hospital, but in certain cases, it can be done at home if the baby is healthy and at low risk of complications.

Babies should have as much skin as possible exposed to the light. Babies are usually naked (or wearing only a diaper) in an open bassinet or warmer, but need to wear patches or a special mask to protect the eyes (image 1). Phototherapy should be continuous and stopped only for feeding and skin-to-skin care of the baby. Some hospitals have special phototherapy blankets that allow treatment to continue while you hold or feed your baby.

Exposure to sunlight was previously thought to be helpful but is no longer recommended due to the risk of sunburn unless ultraviolet rays are filtered out. Sunburn does not occur with the lights used in phototherapy.

Phototherapy is stopped when bilirubin levels drop to a safe level. It is not unusual for babies to still appear jaundiced for a period of time after phototherapy is completed. Bilirubin levels may rise again 18 to 24 hours after stopping phototherapy. Although rare, this requires follow-up for those who may need more treatment.

Side effects — Phototherapy is very safe, but it can have temporary side effects, including skin rashes and loose stools. Overheating and dehydration can occur if a baby does not get enough breast milk or formula. Therefore, a baby’s skin color, temperature, and number of wet diapers should be closely monitored.

Unusually, some babies can develop “bronze baby” syndrome, a dark, grayish-brown discoloration of the skin and urine. Bronze baby syndrome is not harmful and gradually goes away without treatment after several weeks.

Breastfeeding during phototherapy — It is important for babies receiving phototherapy to drink adequate fluids (ideally breast milk) since bilirubin is excreted in the urine and stool. Breastfeeding should continue during phototherapy. Use of oral glucose water is not necessary. In babies with serious dehydration, intravenous (IV) fluids may be necessary to correct the loss of fluid.

Babies who are not able to get enough breast milk, lose a lot of weight, or are dehydrated may need extra expressed breast milk or medically recommended formula for a short time. Mothers who supplement with formula should continue to breastfeed and/or pump regularly to maintain their milk supply.

There is some controversy about the practice of giving supplemental formula to exclusively breastfed babies. If you are considering doing this, it’s a good idea to talk to your baby’s doctor or nurse first. (See “Patient education: Breastfeeding guide (Beyond the Basics)”.)

Exchange transfusion — Exchange transfusion is an emergency, life-saving procedure that is sometimes necessary to rapidly decrease bilirubin levels. The transfusion replaces a baby’s blood with donated blood to quickly lower bilirubin levels (2 to 3 hours). Exchange transfusion is performed only for babies who have not responded to other treatments and who have signs of, or are at significant neurologic risk due to bilirubin toxicity.

Cholestatic jaundice in newborn:

This is a different type of jaundice due to liver disease (Not due to excessive red blood cell breakdown or immature liver). There are several diseases that can cause jaundice in new born such as biliary atresia (Block in bile duct), metabolic disorders, genetic disorders etc

How to differente cholestatic jaundice from physiological jaundice?

We can request the lab to perform split bilirubin, where they will look at indirect fraction and direct fraction of bilirubin. If the indirect fraction is more than 10% of total bilirubin, it is suggestive of cholestatic jaundice. All cholestatic jaundice has to be thoroughly investigated as it always indicates underlying liver disease.