Introduction

Jaundice is a common occurrence in the newborn nursery; about 10% of full-term and over 50% of premature infants become clinically jaundiced during the first week of life. Physiologic jaundice, mild and transient elevation of serum bilirubin is benign and occurs in virtually every newborn which is probably related to several factors: increased haemolysis from trauma inherent in the birth process, immature uptake, or conjugation in the liver, or both and enterohepatic recirculation.

Some of these infants require intervention to prevent more severe jaundice, since high levels of unconjugated bilirubin may exceed the binding capacity of albumin, permitting bilirubin staining of the basal ganglia (kernicterus), which can result in cerebral palsy or death.

Causes of jaundice in newborn

In newborns, jaundice may occur due to immature liver. But elevated levels of bilirubin in pathological jaundice may lead to brain damage (kernicterus). Newborn jaundice require medical evaluation. Some common causes of jaundice in newborn are -

Physiological jaundice

Physiological jaundice detected on 2nd or 3rd day of life. This condition is transient and harmless, occurs due to immature liver of baby. As liver matures, the jaundice eventually disappears.

Inadequate breast milk

Jaundice may occur if newborn is not able to receive adequate milk due to insufficient milk production by mother or due to poor feeding by infant, which lead to dehydration and less bowel movements with subsequent decrease in bilirubin excretion. If intake is inadequate, the infant should receive supplemental formula and the mother should be instructed to nurse more frequently and to use an electric breast pump every 2 hours to enhance milk production. Consultation with a lactation specialist should be considered. Because hospital discharge of normal newborns occurs before the milk supply is established and before jaundice peaks, a follow-up visit 2 days after discharge is recommended by the AAP to evaluate adequacy of intake and jaundice.

Signs of inadequate breast milk intake

1. Weight loss of > 8–10% from birth
2. Fewer than six noticeably wet diapers per 24 h by day 3–4
3. Fewer than four stools per day, or still meconium, by day 3–4
4. Nursing fewer than eight times per 24 h, or for less than 10 min each feeding

Cephalohematoma

At the time of birth, injuries on head may occur which results in collection of blood under scalp. As this blood breaks down itself, levels of serum bilirubin suddenly increase, which results in jaundice.

Signs and symptoms

Jaundice causes a yellow color of the skin particularly face, chest, belly area, legs and soles of foot. Infants with severe form jaundice may be very tired and feed poorly.

Examination and Lab investigation

1. Because most newborns are discharged at 24–48 hours of age. Hospital checks total bilirubin levels on all babies at about 24 hours of age. Hospitals use probes that can estimate the bilirubin level just by touching the skin (transcutaneous bilirubin measurement). High readings need to be confirmed with blood tests.
2. In all infants, an assessment of risk for severe hyperbilirubinemia should be performed before discharge. As recommended by the American Academy of Paediatrics, follow-up within 24–48 hours for all infants discharged before 72 hours of age (depending on the number of risk factors present) is imperative.
3. Although jaundice is usually visible above a TSB level of 5 mg/dL (86 mmol/L), visual estimation of the bilirubin level is inaccurate. TSB should be measured and interpreted based on the age of the infant in hours at the time of sampling.
4. Infants with a TSB level greater than the 95th percentile for age in hours have a 40% risk of developing significant hyperbilirubinemia. Serial bilirubin levels should be obtained from a single laboratory whenever possible to make interpretation of serial measurements more meaningful.

Management of newborn with jaundice

1. Treatment is not needed most of the time. Treatment of hyperbilirubinemia is not yet standardized. Most cases of moderate jaundice will resolve with general supportive measures to ensure adequate fluid and caloric intake and bowel function.
2. Severe jaundice, particularly in the presence of a haemolytic process, may require exchange transfusion; this process removes approximately 80% of the foetal red cells and 50% of the serum bilirubin.
3. Phototherapy has been proved effective in reducing the serum bilirubin level and in reducing the necessity for exchange transfusion. Some doubt remains about its safety, since it utilizes an intense form of energy with largely unknown biologic effects.
4. At present, phototherapy is clearly indicated only when there is a significant risk that hyperbilirubinemia will become severe enough to require an exchange transfusion if untreated; it cannot be used as a substitute for the initial exchange in erythroblastosis, whose primary purpose is to remove sensitized red cells and to correct anaemia.
5. Jaundice of sufficient degree to require phototherapy must be evaluated to determine the cause of the hyperbilirubinemia, since the jaundice of infection, haemorrhage, haemolysis, or metabolic disorders may respond to phototherapy initially, causing a dangerous delay in reaching the primary diagnosis.
6. Infants receiving phototherapy should be protected from the direct adverse effects of light by shielding their eyes and from the many indirect effects (e.g., hyperthermia, dehydration) as well.
7. Feed the baby often (up to 12 times a day) to encourage frequent bowel movements. These help remove bilirubin through the stools.

References

1. Gourley, G. Bilirubin metabolism and kernicterus. Adv. Pediatr. 44:173-229, 1997. This article presents an excellent review of the cellular processes involved, but also contains a good discussion of clinical management issues.
2. Newman, T. and Maisels, M. Evaluation and treatment of jaundice in the term newborn: A kinder, gentler approach. Pediatrics 89:809-818, 1992. Lead article in a unique collection of commentaries on state-of-the-art. This series of articles is the next best thing to getting several of the world's authorities on neonatal jaundice together and listening in while they debate current practices. A commentary is added from the other side of the Atlantic in Arch. Dis. Child. 68:529-532, 1993.
3. Watchko, J. and Oski, F. Kernicterus in preterm newborns: Past, present and future. Pediatrics 90:707-715, 1992. Fascinating and sobering historical overview-what we don't know about neonatal jaundice still holds the upper hand.
4. Bifano, E. and Ehrenkranz, R. (eds.). Perinatal hematology. Clin. Perinatol. 22(3), 1995. This volume contains articles on management of Rh-related disease, and an update on new diagnostic and treatment modalities.Etiologic Factors: Erythroblastosis
5. Duerbeck, N. and Seeds, J. Rhesus immunization in pregnancy: A review. Obstetr. Gynecol. Surv. 48:801-810, 1993. Dramatic strides in both prevention and treatment have set the stage for potential eradication of this disorder.
6. Weinstein, L. Irregular antibodies causing hemolytic disease of the newborn. Obstet. Gynecol. Surv. 31:581-591, 1976. Isoimmunization by antigens other than Rh(D).