Q&A Newborn
How will I know if my newborn baby has jaundice after birth? What should I do and how is it treated?
DR MARETHA COMBRINK
ANSWERS: Jaundice is a common problem observed in neonates. Approximately 60 percent of full-term infants and 80 percent of preterm infants will develop neonatal jaundice during the first week of life. The yellow colour usually results from accumulation of bilirubin pigment in the skin.
Bilirubin is derived from the breakdown of haemoglobin in red cells. During pregnancy, the fetus has a higher number of red cells and haemoglobin to carry oxygen due to the relative hypoxic (oxygen-poor) environment. After birth, when the infant starts breathing air, the high amount of haemoglobin in red cells is no longer required, and the cells start breaking down through a process called haemolysis. Factors such as prematurity, delayed cord clamping, significant bruising during birth, blood group incompatibility, breastfeeding and EastAsian ancestry can increase an infant’s chances of developing jaundice. Physiologic jaundice, the most common type, is present on day two or three of life, peaks at day four, and decreases after day five to seven.
Pathologic jaundice presents within the first 24 hours of life or lasts longer than 14 days.
Early jaundice is usually due to blood group incompatibility or other unusual antibodies in maternal blood. Late onset or prolonged jaundice may be due to surgical conditions (biliary atresia, choledochal cyst etc.), neonatal infections, or enzyme defects (galactosaemia or G6PD). Breastmilk jaundice is a type of jaundice associated with breastfeeding. It typically occurs one week after birth. The condition can sometimes last up to 12 weeks, but it rarely causes complications in healthy, breastfed infants. The exact cause of breastmilk jaundice is unknown, but the enzyme glucuronidase that is present in breastmilk has been suspected to play a role in the development of jaundice. Jaundice may be present at birth or may appear at any time during the neonatal period, depending on the cause. It usually becomes apparent starting on the face and progressing to the abdomen and then feet as the blood levels increase. Bilirubin is toxic to cells of the brain. Although not common, if a baby has severe jaundice, there is a risk of bilirubin passing into the brain and staining the nerve cells or ganglia. This condition is called acute bilirubin encephalopathy, and prompt treatment may prevent significant lasting damage. The risk of bilirubin encephalopathy increases when the level of bilirubin rises too high.
Maternal blood tests are required for blood grouping and/or specific antibody tests.
Infant blood tests will depend on the severity of jaundice but will mostly include a thyroid function screening test on the cord blood and/or a transcutaneous or serum bilirubin test. Bilirubin levels should be interpreted according to the infant’s age in hours.
If the infant requires phototherapy or if the bilirubin value increases rapidly
– other tests such as infant blood group and antibody tests, as well as infection screening will be considered. Prolonged jaundice (more than 14 days) requires additional investigation such as liver function tests, specific enzyme tests and abdominal ultrasound and/or radionuclide scans.
The most common and very effective treatment for physiologic jaundice would include phototherapy with a blue light. Bilirubin absorbs this light from the skin surface, becomes more soluble and is excreted in the stool and urine. Intravenous immunoglobulins is considered in patients with excessively high bilirubin levels close to exchange transfusion levels and patients with proven blood group incompatibility or other immune antibodies.
Whole blood exchange transfusion is done when dangerously high levels of bilirubin in the blood is found. The infant’s entire blood volume is replaced.
The treatment of pathological jaundice is dependent on the cause.
The best prevention of infant jaundice is adequate feeding. Breastfed infants should have eight to 12 feedings a day for the first several days of life.
Intensive early screening and phototherapy has significantly decreased the need for exchange transfusions and complications such as bilirubin encephalopathy.