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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Jaundice

jaundice_smallJaundice is the yellowish staining of the skin and whites of the eyes (sclerae), caused by high levels of bilirubin in the blood (hyperbilirubinemia). Bilirubin is a chemical that is produced when red blood cells become old and are destroyed by the body. Before birth babies need high levels of red blood cells in order to obtain oxygen from their mothers. After birth, when they start breathing on their own, they no longer need oxygen rich (foetal) haemoglobin from their mothers. The red blood cells containing foetal haemoglobin need to be broken down and eliminated from their bodies. The by-product of this process is bilirubin. While growing in the womb, the foetus receives nutrients through the umbilical cord. By-products such as bilirubin are removed from the baby's body in the same way. After birth, the liver starts doing this job. It can take time for the baby's organs to get rid of excess bilirubin effectively.

Types of jaundice in newborns:

Newborns may develop jaundice from a build-up of bilirubin for different reasons:

Normal or physiologic jaundice is the most common, affecting more than half of all newborns to some extent. The condition is usually at its worst when the baby is 2-4 days old and tends to go away within 2 weeks without causing a problem.

Pathologic jaundice is caused by medical conditions. The most common being blood type incompatibilities, as well as prematurity, infection, liver damage due to rubella, syphilis, or toxoplasmosis, and metabolic conditions such as hypothyroidism. This type of jaundice usually begins earlier or later than physiologic jaundice, and levels of bilirubin are higher.

Breastfeeding jaundice is the result of mild dehydration, which may exacerbate or prolong physiologic jaundice. Dehydration makes it more difficult for the baby's immature system to effectively remove bilirubin. Late-onset or breastmilk jaundice is probably caused by a factor in some mother's milk that delays or prolongs the excretion of excess bilirubin. This type of jaundice may appear in some healthy, breastfed babies during the second week of life. Usually between day 10 and day 14. It may also develop in infants who previously had breastfeeding or physiologic jaundice, or a combination of the two that resolved (generally between days 5-7).

It is important to distinguish between the different types of jaundice, because each has different causes, consequences and treatments.

Diagnosis:

Doctors, nurses and family members will watch for signs of jaundice at the hospital, and when the newborn goes home. Any infant who appears jaundiced should have their bilirubin levels measured immediately. This can be done by means of a blood test.

Bilirubin is measured in milligrams per deciliter of blood (mg/dl). The average level for an adult is 1mg/dl. On approximately the third or fourth day of life, the average full term newborn has a peak level of 6mg/dl. By the end of the first week, this level usually drops to about 2-3mg/dl, and by the end of the second week the levels resemble those of an adult.

Many hospitals check a baby's total bilirubin level at about 24 hours of age. Hospitals use probes that can assess the bilirubin level just by touching the skin. High readings need to be confirmed with blood tests.

The tests that are likely to be done include: complete blood count, coomb's test, and reticulocyte count. Further testing may be required for babies who need treatment.

Symptoms:

Symptoms depend on the cause and severity but may include:
  • A yellowish tinge to the skin, usually appearing first on the face and scalp
  • A yellow tinge to the white parts of the eyes
  • In moderate jaundice, the yellow tinge spreads to the skin of the body
  • In severe cases, the hands and soles of the feet may also be affected
  • Unusual drowsiness
  • Feeding difficulties
  • Light-coloured faeces
  • Dark urine

Causes:

Jaundice is the result of excess bilirubin in the blood. Bilirubin is removed from the bloodstream by the liver and excreted in the infant's stool. Bilirubin accumulates in meconium (the black, tarry foetal stool during the first few days of life) and if not excreted, can be reabsorbed into the baby's system. During the first few days after birth, the newborns immature liver may not be able to process and excrete bilirubin fast enough. This accumulation of bilirubin causes jaundice to develop. The condition is particularly common in premature infants.

Infants who do not nurse well or those whose mother's milk is slow to come in, are often more prone to the condition. This is known as breastfeeding jaundice and is seen in the first week of life. Breastfeeding jaundice can occur when baby does not get enough fluids, most commonly because feeds are spaced too far apart. The average baby needs between 28.4 - 42.5g of fluids at least every 4 hours. If jaundice is noticeable, it may help to feed your baby, breast milk or formula, if that is your preference, every two hours. Dehydration or poor weight gain can make jaundice worse.

Blood bilirubin levels are higher, on average, in breastfed babies than bottle-fed infants and may remain elevated for longer (as long as 6 weeks). When blood bilirubin levels rise rapidly late in the first week or second week of life, breastmilk jaundice is diagnosed. The condition is due to a substance in some women's milk that affects the breakdown of bilirubin and occurs in approximately 2% of breastfed infants.

Excess bilirubin may also build up if it is unable to effectively move from the liver through the digestive tract. Jaundice can also occur if the liver is overloaded or damaged.

Severe newborn jaundice may occur if your baby has a condition that requires the frequent replacement of red blood cells, such as:
  • Abnormal shaped blood cells
  • Blood type mismatch between the mother and baby
  • Bleeding underneath the scalp caused by a difficult delivery (cephalohematoma)
  • High levels of red blood cells (this is more common in premature babies and some twins)
  • Infection
  • Enzyme deficiency (a lack of certain important proteins)

Prevention and treatment:

When determining treatment, several factors need to be considered: the baby's total bilirubin level, how fast the level has been rising, whether the baby was born early (premature babies are more likely to be treated at lower levels), and how old the baby is now. Most cases of physiologic jaundice resolve without the need for phototherapy.

There are several suggestions for treating normal jaundice:

Feed your baby early and often (up to 12 times a day). The average newborn nurses every 1.5 - 3 hours. This includes longer feeds and shorter nursing snacks. Besides weight gain, your baby's wet diapers and bowel movements are the best indication of how much milk they are taking in. Remember that colostrum (the sticky yellow fluid that comes out of the breast before milk "comes in") is not only perfect for a newborns' sensitive digestion and the provision of important antibodies, but acts as a natural laxative too. Frequent stooling helps to lower bilirubin levels. By the time your baby is 4 - 5 days old, he or she should be having "milk stools", which are yellowish in colour. Your baby should have 2 - 5 substantial bowel movements in a 24-hour period and many newborns pass stool after every feed for the first few weeks of life. If your baby is stooling less, it may mean that he or she is not getting enough milk.

Avoid water supplements. Interrupting breastfeeding and/ or giving glucose feedings seems to increase rather than decrease bilirubin levels, and can also interfere with the establishment of lactation. 98% of bilirubin is excreted in the stools and only 2% in the urine. Colostrum and milk contain fat, which stimulates bowel movements. In contrast, water just fills your baby up so that he or she is less interested in nursing. During your baby's first few days, he or she may only wet once or twice a day, due to a small intake of colostrum. Once your milk comes in, the average baby wets between 6-8 times in a 24-hour period. The urine should be pale, colourless and mild smelling. Dark, concentrated urine can mean that your baby is not getting enough milk.

Encourage your baby to stay awake and feed regularly. Jaundice has a tendency to make your baby sleepy, especially if he or she is "under the lights".

Supplement feeds with your expressed milk. If your baby is sleepy and lethargic at the breast and is having fewer than 3 substantial bowel movements in a 24-hour period, consider expressing your milk after feeds and giving it to him or her; using a syringe, cup or tube-feeding device if possible.

Expose your baby to indirect sunlight. Remember that your baby's skin is very sensitive and cannot be in direct contact with the sun. Place your baby in their diaper, in a room that gets a lot of light.

Certain medications make it more difficult for the baby's body to remove bilirubin and may lead to more severe jaundice. Avoid medications with aspirin and sulfa drugs. Make your doctor aware of all medications you are taking, so that you can discontinue or find substitutes for those that may be problematic.

Some infants need to be treated before they leave the hospital. Others may need to go back to the hospital when they are a few days old. Treatment usually lasts 1-2 days. Phototherapy is used on infants whose bilirubin levels are very high. This involves the use of fluorescent lights (often called bililights) that help break down bilirubin in the skin. The infant is placed under these artificial lights in a warm, enclosed bed to ensure temperature constancy. The baby will only wear a nappy and their eyes are covered to protect them from the light. They are given extra fluids to compensate for the increased water loss through the skin, and may be restricted to the nursery except for feedings. It is recommended that breastfeeding continue during phototherapy.

If your baby's bilirubin levels are not excessively high or are not rising too quickly, it may be possible to do phototherapy at home. This involves the use of a fibre-optic blanket, which has tiny bright lights inside or a bed that shines light up from the mattress. A nurse will help you use the bed or blanket, and check up on your child at home. This needs to be done on a daily basis, with the careful monitoring of your child's weight, feedings, skin and bilirubin levels. You will be asked to count the number of wet and dirty nappies.

In the most severe cases, an exchange transfusion may be required. During this procedure, the baby's blood is replaced with fresh blood. Intravenous immunoglobulin may also be very effective in reducing bilirubin levels.

Monitoring jaundice:

A health provider should see all babies in the first 5 days of life, to check for signs of jaundice. Babies, who go home within 24 hours of birth, should be seen by 72 hours. Infants sent home after 48 hours, should be seen again at age 96 hours. Infants, who leave the hospital after 72 hours, should be scheduled for at least one follow-up visit during the first week of life. Through careful monitoring most complications can be prevented.

Complications:

Rare but serious complications can result from high bilirubin levels. They include cerebral palsy, deafness and kernicterus (brain damage from excessive bilirubin levels).

Call your health care provider if:
  • The jaundice is severe and your baby appears to be bright yellow.
  • The jaundice continues to increase after the newborn visit, persists for longer than 2 weeks, or other symptoms appear.
  • Other symptoms may include irritability, sluggishness and a high-pitched cry.
  • The feet, especially the soles are yellow.

Prognosis:

Physiologic jaundice is a common and generally harmless condition with no adverse after affects, provided that bilirubin does not reach dangerous levels. It usually takes a newborn's liver a week or two to mature enough to handle the build-up of bilirubin in the blood.

References:

Murkoff H, Eisenberg A, Hathaway S. What to expect the first year. London: Simon & Schuster; 1997.

http://www.breastfeedingbasics.com/articles/jaundice-in-the-breastfed-baby .

PubMed Health. Newborn Jaundice. A.D.A.M. Medical Encyclopedia. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002526/ . Reviewed November 13, 2011. Accessed April 25, 2013.

WebMD: Children's Health. Types of Jaundice in Newborns. Healthwise. http://children.webmd.com/types-of-jaundice-in-newborns . Revised May 10, 2010. Accessed April 27, 2013.