Clinical jaundice occurs in 2/3 of all newborn babies (60% of term infant and 80% of preterm infants) during the 1st week of life. Defined as the yellow coloration of skin and sclera due to increased serum bilirubin concentration and evident when the level exceeds 50 µ mol/L or 3mg/dl. Bilirubin consists of conjugated and unconjugated bilirubin and it is abnormal to have conjugated bilirubin accounting for more than 15% of the total serum bilirubin.
At birth, a baby's liver is still developing its ability to process bilirubin. Therefore, bilirubin levels are a little high at birth and jaundice is present to some degree in almost all newborns. As red blood cells break down, your body builds new cells to replace them. The old ones are processed by the liver. If the liver cannot handle the blood cells as they break down, bilirubin builds up in the body and your skin may look yellow.
It is evident on the skin of the face, in the naso-labial folds, and on the tip of the nose. The sclera will also he icteric hut neonates keep their eyes lightly closed. It is essential that all newborn babies are examined in conditions of adequate day light to exclude jaundice. Excessive hyperbilirubinemia can lead to permanent brain damage (i.e., kernicterus).
In majority of cases jaundice is physiological, appears on the 3rd day, disappears on the 7th day, and serum bilirubin seldom exceeds 170 mol.
Jaundice in a newborn is rarely caused by a serious illness. However, possible disorders that can cause jaundice in a baby .There are three types of jaundice- hemolytic, hepatocellular and obstructive. The causes are follows:
i) Hemolytic jaundice: Rh & ABO incompatibilities, Hereditary sperocytosis, Thalassemia, Sickle cell anemia, Glucose-6-PD deficiency
ii) Hepatocellular jaundice: Acute hepatitis,Chronic hepatitis, Cirrhosis,Toxic injury of the liver by hepatotoxic drugs-INH, rifampicin, etc.
iii) Obstructive jaundice:
a) Intrahepatic: Viral hepatitis, Fatty liver,
b) Chemical or drug induced.
c) Biliary chirrhosis: Cystic fibrosis, Dubin-Johnson syndrome, Sex hormone, Estrogen, anabolic steroids.
d) Extrahepatic: Biliary atresia, Chledochal cyst, Gall stone, Blockage of ampulla of Vater by Ascaris lumbricoides(AL) or growth in the head of pancreas
Treatment and Safety of sunlight exposure:
Most jaundice requires no treatment. When treatment is necessary, placing your baby under special lights while he or she is undressed will lower the bilirubin level. Depending on your baby’s bilirubin level, this can be done in the hospital or at home. Jaundice is treated at levels that are much lower than those at which brain damage is a concern. Treatment can prevent the harmful effects of jaundice.
Putting your baby in sunlight is not recommended as a safe way of treating jaundice. Exposing your baby to sunlight might help lower the bilirubin level, but this will only work if the baby is completely undressed. This cannot be done safely inside your home because your baby will get cold, and newborns should never be put in direct sunlight outside because they might get sunburned.
During phototherapy, the treatment of choice for jaundice, babies are placed under blue lights (bili lights) that convert the bilirubin into compounds that can be eliminated from the body.
But recent study shown that children who received light therapy (phototherapy) for jaundice as infants appear to have an increased risk of developing skin moles in childhood, according to a report in the issue of Archives of Dermatology, one of the JAMA/Archives journals. Some types of moles are risk factors for developing the skin cancer melanoma.
It is noted that there is no significant difference in the duration of phototherapy or need for additional phototherapy when comparing fiberoptic and conventional phototherapy in the treatment of hyperbilirubinemia in premature infants ;study shown.
Is breast feeding ok?
Breast-fed babies have a higher risk of jaundice, but for most newborns the risk is slight and is far outweighed by the benefits of breast-feeding. In addition, if a mother's milk is slow to let down, her baby may not gain weight as readily, which makes jaundice more pronounced. A slow start to breast-feeding may also lead to some dehydration in the baby, which may raise the bilirubin level.
More frequent feedings of breast milk or formula to help infants pass the bilirubin in their stools may also be recommended.
Breast-feeding more than the daily usual of eight to 10 times, which will encourage your baby to have more bowel movements, might reduce the risk. Breast-milk-related jaundice normally appears four to seven days after birth and may last for several weeks.
Colostrum, the "first milk," helps your baby pass these stools. The sooner you put your baby to the breast, the quicker colostrum gets into her system. Colostrum acts like a laxative and helps push the meconium (meconium, a tarry substance made up of all her bowels have accumulated during nine months in the womb) out of your baby's bowels. Your baby will have these stools until your milk comes in — so the sooner and more frequently you breastfeed, the quicker the meconium clears from her system.
Since meconium buildup can cause jaundice, it's important to breastfeed at least ten to 12 times in 24 hours to clear it out of your baby's system.
Study confirms and stated that although breastfeeding per se does not seem related to the increased frequency of neonatal jaundice but to the higher bilirubin level in a very small subpopulation of infants with jaundice. In fact, in the breastfed infants, there is a small subpopulation with higher serum bilirubin levels. These infants, when starved and/or dehydrated, could probably be at high risk of bilirubin encephalopathy.
Guidelines for physicians :
These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 35 or more weeks of gestation. In every infant, we recommend that clinicians should:
1) promote and support successful breastfeeding;
2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia;
3) provide early and focused follow-up based on the risk assessment; and
4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus).
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