Neonatal Jaundice

The most frequent risk factors for neonatal jaundice include ABO incompatibility, Rh incompatibility, and G6PD deficiency. Other contributing factors include:

• Maternal diabetes
• Maternal race
• Premature birth
• Maternal height
• Polycythemia (a form of blood cancer)
• Male gender of the newborn
• Cephalohematoma (a blood clot between the skull and scalp)
• Medications such as sulfa drugs, penicillin, and ceftriaxone
• Trisomy 21 (also known as Down syndrome)
• Weight loss during pregnancy
• Breastfeeding

Jaundice is primarily identified through visual examination of the newborn's skin and eyes. However, bilirubin levels must be measured to assess the severity of the condition and determine the appropriate course of treatment. The following methods are used for diagnosis:

Clinical Physical Examination

A visual assessment of bilirubin-induced skin discoloration can serve as an initial guide to estimate the level of jaundice. This examination follows a cephalo-caudal pattern (from head to toe). During the physical examination, the healthcare provider should:

• Inspect the baby in natural daylight.
• Apply gentle pressure on the skin with their fingers to blanch the skin and observe the underlying tissue color.
• If the baby exhibits yellow discoloration beyond the thighs, a laboratory confirmation of bilirubin levels is necessary.

Note: Clinical assessment may be unreliable in newborns with darker skin tones or those receiving phototherapy.

Laboratory Tests

Bilirubin levels can be measured through the following methods:

• Biochemical testing: The van den Bergh reaction is the gold-standard laboratory test for bilirubin estimation. This chemical test detects both total and conjugated bilirubin levels.
• Bilimeter: This device uses spectrophotometry to evaluate the total bilirubin concentration in the serum. Since unconjugated bilirubin is the predominant form in neonates, this method is particularly effective for newborns.
• Transcutaneous bilirubinometer: This non-invasive tool measures bilirubin levels by detecting skin pigmentation. However, its accuracy may vary based on skin color and thickness.

Clinical Approach

The initial evaluation for neonatal jaundice involves determining whether it is physiological or pathological. The diagnostic process includes:

• Prematurity considerations: Preterm infants require special evaluation based on their degree of prematurity and birth weight.
• Hemolysis indicators: The presence of hemolytic jaundice is suspected if:
• Jaundice appears within the first 24 hours of life.
• The infant shows pallor (pale skin) or hydrops fetalis (severe swelling).
• The baby has hepatosplenomegaly (enlarged liver and spleen).
• A blood smear reveals hemolysis (destruction of red blood cells).
• The reticulocyte count exceeds 8%.
• Bilirubin levels rise rapidly (more than 5 mg/dL in 24 hours or 0.5 mg/dL per hour).
• There is a family history of hemolytic conditions.

Although neonatal jaundice cannot always be prevented, certain measures can help reduce its occurrence and severity. These include:

• Awareness programs: Government and public health organizations should conduct seminars, workshops, and training sessions for mothers to increase awareness of neonatal jaundice.
• Research and innovation: Scientists should focus on developing safer and more effective treatments with minimal side effects.
• Blood group screening: Couples should be encouraged to screen for ABO and Rh compatibility before marriage.
• Avoiding consanguineous marriages: Marriages between close relatives should be discouraged to reduce the risk of genetic conditions linked to jaundice.
• Postnatal blood testing: After delivery, newborns should undergo blood testing to identify blood group incompatibilities.

If jaundice is present, certain steps can prevent it from worsening:

• Adequate feeding: Ensuring the baby is fed adequately with breast milk helps eliminate bilirubin through the stool.
• Frequent feedings: Newborns should be fed 8 to 12 times per day during the first few days to help clear bilirubin from the body.
• Supplementing with formula: If the baby is not breastfed, they should be given 1 to 2 ounces of formula every 2 to 3 hours in the first week.
• Monitoring for symptoms: Babies should be closely observed for yellowing of the skin and eyes during the first five days of life.

Specialists to Consult

Although most cases of neonatal jaundice are mild and harmless, consultation with a pediatrician is necessary in certain situations. Parents should seek medical attention if:

• The jaundice spreads rapidly or becomes more severe.
• The baby’s skin or eye color darkens.
• The newborn develops a fever above 38°C (100°F).
• The baby has feeding difficulties, appears unusually sleepy or irritable, or cries with a high-pitched sound.

Treatment is typically only required for newborns with high bilirubin levels. Most cases resolve naturally within 10 to 14 days without causing harm. However, if bilirubin levels are significantly elevated, the following treatments may be used to reduce the risk of complications, such as kernicterus, a form of brain damage caused by excess bilirubin.

Phototherapy

Phototherapy uses special light (not sunlight) to help the baby’s liver break down and eliminate bilirubin more effectively. During the procedure:

• The baby is placed under the light in a cot or incubator, with their eyes covered.
• Breaks are given every 30 minutes for feeding, changing, and comforting the baby.
• If jaundice does not improve, intensive phototherapy may be used. This involves:
• Increasing the light intensity or using an additional light source, such as a light blanket.
• Continuous exposure without breaks during intensified phototherapy.
• The baby’s temperature is monitored regularly to prevent overheating.
• Intravenous (IV) fluids may be administered if the baby becomes dehydrated or is unable to consume enough milk.
• Bilirubin levels are measured every 4 to 6 hours initially, and once they stabilize, they are checked every 6 to 12 hours.
• Phototherapy is discontinued once bilirubin levels decrease to a safe range, which typically takes about 2 days.
• In mild cases, phototherapy can be performed at home using a "bili" blanket.

Exchange Transfusion

In cases of extremely high bilirubin levels or when phototherapy fails, an exchange transfusion may be necessary. This involves:

• Inserting a thin plastic tube into a blood vessel (umbilical cord, arm, or leg).
• Removing small amounts of the baby's blood and replacing it with donor blood of the same blood type, which has lower bilirubin levels.
• Continuous monitoring during the procedure to address complications, such as bleeding.
• Testing the baby’s blood within 2 hours after the transfusion to assess effectiveness.
• The transfusion may need to be repeated if bilirubin levels remain elevated.

Intravenous Immunoglobulin (IVIG)

If jaundice is due to Rh incompatibility, IVIG may be administered. This is typically considered when phototherapy alone fails to lower bilirubin levels.

Kasai Procedure (Hepatic Portoenterostomy)

Babies diagnosed with biliary atresia or Type IVb choledochal cyst may require a Kasai operation to restore bile drainage. For the best outcomes, this surgery should be performed within two months of birth.

Other Treatments

The management of conjugated hyperbilirubinemia depends on the underlying cause:

• Infection-related jaundice requires treatment of the infection itself.
• Metabolic cholestasis responds to correction of the primary disorder and improvement of liver function.
• PN-induced cholestasis is managed by reducing manganese and copper content in parenteral nutrition and initiating oral feeds as early as possible to minimize liver damage.

Severe jaundice in newborns can lead to serious complications, including:

Bilirubin-Induced Neurologic Dysfunction (BIND):

• This condition refers to the neurological effects of bilirubin toxicity, which may cause initial low muscle tone (hypotonia), followed by increased muscle stiffness (hypertonia), and spasms (opisthotonus) or repetitive neck contractions (retrocollis). BIND is classified into acute and chronic stages and occurs due to bilirubin binding to brain tissue, leading to neurotoxicity.

Acute Bilirubin Encephalopathy (ABE):

• ABE is a potentially life-threatening condition that can cause lasting neurological damage. Symptoms include lethargy, poor muscle tone, and weak sucking reflex. Early stages of ABE are reversible with prompt treatment.

Chronic Bilirubin Encephalopathy (Kernicterus):

• If ABE worsens, it may lead to kernicterus, an irreversible condition caused by bilirubin-induced brain damage. It is characterized by involuntary movements, cerebral palsy, seizures, abnormal posturing, vision issues, and hearing loss.

Neonatal Cholestasis:

• Infants with cholestasis face the risk of liver failure, cirrhosis, and in rare cases, liver cancer (hepatocellular carcinoma). Prolonged cholestasis may also lead to malnutrition, poor weight gain, and deficiencies in fat-soluble vitamins.

Phototherapy and exchange transfusion are the primary treatments for neonatal jaundice. However, some alternative therapies have shown promise in managing the condition:

Metalloporphyrins:

• These synthetic compounds inhibit heme oxygenase, the enzyme responsible for bilirubin production. Metalloporphyrins, such as tin-protoporphyrin (SnPP) and tin-mesoporphyrin (SnMP), are being explored for their potential to prevent and treat severe jaundice.

Natural Remedies:

• Magnesium: Research indicates that pregnant women taking 250 mg of magnesium daily for six weeks may reduce the risk of neonatal jaundice by lowering bilirubin production.
• Probiotics: Supplementing newborns with probiotics may help reduce bilirubin levels and alleviate jaundice symptoms by promoting bilirubin clearance.
• Barley Seed Flour: In some cultures, barley seed flour is applied to a baby's skin along with light exposure. This traditional remedy has been shown to reduce jaundice symptoms, as the barley flour acts as an antioxidant and helps lower bilirubin levels.

Neonatal jaundice is a common condition in newborns. Here are some tips for managing it at home:

• Stay in touch with the pediatrician: Regularly update the doctor about any changes in the baby’s condition. Contact the doctor immediately if the yellowish tint on the baby's skin intensifies.
• Ensure proper feeding: Keep the baby well-fed to help the body eliminate excess bilirubin.
• Follow feeding recommendations: Even if breastfeeding contributes to jaundice, continue nursing the baby as advised by the pediatrician. Breastfeeding should be done 8 to 12 times daily, while formula-fed babies should have at least 6 to 10 feedings each day.
• Sun exposure: Briefly expose the baby to indirect sunlight, as it can aid in breaking down bilirubin.
• Monitor symptoms: Watch for any rise in body temperature, loss of appetite, or unusual fussiness.
• Hydrate sufficiently: Ensure the baby remains properly hydrated.
• Prevent weight loss: Frequent feedings and supplementation, if necessary, can help avoid weight loss.

Neonatal jaundice, while concerning, is generally harmless and resolves on its own. To manage the condition effectively:

• Observe the baby closely: Watch for any yellowing of the skin or eyes.
• Provide sufficient nutrition: Ensure the baby is properly fed to prevent dehydration and aid in bilirubin clearance.
• Sunlight exposure: Briefly expose the baby to morning sunlight (between 7–9 AM) to help break down bilirubin.
• Frequent breastfeeding: Nurse the baby frequently to promote bilirubin elimination.
• Watch for warning signs: Be alert for signs of lethargy, irritability, or high-pitched crying, and consult the pediatrician if they appear.
• Keep the baby comfortable: Ensure the baby is hydrated, well-fed, and warm.
• Stay connected with the pediatrician: Regular checkups and monitoring are essential to track the baby's progress.