Dr Beatrice Ezenwa is a Senior Lecturer and consultant neonatologist with the College of Medicine, University of Lagos. She talks about the dangers of neonatal jaundice
What is neonatal jaundice?
Jaundice is the yellowish discolouration of the sclera (of the eyes), skin and mucous membranes due to the deposition of bilirubin pigment. Bilirubin is produced when the red blood cells, which carry oxygen in the body, are broken down.
How common is neonatal jaundice?
Neonatal jaundice is very common in the newborn period and it affects both term and preterm infants. About 60 per cent of all term newborns and 80 per cent of preterm newborns are jaundiced in the first week of life.
What causes jaundice?
Jaundice is caused by excess bilirubin in the blood (hyperbilirubinaemia) which then gets deposited in the tissues. When it occurs in the newborn period, it is called neonatal jaundice or neonatal hyperbilirubinaemia. Neonatal jaundice is the most common problem encountered in the newborn. There are two types of bilirubin: Conjugated and unconjugated bilirubin.
Conjugated bilirubin (direct-reacting) is bilirubin that has undergone conjugation in the liver cell by the enzyme uridine diphosphoglucuronic acid (UDP)–glucuronyl transferase to form the polar, water-soluble glucuronide of bilirubin. It is much less common than unconjugated jaundice in the newborn. Its presence indicates a much more serious liver pathology or systemic illness.
Unconjugated bilirubin (indirect-reacting) is the end product of red blood cell heme-protein breakdown from a series of enzymatic reactions in the reticuloendothelial cells of the liver. It is the commonest form of jaundice in the newborn and, when elevated, can pass through the blood-brain barrier and cause brain damage. This damage can occur only in the newborn period.
How is jaundice classified?
Neonatal jaundice can be classified based on the nature of the bilirubin, whether it is conjugated or unconjugated. Conjugated jaundice is further divided into those caused by problems in the liver and those caused by problems outside the liver.
For the unconjugated hyperbilirubinaemia, it is further classified as physiologic or pathologic jaundice. Pathologic jaundice is sub-classified again into haemolytic and non-haemolytic jaundice. Each of these types of jaundice are caused by different pathologies and may be managed differently.
Are there risk factors for neonatal jaundice?
Yes. There are many risk factors for neonatal jaundice. The commonest risk factors for developing newborn jaundice include prematurity, neonatal sepsis, babies whose blood type isn’t compatible with the blood type of their mothers, babies who aren’t getting enough breast milk or feeds, those with liver problems and enzyme deficiencies (e.g G6PD deficiency), those with abnormality of red blood cells, bowel obstruction, bruises and trauma and infants of diabetic mothers among others.
In Nigeria, neonatal jaundice is seen most in four categories of newborns. These are infants born preterm, infants with blood group incompatibility to that of their mothers, infants with infections and those with Glucose 6 Phosphate Dehydrogenase deficiencies.
Why is jaundice common in newborn babies?
Jaundice is common in newborn babies because babies have a higher number of red blood cells in their blood, which are broken down and replaced frequently. While in the womb, babies are exposed to relative hypoxia (lack of oxygen). This makes them produce more red blood cells to help collect more oxygen from the mother. At birth, they are exposed to high ambient oxygen and the excess red blood cells they accumulated in the womb are no longer needed, so they begin to break down and release bilirubin.
Usually the liver removes the bilirubin from our blood stream, but a newborn baby’s liver is not fully developed, so it is less effective at removing the bilirubin from the blood. The result is the accumulation of bilirubin in the blood which is seen as jaundice.
What are the symptoms of jaundice?
Yellowness of the skin and the whites of the eyes are the main symptoms of neonatal jaundice. This usually appears within the first few days of birth and can be checked by looking at the sclera or by blanching the skin of the infant. When jaundice becomes severe, other symptoms such as poor feeding, decreased stooling or urination, excessive weight loss, and poor sucking starts to appear.
The early or acute neurological manifestations of neonatal jaundice (such as poor suck, lethargy, seizures) seen in the first few days or weeks of life is termed ‘Acute Bilirubin Encephalopathy’ while the chronic or permanent clinical manifestation of bilirubin toxicity, such as abnormal posturing, choreo-athetoid cerebral palsy, is called ‘Kernicterus’.
How is jaundice diagnosed?
Jaundice is diagnosed by both examination and by laboratory investigations. Jaundice in the newborn can be physiologic or pathologic.
In physiologic jaundice, it is a diagnosis of exclusion. The jaundice becomes visible on the second or third day, usually peaking between the fourth to fifth day in term and seventh day in preterm infants and clearing before the fourteenth day of life. The serum bilirubin does not rise above 15mg/dl in a term infant.
Pathologic jaundice can appear within 24 hours of birth. The serum bilirubin is usually >12mg/dl and rises faster than 5mg/dl in 24 hours. It can also persist after two weeks of life.
How is jaundice treated?
There are different ways jaundice can be treated, depending on its severity and causes. Physiologic jaundice is usually self-limiting and requires no treatment. However, it is difficult to determine which jaundice is physiologic at the onset.
Pathologic jaundice is treated with phototherapy as the first line of management. Very severe jaundice may require exchange blood transfusion. Optimal treatment requires that the cause of the jaundice should also be treated, if known. For example, if the cause was determined to be bacterial sepsis, it should be treated with appropriate antibiotics in addition to the phototherapy.
Is it true that traditional herbs can cure jaundice?
There is no place for pawpaw water, herbal concoctions, Mentholatum (ointment) and other traditional remedies as well as sun exposure in the treatment of severe and pathologic jaundice, rather they cause more harm and complications for the infant. In places where sunlight is employed as a mode of treatment, filtered sunlight is used and this is done with the aid of a special equipment. Exposing the newborn under direct sunlight, as practised by some mothers, exposes these infants to the risk of sunburn, dehydration and other severe skin diseases without effectively reducing the offending bilirubin. Some medications and herbal concoctions given to treat jaundice by some mothers also worsen the case, as they put more stress on a liver that was already stressed and struggling to eliminate excess bilirubin.
Is formula milk good for treating neonatal jaundice?
Formula is not specifically indicated for neonatal jaundice. However, one of the risk factors for neonatal jaundice is inadequate intake of feed leading to dehydration and increased entero-hepatic circulation of bilirubin and decreased production and elimination of stercobilinogen in the stool. So, a baby who is not adequately being fed breast milk or where breast milk is not available can be given formula milk to prevent this type of jaundice called breastfeeding jaundice. As the name suggests, adequate breastfeeding prevents and treats this jaundice.
How serious is neonatal jaundice?
Neonatal jaundice is the commonest neonatal emergency seen in hospitals. Severe neonatal jaundice is a preventable cause of neonatal morbidity, mortality and long-term neuro-developmental abnormality. It is a major cause of cerebral palsy. Jaundice is toxic to the developing brain and it is only in the newborn that it can cause permanent damage to the brain. Once the yellow pigment (bilirubin) crosses the blood-brain barrier, it stains the brain tissue and permanently damages the neurons. If jaundice is noticed early and appropriate treatment isgiven, this damage can be avoided. This is why it is very important that jaundice is recognised early and treated.
What happens if jaundice is untreated?
Pathologic jaundice should always be treated. A severe neonatal jaundice can cause debilitating and permanent neurological sequelae such as cerebral palsy and even death in the affected child. This is, however, a preventable calamity in the newborn.
Are there signs that a baby with jaundice needs emergency care?
Jaundice is a neonatal emergency that should not be toyed with. If jaundice is noticed in a child, he/she should be taken to a hospital for appropriate review and management. As mentioned earlier, you cannot determine a harmless jaundice the first time it is seen. Until it clears without meeting any of the criteria for pathologic jaundice, you cannot say for sure. There are some signs and symptoms which may indicate severe jaundice requiring emergency care. These include jaundice seen on the skin of the abdomen and below, poor suck, weak and shrill cry, fever, unresponsiveness, etc.
How long does it take for jaundice to go away?
It depends on the type of jaundice and the causative factor and also the effectiveness of the treatment given. Both physiologic and well-treated neonatal jaundice may clear within two weeks of life. Prolonged jaundice is a jaundice that lasts more than two weeks. And it has numerous causative factors too such as hypothyroidism, breast milk jaundice, galactosaemia, prematurity, and Down’s syndrome.
Is there anything that can be done to prevent neonatal jaundice in the pregnancy stage?
There are some things that can be done during pregnancy to minimise newborn jaundice even if it cannot be totally prevented. These include checking the blood type of all pregnant women to rule out the possibility of blood group and rhesus incompatibilities that can lead to newborn jaundice, prevent maternal infections and adequately manage maternal chronic illnesses during pregnancy, such as maternal diabetes, which can cause excessive red cell production in the foetus.
What can be done to nurse a jaundiced baby who is a poor feeder?
A jaundiced baby who was feeding normally before and now feeds poorly may be an indication that the jaundice has worsened and the baby is very ill. The baby should be taken to hospital immediately so that treatment can be commenced for the jaundice. It is an emergency.