Bilirubin is a chemical compound (yellow in color) present in the blood that is responsible for breaking down “heme”. In some newborns, there is increased production of bilirubin which gets accumulated causing neonatal jaundice. Various factors like health, premature birth, postnatal age and TSB value determines increased secretion of bilirubin in babies. Risk of neonatal jaundice depends on the gestational age and total serum bilirubin levels in the blood. Jaundice causes yellow coloration of the skin and eyes. Treatment for neonatal jaundice includes exchange transfusion of blood and phototherapy depending on the health of the infant.
Level Of Bilirubin :
The symptoms of jaundice become visible with increasing levels of serum bilirubin. If the level of bilirubin is 2-3 mg/dL then discoloration can be seen on the sclera and if he levels ranges from 4-5 mg/dL face of the baby gets yellowish. With more and more volumes of bilirubin level is increased in blood head to foot discoloration can be seen in babies. It can affect the umbilicus if the levels are more than 15 mg/dL and even on the feet if it is more than 20 mg/dL.
Increased level of bilirubin in blood is known as hyperbilirubinemia and it can cause various complications. This condition can become evident in the first week of infants. In severe cases it can lead to kernicterus causing brain damage.
Hemoglobin present in the blood gets broken down destroying old blood cells and producing new ones. In this process bilirubin is secreted in two forms known as unconjugated bilirubin and conjugated one. Unconjugated form of bilirubin is the compound that binds the albumin for sending it to the liver for absorption. And the conjugated bilirubin is stored in the duodenum and lastly flushed out during excretion process. The unconjugated form of bilirubin is recycled into the blood for further re-absorption.
Neonatal jaundice occurs when there is disruption in the metabolism of bilirubin either due to increased accumulation of conjugated bilirubin or reduction in the liver uptake of unconjugated form.
Neonatal Jaundice Causes :
- Several factors can cause neonatal jaundice. It occurs due to increased production of bilirubin or due to reduction of uptake of bilirubin by the liver or decreased conjugation process. In some cases the stored-up molecules of conjugated bilirubin does not get excreted properly thereby accumulating loads of bilirubin in the body.
- Any problem or dysfunction of liver can lead to cholestasis or neonatal heptatitis.
- Hyperbilirubinemia (increased amounts of bilirubin) can occur in many newborns due to shorter life of freshly produced RBC. Within couple of days, level of bilirubin can increase drastically and often this occurs during the first week of birth. It would resume normal levels after 1-2 weeks.
- Jaundice can occur in breastfed babies during the first week of birth due to increase in enterohepatic circulation. Some infants would consume reduced quantity of milk leading to low calorie intake and dehydration. This can cause reduction in the volumes of intestinal bacteria resulting in the bilirubin accumulation leading to neonatal jaundice.
- In some infants, intake of breast milk can also cause jaundice. Breast milk contains added quantities of Beta glucuronidase which can trigger deconjugation of bilirubin and this can occur within 2 weeks of birth.
- Neonatal jaundice can develop when the total serum bilirubin levels is more than 5 mg/dL. Babies born with hypothyroidism or sepsis can develop jaundice within 1-2 weeks of birth.
- Presence of sickle cell anemia in the newborns or presence of abnormal cell shape can cause neonatal jaundice.
- If there is blood mismatch between the baby and the mother or if there is Rh incompatibility it can cause jaundice.
- Reduction in the level of important proteins or absence of certain enzymes can also cause baby jaundice.
- The risk of neonatal jaundice is high if the mother is taking specific medications during the term of pregnancy.
- Birth infections like syphilis or rubella can increase the level of bilirubin causing jaundice.
Parents should consult their pediatrician if any of the following symptoms are observed in newborns. Poor feeding, vomiting immediately after feeding, sluggishness, mild to moderate fever, repeated crying, and problems in breathing. It is not necessary that the skin color would change to yellow in all the infants that develop jaundice.
- The doctor would first complete physical examination of the affected infant paying close attention to skin discoloration. He would check for signs of hemolytic anemia. Further he would gather information of maternal diabetes or history of family jaundice.
- He would check for signs of irritability or lethargy and also identify symptoms of sepsis. The abdomen of the infant is examined for distension or fluid accumulation. Blood culture can be done to check the levels of bilirubin. TSB levels higher than 5 mg/dL/day indicate neonatal jaundice.
- In addition to the above, the doctor may request for CBC, Coombs test and Reticulocyte count test.
Neonatal Jaundice Treatment :
Phototherapy is the standard treatment given for neonatal jaundice. In this therapy, fluorescent light of 425-475 nm wavelengths is directly passed into the baby’s body under controlled settings. Light therapy would effectively isomerize the unconjugated form of bilirubin into water soluble molecule which can be excreted by the kidney. By this method excess of bilirubin can be flushed off the body thus preventing kernicterus. Phototherapy is the best option for neonates born before full gestation period to reduce unconjugated bilirubin from the body.
Exchange transfusion is another method for removing excess of bilirubin for hyperbilirubinemia cases. This method is often preferred for infants with low immunity. Blood sample is taken from the affected infant and is replaced with donor RBC that does not possess the RBC membrane or antigen molecule that is binding the antibodies. If the newborn is sensitive to AB antigens, doctors may use O blood group and Rh negative factor blood can be used in case the new baby is sensitized to Rh antigen. But before proceeding with exchange transfusion, the doctor would check for the levels of unconjugated bilirubin of the baby.
Frequent feeding of the baby is very much essential for affected infants. Similarly frequent bowel movement is to be encouraged for such babies. Phototherapy session for the infant can be easily carried out using a special fiberoptic blanket that is embedded with tiny lights. The baby’s number of feeds, his weight and skin discoloration should be monitored. And the parent should keep watch of the number of bowel movements each day and report it to the doctor.
Often, the outlook for neonatal jaundice is good. Even without treatment many infants would outgrow the symptoms during the second week. However infants with high levels of bilirubin should be treated quickly to prevent kernicterus.
Tips For Prevention :
- You need to closely observe the baby shortly after the birth and look for signs of skin discoloration and poor feeding.
- Mothers should increase feeding frequently (8-13 times a day) to reduce the risk of jaundice.
- Pregnant women can undergo clinical tests to find out the blood type. And women with Rh negative factor should be monitored for antibodies level of the infant.
- Blood sample of the baby is to be collected and tested for bilirubin level in the first day.