Jaundice in Newborn

Dr. Amit Nigade, Dr R. Kishore Kumar
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Introduction
Jaundice in newborns is yellowish discolouration of the skin and eyes due to accumulation of bilirubin in these tissues. Almost all neonates (Approximately 60 % term and 80 % preterm infants) presents with Jaundice in first week of life. If bilirubin levels remain high, infants are at risk of bilirubin-induced neurological dysfunctionBilirubin is produced from breakdown of heme proteins. Afterwards it is transported to liver with the help of albumin. In liver it undergoes conjugation to form water soluble forms which are excreted through urine and stools.
Physiological Jaundice appears from 24 to 72 hours of age and peaks by 4 to 5 days in term neonates and later in preterm neonates. It disappears by 10 – 14 days and attributed to physiological immaturity.
Pathological Jaundice appears within 24 hours of birth and rate of rise of bilirubin is more than 0.2 mg/dl/hr and exceeding 15 mg/dl.
Factors which are responsible for increases in Neonatal jaundice are increase production of bilirubin, ineffective hepatic uptake, deficient conjugation of bilirubin and increased enterohepatic conjugation.
The cause of increase in production of bilirubin could be hemolytic as well as non-hemolytic.

Table 1
Hemolytic Causes Other causes
1. Immune Mediated hemolysis - Rh, ABO and other minor blood group incompatibilities 2. Red Cell membrane defects - Hereditary Spherocytosis, Elliptocytosis etc 3. Red cell enzyme deficiencies - G6PD deficiency, Pyruvate kinase deficiency etc 4. Hemoglobinopathies - Alpha and Beta thalassemia Sepsis, DIC, Extravascular blood (hematomas like cephalohematoma), polycythaemia, IDM babies
Increased enterohepatic circulation in breast milk jaundice, pyloric stenosis and obstruction and ileus of intestine


The common reason of decreased or impaired conjugation is seen in physiological hyperbilirubinemia, preterms, breast feeding Jaundice and hypothyroidism. Rare syndromes like Criggler-Najjar type 1 and 2, Gilbert Syndrome also cause decreased clearance.The common reason of decreased or impaired conjugation is seen in physiological hyperbilirubinemia, preterms, breast feeding Jaundice and hypothyroidism. Rare syndromes like Criggler-Najjar type 1 and 2, Gilbert Syndrome also cause decreased clearance.1. Transcutaneous bilirubin measurement – It works on principle of multi wavelength spectral reflectance from Yellow Skin colour.

2. Point of care testing analysers - POCT analysers are now widely used in NICU for bilirubin measurements in addition to blood gas and electrolytes using spectrophotometry.

3. Serum Bilirubin measurements – Mainly Diazo dye binding, spectrophotometry, or oxidation by bilirubin oxidase or by potassium ferricyanide methods are used for the bilirubin measurements.

4. End Tidal Carbon monoxide estimation – Carbon monoxide is produced in equimolar concentration when hemoglobin is oxidized. Its measurement in breath is alternative means of detecting jaundice.

5. Other tests – depending upon aetiology of the Jaundice relevant tests can be done.1. Phototherapy – Phototherapy has become standard of care for unconjugated Jaundice in infants. It acts by configurational isomerization, structural isomerization and photooxidation. It involves exposing naked infant to blue, cool white or green light of wavelength 450 – 460 nm. The number of devices that can be used to give phototherapy are halogen spotlight, florescent tubes (Mainly CFL), fibreoptic blankets and gallium light emitting diodes (LED) phototherapy.

Several guidelines have been developed for initiating phototherapy like AAP Subcommittee of hyperbilirubinemia management and NICE guidelines. People in remote areas can use various apps to decide whether phototherapy is required or not ex: Bili app. However there are no evidence based guidelines for starting phototherapy in preterm infants, reference books provide tables depending upon expert opinion.

Phototherapy can be stopped when serum bilirubin levels falls below 2 mg/dl below threshold level. Rebound level of bilirubin or early follow up is needed in case of prematurity, DCT positive cases and treatment started within 72 hours.

An inability to see decline in bilirubin of 1-2 mg/dl after 4 – 6 hours and/or keep bilirubin below the exchange transfusion level is failure of phototherapy.

Universal screening before discharge either with TsB or TcB for prediction of severe bilirubinemia in infants is recommended by experts. Hour specific nomogram with clinical risk factors provide guidance for subsequent follow ups.


2. Exchange transfusion - Exchange transfusion is used for avoiding bilirubin toxicity when other therapeutic modalities have failed or not sufficient. In this procedure infants blood is replaced by fresh whole blood in equal portions. Bilirubin is potential neurotoxin; free bilirubin can enter brain and cause apoptosis and necrosis of cells. Bilirubin induced neurologic dysfunction is divided into acute and chronic forms (kernicterus). Acute BIND progresses through three stages early, intermediate, and advanced. Acute BIND can be reversible if treated promptly or it may lead to chronic permanent neurological dysfunction (kernicterus). Kernicterus is yellowish staining of brain stem nuclei and cerebellum. It develops within first year of age. It leads to choreoathetoid cerebral palsy, sensorineural hearing loss, upward gaze abnormalities and dental enamel hypoplasia.

References
Jaundice in Newborn Jaundice in Newborn 09/02/2020
Jaundice In Newborn - Patient Education >>
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