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Neonatal Jaundice Jaundice   occurring   in   the   newborn   is   referred   to   as   neonatal   jaundice.   It   is   quite common,   usually   harmless   and   resolves   in   two   weeks   ( physiological   jaundice ).   If   it is   severe   and   prolonged,   it   may   be   pathological,    requiring   further   investigations   to find the cause. It    is    characterised    by    yellowish    discolor ation    of    the    skin    and    eyes    due    to accumulation   of   a   toxic   pigment   called   bilirubin    in   the   blood.   Jaundice   per   se   is not a disease but a symptom that may signify an underlying disease. Approximately 60% of term babies and 80% of preterm babies  develop jaundice. Bilirubin Formation and Excretion One   of   the   important   sources   of   bilirubin   in   the   body   is   when   red   cells   are broken   down    due   to   aging   of   the   cells   when   they   are   replaced   by   new   red   cells   from the   bone   marrow.   The   bilirubin   from   red   cell   breakdown   is   processed   in   the   liver and excreted from the body . Physiological Jaundice The most common cause of neonatal jaundice is physiological jaundice. This occurs because newborns have more red cells than adults and hence more is broken down . Additionally the newborn liver is immature  and unable to handle the increased amounts of bilirubin being formed. This results in accumulation of bilirubin in the blood with symptoms of jaundice. The   physiological   jaundice   described   above   usually   presents   between   day   2   –   4    after   birth,   peaks   at   one   week   and   gradually resolves spontaneously in about two weeks . Pathological Jaundice In   some   cases   however,   jaundice   is   caused   due   to   some serious   underlying   disease   of   the   blood   or   liver.   This   is termed pathological jaundice. Pathological    jaundice    shows    many    of    the    following features It appears on the first day of life itself Bilirubin   levels   in   the   blood   may   be   very   high with severe jaundice Baby   is   ill   and   does   not   feed   well   and   appears irritable Jaundice    is    still    present    even    after    two    weeks (prolonged     jaundice);     the     baby     passes     pale chalky    appearing    stools    (due    to    absence    of bilirubin   in   the   stool)   and   dark   colored   urine   (due to increased bilirubin pigment) Enlarged     liver     and     spleen,     small     head     size (microcephaly)      seen      in      some      congenital infections It   is   important   to   recognise   and   treat   pathological   jaundice   in   the   neonate   promptly   because   high   bilirubin   levels   in   the bloodstream (hyperbilirubinemia) can result in deposition of bilurubin in the brain with serious consequences . Causes of Pathological Jaundice  ABO or Rh incompatibility between mother’s and baby’s blood group - (Increased Red cell destruction) Inherited disorders of the red cell - (Increased Red cell break down) Neonatal   infections    Toxoplasmosis,   rubella,   cytomegalovirus   (CMV),   herpes   simplex,   syphilis. These   are   referred   to   as TORCHS complex and should be ruled out Inherited disorders of bilirubin metabolism  – Criggler Najjar syndrome, Dubin Johnson syndrome, Gilbert syndrome Other uncommon causes include diseases of the biliary system eg biliary atresia and certain inherited metabolic diseases Risk factors of developing Neonatal jaundice Preterm or low birth weight babies Male babies East Asian ancestry Breastfed babies Sibling who had neonatal jaundice Babies born to diabetic mothers Populations living at high altitudes Diagnosing Neonatal Jaundice Neonatal    jaundice    is    usually    evident    on    physical    examination.    However,    it    may    be difficult   to   discern   on   darker   skin   and   when   there   is   an   index   of   suspicion,   a   blood   test is done to measure bilirubin levels . Some   centres   initially   measure   bilirubin   using   a   device   that   measures   bilirubin   levels through     the     skin     ( transcutaneous     screening ).     When     the     bilirubin     value     on transcutaneous   measurement   exceeds   a   certain   value   (250   micromol/L),   blood   testing may be done to measure bilirubin levels and confirm the diagnosis. Tests to determine the cause of pathological jaundice Once   the   diagnosis   of   pathological   neonatal   jaundice   is   established,   other   tests   may   be   required   to   determine   the   cause   of hyperbilirubinemia. Liver function tests  - to rule out primary liver disease Urine culture and sensitivity – to rule urinary tract infection (UTI) Neonatal infection screen  (TORCH screen) – It is mandatory to do a TORCH screen Tests to determine presence of increased fetal red cell break down and find the cause Thyroid function tests  – to test for congenital hypothyroidism Imaging studies  – ultrasound abdomen, specialized imaging to look for liver and biliary pathology Liver biopsy  – rarely, a liver biopsy may be needed if other tests prove non-diagnostic Treatment of   Neonatal jaundice Physiological   jaundice   presenting   a   few   days   after   birth   has   to   be   monitored   by   measuring   serum   bilirubin   regularly   and   if   it is not severe and gradually resolves over the next few days it may not need any treatment. Treatment of pathological neonatal jaundice depends on the following: Rate at which bilirubin levels are rising Presentation of jaundice within 24 hours of birth Whether baby is preterm: preterm babies are unable to tolerate high bilirubin levels well General condition of the baby The treatment modalities include the following Phototherapy Phototherapy   should   be   urgently   begun   if   bilirubin   levels   are   rapidly   rising   in the   baby.   It   involves   placing   the   baby   under   the   light   source   with   as   much   of   the skin exposed as possible (the eyes should be protected with pads). The    light    waves    are    absorbed    by    the    skin    and    convert    the    bilirubin    into    a harmless substance which is then excreted. Exchange transfusion In   exchange   transfusion,   a   part   of   the   baby’s   blood   is   removed   and   replaced   with matching blood   transfusion.   Bilirubin   levels   above   a   certain   threshold   level   necessitates exchange   transfusion.   This   is   essential   to   prevent   adverse   effects   of   bilirubin toxicity on the brain. Treatment of the cause   Antibiotics to treat UTI Thyroid replacement in congenital hypothyroidism Biliary system disease may require surgery within two months for a better outcome Lakshmi Venkataraman. MD This Topic is discussed in the “Forum” under Paediatrics listed as Neonatal Jaundice
Jaundice in the New Born
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