Jaundice in Newborn

• Jaundice is a yellow discoloration of the skin and/or whites of the eyes that is often seen in newborn infants.
• The discoloration is caused by a yellow substance called bilirubin.
• Jaundice is not a disease, but is a symptom of an elevated blood bilirubin level
• Jaundice is not painful, but serious complications can occur if elevated bilirubin levels are not treated in a timely manner.
• Jaundice is a marker used to identify those infants who may be at risk for developing severe hyperbilirubinemia.
• Severe hyperbilirubinemia can be toxic to the nervous system of infants, potentially causing brain damage.

Signs and Symptoms:

• Jaundice initially causes the skin to become yellowed. Later, the whites of the eyes may have a yellowish tinge. These changes may be hard to recognize in children with a dark skin color or if a baby is unable to open eyelids. The color change:
• Is noticeable in the face first, and may progress down the chest, abdomen, arms, and then finally the legs.
• Can be checked by pressing one finger on your baby's forehead or nose. If the skin is jaundiced, it will appear yellow when you release pressure from the skin.
• Can be tracked in some babies by pressing over the bony prominences of the chest, hips, and knees to check if the jaundice is progressing.
• Should be checked before your baby leaves the hospital. If your baby goes home sooner than 72 hours after birth, you will need to monitor the baby's skin color at home every day. In addition, your infant should see a doctor or nurse within one to three days after going home.

Worsening of Jaundice

• If the yellow coloring is at the knee or lower, or if the yellow color is more intense, lemon yellow to orange yellow
• If the baby has any difficulty in feeding
• If it is hard to wake up your infant
• If your infant is irritable and is difficult to console
• If your infant arches his/her neck or body backwards

Causes

‘Too early’ (< 24 hours of age)

• always pathological
• usually due to haemolysis, with excessive production of bilirubin
• babies can be born jaundiced due to:

hepatitis (unusual)

severe haemolysis

• causes of severe haemolysis (decreasing order of probability):

ABO incompatibility

Rh iso-immunisation

sepsis

• rarer causes:

other blood group incompatibilities

red cell enzyme defects eg G6PD deficiency

red cell membrane defects, eg, hereditary spherocytosis

‘Too high’ (24 hours -10 days of age)

• If the SBR concentration exceeds 200-250 micromol/L, over this time, various causes include:
• mild dehydration/insufficient milk supply (breastfeeding jaundice)
• breast milk jaundice
• haemolysis - continuing causes as discussed under ‘too early’
• breakdown of extravasated blood (eg cephalhaematoma, bruising, CNS haemorrhage, swallowed blood)
• polycythaemia (increased RBC mass)
• infection - a more likely cause during this time
• increased enterohepatic circulation (e.g. bowel obstruction)

‘Too Long’ (> 10 days of age, especially > 2 weeks)

• The major clue to diagnosis is whether the elevated bilirubin is mostly unconjugated (>85%) or whether the conjugated fraction is substantially increased (>15% of the total).
• breast milk jaundice (diagnosis of exclusion, cessation not necessary)
• continued poor milk intake
• haemolysis
• infection (especially urinary tract infection)
• hypothyroidism

References:

1. http://www.uptodate.com/contents/jaundice-in-newborn-infants-beyond-the-basics
2. http://www.health.vic.gov.au/neonatalhandbook/conditions/jaundice-in-neonates.htm