by Dr Zarina A Latiff, Hospital UKM
What is jaundice?
Jaundice is the yellow discolouration of the sclerae (whites of the eyes) and skin. It occurs in ˜60% of mature babies and 80% of premature babies during the first week of life. Jaundice is often apparent on the face first and as it increases in severity will progress downward i.e. from the abdomen towards the legs. Jaundice may be demonstrated by pressing lightly on the skin with a finger; the yellow colour is seen more easily in the ‘fingerprint’ area than in the surrounding skin. This examination should be done under either natural/fluorescent light as other light source/bulbs may emit a yellowish tinge, which will only cause confusion. There are 2 types of jaundice: unconjugated and conjugated of which the unconjugated type is more common in the newborn.
Why is my baby jaundiced?
Jaundice is due to the deposition, in the tissues, of a yellow pigment called bilirubin. When the bilirubin exceeds a certain level, jaundice becomes obvious to the observer. Bilirubin is the end product of breakdown of red blood cells. This unconjugated form of bilirubin is then processed by the liver to become the conjugated form. Conjugated bilirubin is further processed in the gut and finally excreted from the body via the stool. In healthy newborns, elevation of unconjugated bilirubin occurs commonly and is known as physiological jaundice. This occurs because:
- There is increased red blood cell (RBC) volume in newborns
- The life span of red blood cells (RBCs) is shorter in newborns as compared to adults
- The liver function is still immature
Physiological jaundice may occur from the 2nd day onwards and peaks by day 3 or 4 of life. Physiological jaundice, however, does not occur on the 1st day nor does it exceed beyond the 2nd week of life in mature babies (or 3rd week in premature babies). If the jaundice persists beyond this period or if the level of jaundice is severe, then your baby should be investigated for other underlying causes. These will include conditions in which there is increased rate of RBC breakdown; amongst the more common conditions include:
- G6PD deficiency (common amongst our population)
- Blood group incompatibility between mother and baby — Rhesus; ABO
- Abnormal red blood cell (RBC) shape — spherocytosis (rounded RBC); elliptocytosis (oval shaped RBC)
- Too much red blood cells
- Extravasated blood (bruises or blood clot) — e.g. cephalhaematoma (collection of blood below the membrane/layer which covers the skull bone) or subaponeurotic haemorrhage (collection of blood below the layer of muscle insertion). The blood within the swelling gets reabsorbed and broken into bilirubin, which subsequently causes jaundice. Both of these conditions are more likely to occur in babies delivered via forceps/vacuum extraction.
If all of the above conditions have been excluded and if it is unlikely that your baby has any other less common conditions (e.g. hypothyroidism — decrease in/absence of thyroid function; infection), there is a possibility that your baby has breast milk jaundice. In breast milk jaundice, the jaundice usually appears at the end of/after the first week of life and may persist up to several weeks or even months. Breast milk jaundice occurs as a result of ‘abnormal’ milk content, which inhibits the bilirubin conjugation activity. Interruption of breastfeeding for 1-2 days with substitution of formula for breast milk (in moderately severe jaundice) will usually result in a rapid decline in bilirubin level after which breastfeeding may be resumed. Provided there are no additional risk factors, babies who have either physiological or breast milk jaundice will remain well and recover completely. All of the problems mentioned so far cause unconjugated jaundice. On the other hand, there are also many causes of conjugated jaundice, the most important being biliary atresia. In biliary atresia, the jaundice is due to obstruction of the bile duct draining the liver. Such obstruction will make the stools look pale (like chalk) and the urine dark. This condition requires urgent investigation and should not be ignored.
Are there any serious effects of jaundice?
Yes, but this will depend on the type and severity of jaundice. Unconjugated bilirubin may penetrate into the brain cells. This occurs when the level of unconjugated bilirubin is very high. Hearing problems is one of the earlier effects detected but if the jaundice is allowed to progress without medical intervention, this will lead to progressive brain damage and at the extreme end, the baby may even be mentally retarded and die.
How is jaundice treated?
Upon admission, the doctor will first evaluate your baby. Appropriate blood tests will then be carried out. Depending on the bilirubin level, phototherapy is usually commenced. Additional intravenous fluid therapy may be required if your baby appears dehydrated and oral feeding is insufficient. Regular monitoring of bilirubin level will be done from time to time and the frequency depends on the severity of jaundice. These levels will be compared to standard charts (which takes birth weight, age and level of bilirubin into consideration) to decide whether phototherapy should be continued, discontinued or whether exchange transfusion is required. Monitoring of bilirubin level is also usually done 24 hours upon termination of phototherapy to ensure that there is no rebound or unexpected rise in bilirubin level again.
What is phototherapy and are there any side effects?
Bilirubin in the skin absorbs light energy maximally in the blue light range. Toxic unconjugated bilirubin is subsequently converted into an alternative non-toxic water soluble form which is readily excreted/removed from the body. Phototherapy should be applied continuously. The baby should be nurse naked to ensure maximal skin exposure and the infant should be turned regularly. The baby’s eyes should be covered to protect the eyes from the light source. Body temperature and hydrational status are also closely monitored. Complications of phototherapy though rare include loose stools, skin rashes, overheating and dehydration. Although retinal damage secondary to phototherapy has only been reported in animal studies, the eye shields are worn to prevent this possibility. Otherwise all these side effects are transient and there are no long-term side effects of phototherapy.
What about exchange transfusion?
Exchange transfusion is used when the bilirubin level is severely elevated or if it remains beyond 340mmol/L (in a term baby) despite effective and adequate phototherapy. Exchange transfusion helps to remove and reduce bilirubin from the baby to a lower acceptable level; it is important that consent to exchange transfusion be obtained quickly when needed as further delay will only increase the likelihood of possible brain damage. Exchange transfusion is usually done via a small catheter (tube) placed in the umbilical cord blood vessel (the vein) where small aliquots/volume of blood is removed slowly and gradually from the baby and is replaced immediately by fresh whole blood obtained from the hospital’s blood bank. The duration of exchange transfusion is usually ˜11/2 to 2 hours depending on the baby’s weight and overall condition. Throughout the process, the baby will be closely monitored. The bilirubin level will also need to be carefully monitored following exchange transfusion to ensure that it does not rise rapidly again. Occasionally, a repeat exchange transfusion may be needed should the levels rise beyond the accepted range once again. Exchange transfusion is an accepted mode of treatment. It has been used worldwide. The main drawback to exchange transfusion is the risk of transmitting major blood borne related infections (e.g. hepatitis B, HIV). However, with continuously improved screening techniques of donor’s blood, this risk is minimised. As with all other form of treatment, the need and benefits for the treatment should be weighed carefully against the possible side effects. In the case of severe jaundice, the risk of brain damage is real and exchange transfusion needs to be strongly considered.
How can I help?
Most babies admitted with jaundice require phototherapy. It is important to ensure that your baby has adequate feeds, more so since phototherapy is used (as fluid loss in increased with the use of phototherapy).It is also advisable that traditional medications be avoided for the time being as its true contents may be unclear and there may be existing substance that could worsen your baby’s jaundice. Another important point to note is that basking your baby underneath the morning sun is not an effective mode of treatment and should therefore be discouraged.
What happens after my baby is discharged?
The need for subsequent follow-up will have been made by your baby’s attending doctor(s). Uncomplicated cases of neonatal jaundice do not require special follow-up; only those with severely elevated bilirubin level (usually unconjugated bilirubin level of >300mmol/L) and especially those who required exchange transfusion will be given NICU clinic appointments. During this follow-up(s), your baby will be assessed in terms of growth and developmental status. In addition to this, a hearing assessment appointment will also be given to ensure that there is no hearing appointment.
If there are any points, which are confusing or unclear to you, or your question is not covered by the information in this article, please ask the doctor looking after your baby.