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Articles : JAUNDICE IN NEWBORNS

Neonatologist Dr. Musa Mohd. Nordin explains why jaundice is common in babies and when treatment is necessary.

As a parent, you might notice that your newborn baby’s skin (especially on the face) and the whites of his eyes look yellow. This yellow discolouration is called jaundice.

Normal jaundice (or physiological jaundice of the newborn) is very common and seen in over two-thirds of all babies. It may be more intense in babies who are born early (preterm). It is different from jaundice in older children and adults which usually results from hepatitis or other liver problems.

Like many new parents, you might be alarmed at your baby’s jaundice. Don’t get too worried because it is most likely a physiological or normal process of maturation in the newborn.

At birth the newborn baby has a higher level of haemoglobin, the protein in red blood cells which transports the oxygen around the body. As the baby’s red blood cells breaks down, due to their shorter life span, the haemoglobin is converted to bilirubin. Bilirubin is the yellow pigment that gives rise to jaundice in the baby.

This bilirubin is further broken down by the liver. However, since the baby’s liver is relatively immature, it is not able to do the job quickly enough. This slow removal of bilirubin leads to its accumulation and hence jaundice. As the liver matures within the first week of life it is able to excrete the bilirubin more efficiently and the jaundice gradually disappears.

At physiological levels, jaundice is harmless. It often appears on day 2-3 of life, peaks at 5-7 days of life and often disappears by 10 days of life. However, very high levels of bilirubin can cause problems in children. The excess bilirubin crosses the blood brain barrier and deposits in the brain causing cerebral palsy, deafness, varying degrees of intellectual retardation and sometimes death.

When a baby is jaundiced, the yellow discoloration of the skin first appears on the face and progresses downwards to the neck, trunk, palms and soles. The doctor uses this technique to asses clinically the severity of the jaundice. He may then order some tests to determine whether the jaundice is at an acceptable level or is higher than normal. If the jaundice is at a higher level, treatment may be required (please see below). The doctor will also need to check your baby regularly, until the jaundice starts receding.

ABNORMAL JAUNDICE

Jaundice which is either more severe or longer lasting than normal is called non-physiological (or pathological) jaundice. This can occur for a variety of reasons, as follows:

Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency. This is an inherited disorder of red blood cells. G6PD is an enzyme which is required to maintain the integrity of the red blood cells. In G6PD deficiency, the red blood cell rapidly breaks down when exposed to certain drugs, food or herbs. All newborns are screened for this disorder at birth by cord blood sampling. Up to 3% Chinese and Malay boys are G6PD deficient.

Baby is born preterm. The more premature the baby the higher is the incidence of jaundice. This is taken very seriously by the doctor because of the increased risk of brain damage at relatively lower levels of bilirubin.

Blood group incompatibility. If your blood group is Rhesus negative (less than 1% of Malaysian women) and baby’s group is Rh positive, the antigens in your blood cross over to baby’s blood and start destroying his red blood cells. This causes his bilirubin levels (and his jaundice) to increase. More commonly if mother is blood group O and baby is either A or B, jaundice can result due to ABO blood group incompatibility. Other blood cell antigens may also have a similar effect, though usually not as severe as Rh incompatibility This is why testing the mother’s blood group at the beginning of pregnancy is so important. It will ensure that the doctor is ready to treat the jaundice that is likely to occur.

Intrauterine infections. Various infections during pregnancy can lead to jaundice in the newborn. These include toxoplasmosis, rubella, cytomegalovirus, herpes and syphilis. They are often associated with other congenital problems.

Infections. Newborn babies have relatively weaker defence systems and are therefore more vulnerable to infections. The premature and small newborns are especially at risk. One of the early signs of infection in the sick newborn is increasing levels of jaundice. The sites of infection include the brain lining (meningitis), blood (septicaemia) and urine.

Obstructive jaundice. Jaundice in association with pale stools and dark urine points to an obstruction in the normal biliary drainage system. This will require careful and prompt evaluation and often the need for early surgery to remove the obstruction to the biliary tree which drains the bilirubin. The 2 common examples of this surgical disorder are biliary atresia and choledochal cyst.

Other factors. Blood cell enzyme deficiencies (which usually run in families), metabolic diseases that affect the liver and neonatal hepatitis can cause abnormal jaundice levels. Your doctor would have to do specialised tests if he suspects that any one of these problems is present.

Breast milk jaundice. If none of the above factors are present, and the baby is otherwise thriving well, baby’s jaundice might well be due to mother’s breast milk. This occurs in up to 3% of breastfed babies. The exact reasons are still not fully understood. Please rest assured that this is an entirely benign and harmless condition. You should continue to breastfeed your baby. Besides, bilirubin has anti-oxidant properties the equivalent of vitamin C and E which helps to protect the baby’s tissues.

TREATING JAUNDICE

If your doctor confirms that baby’s jaundice is at a normal level, he will not recommend any treatment because the jaundice will eventually disappear on its own.

If the bilirubin level in the blood is higher than normal, your baby may be placed under special lights for a few days, This treatment for jaundice is called phototherapy. The light helps to convert bilirubin into a harmless compound and also changes it into a by-product which can be readily excreted in the stools and urine. Serum bilirubin levels are measured regularly to asses the response to phototherapy. Phototherapy is usually done in the hospitals but home phototherapy can also be arranged in some areas where the service is available.

If there are any other problems causing baby’s jaundice, your doctor will administer the appropriate treatment (eg giving antibiotics if there is bacterial infection).

If the bilirubin is very high, as sometimes happens in G6PD deficiency and blood group incompatibility, baby may need to undergo a procedure called an “exchange blood transfusion”. An exchange transfusion brings down the bilirubin level by 50% within 1-2 hours and therefore helps to protect the brain from the potential toxic effects of the grossly elevated bilirubin.

Jaundice in the newborn is very common. It is essentially a benign condition which often do not require any medical intervention whatsoever. Only a minority of jaundiced babies require further evaluation and treatment. And this is often safely and effectively treated with phototherapy.

Article courtesy of Positive Parenting, a community education programme by the Malaysian Paediatric Association in collaboration with the Obstetrical & Gynaecological Society of Malaysia and Nutrition Society of Malaysia. The programme is supported by unconditional educational grants from Dutch Lady Nutrition Centre and Woodwards Gripe Water. To receive a free copy of the Positive Parenting magazine (excluding postage & handling), please contact Tel: (03) 5621 1408.