Jaundice may pose serious threat to newborns: Expert

By Donya Betancourt

SANUR, Bali (JP): Some newborns develop a condition called "neonatal jaundice" or "hyperbilirubinemia", which happens to about 25 percent to 60 percent of all newborns.

What is jaundice?

Jaundice is a condition when a person has yellow eyes and yellow skin. The color results from "bilirubin" which is a yellow pigment produced from red blood cells breaking down.

The physician diagnoses "jaundice" by measuring the bilirubin level. Asians and Native American babies have elevated levels that may be nearly double those of Caucasians and African Americans.

Mild cases of neonatal jaundice usually resolve over the first few weeks of life, but persistently high concentrations of bilirubin can be dangerous.

Elevated levels of bilirubin interfere with a number of cellular processes, and may be neurotoxic. Jaundice progresses from head to toe, so an infant with mild facial jaundice is less of a concern than an infant who has total body jaundice.

The skin should be checked against a white background over the forehead and sternum, especially in darker skinned babies, to accurately assess the degree of jaundice. Placing the baby on a white sheet or blanket is also helpful, as opposed to using a yellow colored background.

Why do red blood cells break down in a newborn?

There are two types of jaundice, "physiologic jaundice" and "pathologic jaundice".

Physiologic jaundice occurs in most healthy full-term babies in the first week of life and does not require special treatment. It occurs from a lack of functions due to immature organs in newborns. This is due to increased production (accelerated red blood cell breakdown), decreased removal (transient liver enzyme insufficiency) and increased reabsorption (enterohepatic circulation).

Neonates have a higher volume of red blood cells and produce the yellow pigment twice as much as adults and older children because red blood cells in newborns have a shorter half-life than an adults production capacity (90 days instead of 120 days in an adult).

Nonphysiologic or pathologic jaundice occurs when there are a number of pathologic conditions that can result in neonatal jaundice. Examples include: Conditions that cause the destruction of red cells, which can occur as a result of hemolysis, certain enzyme deficiencies, or structural abnormalities in red cells. The types of intestinal bacteria that metabolize bilirubin, and in such cases, significant amounts of bilirubin is reabsorbed into the blood.

Common causes

The most common cause is blood group incompatibility, I would like to write about this topic more clearly in case you face this problem.

Blood group incompatibility occurs when the mother and her baby have differing blood types (ABO and/or Rh). When blood types differ, the mother may produce antibodies to destroy the infant's red blood cells. Blood incompatibility may even threaten the fetus. The rapidly destroyed cells may overwhelm the body's ability to get rid of the yellow pigment and consequently, increase in levels.

Jaundice may be apparent during the first day of life. In the past, Rh incompatibility was a relatively common cause of the most severe form of jaundice. However, injecting the mother with RhoGAM within 72 hours of delivery can prevent this condition.

RhoGAM prevents the formation of anti-Rh antibodies that can endanger future Rh-positive pregnancies.

The relative positions of the mother and the baby immediately following delivery should also be taken into account. If the baby is below the level of the mother, gravity drainage of blood to the baby may occur before the umbilical cord is cut. The baby must destroy and excrete these excessive red blood cells from the body. Increased red blood cell breakdown results in an increase in yellow pigment production. This condition is called "polycythemia".

The delivery process and extensive bruising of the baby is associated with higher bilirubin levels as healing occurs. A lack of bilirubin excretion, most often occurs when the bilirubin -- which has already been processed by the liver and sent to the intestine for removal, is reabsorbed before it can be excreted in the stool.

Jaundice related to breast-feeding is an example of under excretion. Breast-milk jaundice occurs in babies that are nursing well, gaining weight, have normal stools and look healthy. The bilirubin level, instead of falling in the first week of life, continues to rise. When the mother stops nursing for 48 hours, the bilirubin level will usually drop by 50 percent. When nursing is resumed, the level will not be as high as before. The cause is unclear but there is a 70 percent recurrence rate in subsequent pregnancies.

However, if the body is unable to get rid of sufficient levels of bilirubin, the level of bilirubin present in the body will increase, resulting in hyperbilirubinemia.

An excessive level of bilirubin can lead to serious neurological damage, which is called "kernicterus". Kernicterus is a serious and life-threatening form of neonatal jaundice that reflects the toxicity of bilirubin to the central nervous system.

Kernicterus -- in both acute and chronic forms -- manifests itself by a variety of neurologic and cognitive defects, ranging from poor suckling and seizures, to low IQ resulting in cerebral palsy, hearing loss and mental retardation. Clearly, this disorder should be treated without delay.

Unfortunately, the specific level of total serum bilirubin at which lasting damage occurs has not been identified, although levels of 12 mg/dL to 14 mg/dL are thought to be the upper limits of "watchful waiting".

Signs

The following points are critical signs to tell you when you should be concerned about jaundice: Jaundice present before 24 hours of age; Excessive weight loss and poor feeding; Infrequent bowel movement; Dark urine or light colored stools; Prematurity; Persistent jaundice beyond two weeks of age.

How is jaundice treated?

Most babies will clear excess bilirubin without treatment. Observation and follow up can be successful in most of healthy neonates. The babies who are unable to get rid of excessive bilirubin will receive treatment as follows.

The most frequently used treatment is phototherapy. The blue portion of the light spectrum causes a chemical reaction that helps in the elimination of bilirubin via stool and urine. The most frequently used form is phototherapy using a standard fluorescent white light.

Another treatment is an exchange transfusion. In this procedure, small amounts of blood (and hence bilirubin) are removed from the baby and replaced with donor blood. This procedure is performed if the risk of kernicterus is high.

Jaundice may be a normal part of a baby's adjustment to life after birth, but extreme jaundice can have very serious consequences. The American Academy of Pediatrics and the American College of obstetricians and Gynecologists recommend that all neonates discharged less than 48 hours of age be seen within three days, either at home or in a health care center, by a medical professional, experienced in assessing neonatal jaundice.

The writer is a pediatrician based in Sanur, Bali. Questions? Contact her at drdonya@hotmail.com or features@thejakartapost.com