Physiological (Normal) Jaundice

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What is neonatal jaundice? – Jaundice in newborn refers to yellowness of the skin and white portion of the eyes (sclera) of a newborn baby. It occurs as a result of excess bilirubin (waste product of red blood cell breakdown) in the blood of a newborn baby. It is a relatively common condition in newborn babies, as it may occur in up to 50% of them. It is an important to watch out for in newborn as excess level of it, when not treated, can result in permanent neurological injury. 

What causes neonatal jaundice?

Normally, bilirubin, which is a waste product of red blood cell breakdown, is metabolised / broken down by the liver from insoluble form to soluble form that can easily be excreted. Physiological jaundice results from the interplay between two major factors:

  1. Excess bilirubin production: During pregnancy, babies are exposed to lower concentration of oxygen than they are when they are born. In order to get enough oxygen for their day-to-day activities before they are born, they produce more red blood cells to carry oxygen and compensate for the low oxygen tension in the womb. After delivery, they are exposed to higher concentration of oxygen, making such quantity of red blood cells not necessary for daily activities. So, the excess red blood cells are cleared by the body, generating high quantity of bilirubin. 
  2. Immaturity of the liver: During pregnancy, because the baby’s liver is undergoing development, the bilirubin produced by the baby, from destruction of old red blood cells, is channelled to the mother, through the placenta, for metabolism. So, effectively, the baby’s liver is not very active in bilirubin metabolism before delivery. 

Symptoms of neonatal jaundice

Neonatal jaundice manifests as yellowness of the skin and white portion of the eyes (sclera). This usually appears between the second and fourth day after the birth of a baby. The yellowness on the skin usually starts from the forehead down to the chest, abdomen, in that sequence while that of the eyes may get deeper as the intensity increases. If jaundice persists or increases in intensity, the baby may refuse to feed; be lethargic or cry frequently. 

Examining the baby entails applying gentle pressure on the baby’s forehead or nose (blanching). The part pressed will turn yellow if the baby has jaundice. If there is no jaundice, the portion of the skim pressed will appear lighter than its normal colour for a brief moment before returning back to normal. This examination should preferably be carried out in natural light by a healthcare provider before the mother is discharged from the hospital. In babies with jaundice, proper investigations can be done to detect the cause and the level of bilirubin in the blood.

Treatment of Neonatal Jaundice

In most babies with physiological jaundice, treatment is not required because:

  1. The liver improves in maturity by the day and thereby improves in its metabolism / breakdown of bilirubin into the soluble form that can be removed from the blood.
  2. The initial clearance of excess red blood cells is one off event. Therefore, the liver gradually clears the bilirubin from the circulation as it matures, resulting in resolution of the jaundice. 

Within a period of two to three weeks, the jaundice usually clears in majority of babies, as most cases are mild to moderate. When the bilirubin level is severely high, treatment may be necessary.

  1. Phototherapy – This involves placing the baby under special light for certain period of time. The baby’s eyes are covered to avoid damage to the eyes. This method is applied when the bilirubin level is not too high (as determined by laboratory test). The light helps convert bilirubin from insoluble to soluble form which can be eliminated in stool and urine without necessarily having to pass through the liver. So, some reasonable quantities bypass the liver and get excreted while the liver continues to handle the much it can at a given time. With this, the body is able to eliminate bilirubin within a short time and thereby prevent the untoward consequences to the baby.
  2. Exchange blood transfusion – This entails removing the baby’s blood stepwise and infusing donor blood into the baby. This helps to reduce the quantity of bilirubin in the circulation and relieve the baby of jaundice. This is done until the bilirubin level (which is checked periodically) becomes normal. 

Complications of Jaundice

The following are complications of untreated neonatal jaundice:

  1. Seizure disorder
  2. Cerebral palsy
  3. Bilirubin encephalopathy / bilirubin-induced neurologic damage (kernicterus)
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