Neonatal Jaundice

Original article by Patrick Green | Last updated on 21/9/2016
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Introduction

Neonatal Jaundice is very common, with 60% of babies being jaundiced at some point. It is however, often very worrying for parents, and for clinicians, the challenge is distinguishing ‘harmless’ physiological/breastfeeding jaundice from jaundice resulting from a more worrying cause.

Neonatal Jaundice can be split into three time periods
  1. Jaundice within the first 24 hours of life.
  2. Jaundice between days 2 and 14.
  3. Prolonged Jaundice occurring after 14 days.
 

Jaundice in the first day of life

  • This is not normal!
  • The commonest cause is due to haemolysis usually due to either ABO incompatibility, Rhesus disease of the newborn or Hereditary Spherocytosis.
  • However can be caused by infection either from the mothers genital tract or in the amniotic fluid, therefore a TORCH screen should be used.
    • Toxoplasmosis
    • Other
    • Rubella
    • Cytomegalovirus (CMV)
    • Hepatitis or Herpes
 

Jaundice in days 2- 14

  • This is a tricky period, as this is the timeframe physiological or breastfeeding jaundice often manifests, however it is also the time more serious conditions also present with jaundice. Although other causes must be excluded, the most common causes in this time period are ;
  • Physiological Jaundice is very common, usually appearing around day 2-4, peaking at 7 days and then regressing. It is caused by a combination of the following two factors:
    • Foetal haemoglobin has a shorter life span than adult haemoglobin and is constantly being broken down at a high rate.
    • The newborn liver cannot cope with all of this bilirubin, and so it builds up in the blood.
  • Breastfeeding Jaundice is thought to result from increased enterohepatic bilirubin. It has long been known that breastfed babies are often more jaundiced, and for longer than bottle fed babies. It is important to reassure the mother that this is a common occurrence; she is not doing it wrong and should continue breastfeeding even though the jaundice may still be there.
 

Jaundice after 14 days

  • This is known as prolonged jaundice.
  • Breastfeeding jaundice can continue into the fourth or fifth weeks, however there are several more severe conditions that could cause the jaundice
  • Congenital hypothyroidism can cause jaundice in this time period, however you would expect this condition to be picked up on the Guthrie heel prick test.
  • Biliary atresia is a rare condition in which all or parts of the biliary tree fail to develop, preventing bile from flowing into the gut. This leads to a high concentration of conjugated bilirubin level in the blood. An important question to ask when taking a jaundice history is the colour of the stools. In biliary atresia the stools are often pale or ‘chalky white’. Ultrasound or radionuclide scans can identify the defect and surgery is needed to create a functional biliary tree.
 

Signs and symptoms

Jaundice gives a yellow/orange to the skin and sclera. In adults it often causes itching; however in neonates this is impossible to tell! There may be signs of the underlying cause, for example pale stools in biliary atresia, or in rhesus disease there is hepatosplenomegaly.
Red flags to look out for are signs of Kernicterus. This is a life threatening condition which happens when the bilirubin levels are  very, very high (>360μmol/L). When bilirubin levels reach this high, they cross the blood brain barrier, and form deposits in the basal ganglia and the brainstem. This can cause neurological signs, such as lethargy, poor feeding, fits, coma and even result in death. Thankfully in the vast majority of cases neonatal jaundice is well monitored and treated, which means very few cases progress to Kernicterus.
 

Investigations of the Jaundiced Neonate

  • As with everything, a thorough history and examination
  • Bloods – Serum Bilirubin
    • FBC
    • Blood Film
    • Blood Group
    • LFTs
    • TFTs
    • Blood cultures – TORCH Screen
    • Coomb’s test
  • Urine dipstick and culture, to look for bilirubin, and a source of sepsis.
  • If prolonged or the clinical picture is suggestive, then biliary US or other radiology.
 

Management

  • Use a bilirubin chart! Measures bilirubin against age. There are normally two lines on it
    • LINE ONE = PHOTOTHERAPY TREATMENT LINE
    • LINE TWO = EXCHANGE TRANSFUSION LINE
  • If under the phototherapy line, and other investigations have come back as negative, then treatment is supportive. Make sure the baby is well hydrated and nourished, and repeat bilirubin levels.
  • If above the phototherapy line then start phototherapy. This is when the baby is subjected to light of a certain wavelength (450nm). At this wavelength is converts non-conjugated bilirubin into a harmless substance and decreases bilirubin levels. The baby needs to be completely naked, apart from eye protection, and needs to be under the lights as much as possible, until bilirubin levels come down. Some mothers find this very frustrating as it reduces bonding time with the baby; however feeding must continue, which gives them some time together. Some babies also develop a rash as a result of the phototherapy. More recently special fibre optic blankets have been developed which can be used.
  • Exchange transfusions are when the baby’s blood is replaced with carefully matched and screened donated blood. Two times the baby’s blood volume is exchanged, either through a UVC (umbilical venous catheter) or a peripheral vein paired with an arterial line.  
 

Useful Resources

The NICE guidelines, although very long, are superb for learning about neonatal Jaundice. There is also a very useful box (p105 I think) that gives a succinct guide to the treatment, well worth a look, but pick out the bits you need!
http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf 

Alternatively NICE guideline 98 has a brief version which summarises the relevant information: http://www.nice.org.uk/nicemedia/live/12986/48679/48679.pdf