Jaundice in Newborn - Normal or Pathological?
Jaundice is a term used to describe the yellow discoloration of skin and white of eyes. When bilirubin level in blood increases, it causes jaundice. Unlike jaundice in adults, which is always pathological (abnormal), jaundice in newborn, called 'neonatal jaundice' in medical terms, is either a normal (physiological) condition or an abnormal disease condition.
Jaundice in newborn is very common; it is seen in about 60% of full-term infants and 80% of pre-term infants. In most cases, a mild jaundice occurring usually on the second or third day of life is a normal physiological phenomenon and it is harmless.
To know about the difference between physiological and pathological jaundice, one needs to know briefly about bilirubin and its metabolism in human body.
Bilirubin is a yellow pigment formed mainly by the breakdown of circulating old red blood cells. The destructive process takes place in the spleen, liver and bone marrow. When a red blood cell is destroyed, the hemoglobin present in it gets disintegrated into its key components, the globin (protein) part and heme part (contains iron). The protein part (globin) and the iron of heme are recycled by the human body and are almost used up. The rest of the heme part is further degraded to form the final product, bilirubin, which undergoes extensive metabolism in the liver. It is then secreted into the bile duct, which carries bile. Through the bile, it reaches the intestine and finally gets excreted through the stools. A small amount of bilirubin is also excreted through urine.
What causes physiological jaundice in newborn?
Usually, a healthy adult liver can handle high levels of bilirubin. Jaundice occurs only when the liver is diseased or an obstruction hinders the transport of bile in the intestine. But the liver of a newborn, which is immature, cannot handle high levels of bilirubin. The red blood cells of a newborn have short life span and get destroyed early. The red blood cell mass of an infant is also more than that of an adult. All these factors increase the burden on the already immature liver. This jaundice, which usually occurs during the second or third day of life, is usually physiological and it does not pose much threat. It does not last more than one to two weeks of age.
Jaundice in breast-fed infants
There are conditions where jaundice occurs in exclusively breast-fed infants.
'Breast milk jaundice', a condition that usually occurs during 4-7 days of age, is possibly due to interactions between breast milk and the hepatic (liver) enzymes. The jaundice may persist longer than a physiological jaundice, but it is usually harmless. Breast feeding should not be discontinued if the baby is really doing well with breast milk. Interruption of breast-feeding for 24-48 hours, with supplementary feeding, may be needed to reduce the level of bilirubin in infants who do not get along well with breast milk.
Another condition called 'breast feeding jaundice' occurs due to inadequate breast milk. Decreased breast milk secretion or improper feeding positions like poor latching of the baby to the breast, reduces the baby's milk intake and affects gut movements. So the bilirubin present in the gut gets absorbed causing jaundice. This jaundice is also harmless. Educating the mother on proper breast-feeding positions and providing supplementary feeds to the baby, if necessary, help to clear this jaundice. Breast feeding need not be discontinued.
What is pathological jaundice?
Jaundice that occurs during the first day of life is likely to be abnormal. Jaundice that appears after 3-4 days of life is also usually pathological. Infants, who have jaundice that persists for more than two weeks, should be tested and closely monitored. Pre-term babies are more likely to develop neonatal jaundice than full-term babies. The normal duration of physiological jaundice is usually longer in pre-term babies than full-term babies.
There are various causes for pathological jaundice. Some of them are:
1. Haemolytic anemia (excessive/rapid destruction of red blood cells). This is the most common cause and it occurs due to various reasons. Some of them are defective red blood cells, incompatibility (mismatch) in blood group of mother and baby, enzyme defects, heredity etc.
2. Polycythemia (increased number of red blood cells)
3. Collection of blood under the scalp of the baby, due to injuries caused during a difficult delivery
4. Diseases of liver or biliary tract
5. Congenital infections (infections like rubella, syphilis etc., transferred from mother to baby during pregnancy/delivery)
6. Post-natal infections (infections acquired after birth)
7. Hormonal disorders (hypothyroidism)
8. Hereditary diseases
In any case, jaundice would be the first presenting symptom. Appearance of symptoms like drowsiness, seizures, lethargy and altered cry of baby indicate very high levels of bilirubin and need immediate attention.
How is the cause of jaundice determined?
Detection of serum bilirubin level is the usual and simple test needed to be done for a mild to moderate jaundice. Depending on the level of bilirubin and the suspected cause of jaundice, tests like blood grouping and typing (to detect blood-group incompatibility) direct Coombs test in infant (for haemolytic anemia), complete blood count, microscopic examination of peripheral blood film, liver function tests etc., are additionally performed.
What is the treatment for neonatal jaundice?
Monitoring bilirubin level is the mainstay of management in a physiological jaundice. Phototherapy is indicated if the level of bilirubin is high or if it rises quickly. Decision regarding phototherapy depends on the age of the baby and the baby's maturity (whether the baby is pre-term or full-term). In case of a pathological jaundice, treatment of the underlying cause, along with phototherapy, is required. Intravenous immunoglobulin, exchange transfusion or surgery may be necessary, depending on the cause of pathological jaundice.
Jaundice in newborn is very common; it is seen in about 60% of full-term infants and 80% of pre-term infants. In most cases, a mild jaundice occurring usually on the second or third day of life is a normal physiological phenomenon and it is harmless.
To know about the difference between physiological and pathological jaundice, one needs to know briefly about bilirubin and its metabolism in human body.
Bilirubin is a yellow pigment formed mainly by the breakdown of circulating old red blood cells. The destructive process takes place in the spleen, liver and bone marrow. When a red blood cell is destroyed, the hemoglobin present in it gets disintegrated into its key components, the globin (protein) part and heme part (contains iron). The protein part (globin) and the iron of heme are recycled by the human body and are almost used up. The rest of the heme part is further degraded to form the final product, bilirubin, which undergoes extensive metabolism in the liver. It is then secreted into the bile duct, which carries bile. Through the bile, it reaches the intestine and finally gets excreted through the stools. A small amount of bilirubin is also excreted through urine.
What causes physiological jaundice in newborn?
Usually, a healthy adult liver can handle high levels of bilirubin. Jaundice occurs only when the liver is diseased or an obstruction hinders the transport of bile in the intestine. But the liver of a newborn, which is immature, cannot handle high levels of bilirubin. The red blood cells of a newborn have short life span and get destroyed early. The red blood cell mass of an infant is also more than that of an adult. All these factors increase the burden on the already immature liver. This jaundice, which usually occurs during the second or third day of life, is usually physiological and it does not pose much threat. It does not last more than one to two weeks of age.
Jaundice in breast-fed infants
There are conditions where jaundice occurs in exclusively breast-fed infants.
'Breast milk jaundice', a condition that usually occurs during 4-7 days of age, is possibly due to interactions between breast milk and the hepatic (liver) enzymes. The jaundice may persist longer than a physiological jaundice, but it is usually harmless. Breast feeding should not be discontinued if the baby is really doing well with breast milk. Interruption of breast-feeding for 24-48 hours, with supplementary feeding, may be needed to reduce the level of bilirubin in infants who do not get along well with breast milk.
Another condition called 'breast feeding jaundice' occurs due to inadequate breast milk. Decreased breast milk secretion or improper feeding positions like poor latching of the baby to the breast, reduces the baby's milk intake and affects gut movements. So the bilirubin present in the gut gets absorbed causing jaundice. This jaundice is also harmless. Educating the mother on proper breast-feeding positions and providing supplementary feeds to the baby, if necessary, help to clear this jaundice. Breast feeding need not be discontinued.
What is pathological jaundice?
Jaundice that occurs during the first day of life is likely to be abnormal. Jaundice that appears after 3-4 days of life is also usually pathological. Infants, who have jaundice that persists for more than two weeks, should be tested and closely monitored. Pre-term babies are more likely to develop neonatal jaundice than full-term babies. The normal duration of physiological jaundice is usually longer in pre-term babies than full-term babies.
There are various causes for pathological jaundice. Some of them are:
1. Haemolytic anemia (excessive/rapid destruction of red blood cells). This is the most common cause and it occurs due to various reasons. Some of them are defective red blood cells, incompatibility (mismatch) in blood group of mother and baby, enzyme defects, heredity etc.
2. Polycythemia (increased number of red blood cells)
3. Collection of blood under the scalp of the baby, due to injuries caused during a difficult delivery
4. Diseases of liver or biliary tract
5. Congenital infections (infections like rubella, syphilis etc., transferred from mother to baby during pregnancy/delivery)
6. Post-natal infections (infections acquired after birth)
7. Hormonal disorders (hypothyroidism)
8. Hereditary diseases
In any case, jaundice would be the first presenting symptom. Appearance of symptoms like drowsiness, seizures, lethargy and altered cry of baby indicate very high levels of bilirubin and need immediate attention.
How is the cause of jaundice determined?
Detection of serum bilirubin level is the usual and simple test needed to be done for a mild to moderate jaundice. Depending on the level of bilirubin and the suspected cause of jaundice, tests like blood grouping and typing (to detect blood-group incompatibility) direct Coombs test in infant (for haemolytic anemia), complete blood count, microscopic examination of peripheral blood film, liver function tests etc., are additionally performed.
What is the treatment for neonatal jaundice?
Monitoring bilirubin level is the mainstay of management in a physiological jaundice. Phototherapy is indicated if the level of bilirubin is high or if it rises quickly. Decision regarding phototherapy depends on the age of the baby and the baby's maturity (whether the baby is pre-term or full-term). In case of a pathological jaundice, treatment of the underlying cause, along with phototherapy, is required. Intravenous immunoglobulin, exchange transfusion or surgery may be necessary, depending on the cause of pathological jaundice.
