NEONATAL JAUNDICE

PHYSIOLOGICAL JAUNDICE

Many babies have some jaundice in the first week of life. This is referred to as physiological jaundice and has the following characteristics:

  • Appears on about the third day.
  • Reaches peak levels 5–8mg/dl (85–135mmol/L) occur in term babies; reduces to normal in about a week.
  • Reaches peak levels of 10–12mg/dl (170–205mmol/L) in preterm babies; falls to normal about 10 days.

Serum bilirubin levels >12mg/dl in term babies and >15mg/dl (>255ìmol/
L) in preterms require investigation.

Management

If a mother notices that her baby is yellow she should bring the baby to a health facility as soon as possible for assessment. If jaundice is physiological, only observation is required. Ensure adequate feeding and hydration.

ACUTE NON-PHYSIOLOGICAL JAUNDICE

This is common and is caused by:

  • ABO incompatibility: Mother group O, baby is A or B or AB
  • Rhesus incompatibility: Mother Rh-negative, baby Rh-positive
  • Sepsis

In ABO and Rhesus incompatibility, jaundice may appear from the first day, whereas in sepsis it may appear any day. It is most likely in babies who are large or small for their gestational age.

Complications

  • Bilirubin toxicity (Kernicterus): Brain damage due to deposition of bilirubin in the brain. It presents with lethargy, poor feeding and vomiting, opisthotonos, seizures, and coma.
  • Death may result from bilirubin toxicity. If the baby survives, mental retardation, cerebral palsy, hearing loss, and learning disorders are known sequalae.

Factors that predispose to development of bilirubin toxicity include:

  • Sepsis
  • Prematurity
  • Acidaemia
  • Hypothermia
  • Hypoglycaemia

Investigations

  • Full blood count include peripheral blood film (PBF)
  • Determine mother’s and baby’s blood group(s)
  • Serum bilirubin levels; direct and indirect
  • Appropriate cultures if sepsis suspected
  • Coomb’s test

Management

All jaundiced babies with blood group or Rhesus incompatibility should be started on phototherapy. The exchange transfusion should be carried out over 45–60 minutes period using aliquots of 20ml of blood in and out for larger babies and 5– 10ml for sick and premature infants. The goal should be an exchange of approximately twice the blood volume of infant (2x85ml/kg). Ensure aseptic
environment.

Treatment of jaundice based on bilirubin levels

Day 4340290510340

Age of baby at review in days Managementby phototherapy Management
by exchange transfusion
Healthy term baby μmol/l (bilirubin) Sick LBW baby μmol/l (bilirubin) Healthy term baby μmol/l (bilirubin) Sick LBW baby μmol/l (bilirubin)
Day 1 Any visible jaundice Any visible jaundice 260 220
Day 2 260 220 425 260
Day 3 310 270 510 340

Note: Sick very low birth weight babies (<1,500g) may not fit in this table as bilirubin toxicity
can occur at much lower levels. In this case the clinician uses own discretion.

PROLONGED NEONATAL JAUNDICE

Prolonged neonatal jaundice is due to hepatitis or biliary obstruction.

  • In obstructive jaundice the stools are pale and urine very dark.
  • Hepatitis may be due to Hepatitis B viral infection, congenital syphilis, or cytomegalovirus, among other causative
    organisms. The baby may show features consistent with the specific infection.

Investigations

  • Bilirubin
  • Test for syphilis
  • Hepatitis B surface antigen
  • Serum transaminases
  • Alkaline phosphatase
  • Abdominal ultrasound

Management

Refer to a specialist urgently. For biliary atresia, surgery is best done within 6 weeks of birth to prevent hepatic damage.