Jaundice is a medical condition of yellow coloration of the sclera and skin due to excess bilirubin.
If there is yellowness of the skin and not of the sclera it is not jaundice. This is most likely to be meconium aspiration or carotenemia.
Bilirubin is produced by the destruction of effete red blood cells in the reticular-endothelial system and from other haem proteins in the liver and bone marrow. Both sources produce unconjugated bilirubin, which is bound to albumin and transported to the liver. Here it undergoes conjugation mediated by the glucosyl transferase enzyme.
The conjugated bilirubin is excreted with bile into the intestine where it is passed out as stercobilin. It is also passed out through urine as urobilinogen It is important to note that conjugate bilirubin can be re-converted to unconjugated bilirubin in the gastrointestinal tract by the action of B-glucosidase especially if there is GIT stasis or delay.
Unconjugated bilirubin is water insoluble but fat-soluble and it is toxic to the brain. It can be excreted in the urine.
What are the types of jaundice?
There are four main types of jaundice include:
1. Physiological jaundice
2. Pathological jaundice
3. Breastfeeding jaundice
4. Breastmilk jaundice
Physiological Jaundice
This is not present at birth as the mother clears bilirubin before birth. At birth, however, bilirubin levels gradually build up but do not appear for one to two days. They are usually clearly intreated and do not make the baby sick.
There are permissible levels and duration of clearance of bilirubin in both full-term babies and pre-term babies.
The permissible levels for a Full-term baby are 12mg%, and for a Pre-term baby is 14-15mg%
The duration of clearance for a Full-term baby is 10-12 days, and for a Pre-term baby is 2 weeks.
It does not mean that these values are safe. If the duration of clearance exceeds the above-given values it is no longer physiological jaundice. This is because the glucuronidase enzyme in the liver now should have been fully developed.
Pathological Jaundice
physiological jaundice is a result of inherent problems in the baby.
What are the causes of pathological jaundice?
- Glucose-6-phosphate dehydration deficiency: The deficiency of this enzyme in the baby account for about 50-70% of neonatal jaundice. The enzyme deficiency when exposed to oxidants such as 8-amino quinolones; sulphonamide, and camphor products and infection cause jaundice.
- Infection: This is the second most commonest cause of jaundice. The organisms are usually gram-negative and hemolytic organisms.
- Low birth weight: Pre-term babies are more likely to have jaundice as there is a greater deficiency of glucosyl transferase
- Let’s-maternal blood incompatibility: ABO and rhesus are implicated
- Idiopathic (unknown cause)
- Close hemorrhage (rare)
- Delayed clamping of the cord (rare)
Criteria for pathological jaundice
- Clinical jaundice in the first 24 hours of life
- Total serum bilirubin level increased by more than 5mg% per day
- Total serum bilirubin level
- Full-term baby with more than 12.9mg%
- Pre-term baby with more than 15mg%
- Conjugated serum bilirubin with more than 1.5 – 2mg%.
- Clinical jaundice persisting in:
Breastfeeding Jaundice
Jaundice is sometimes more common in breastfed babies than in fed with formula. Breastfeeding jaundice frequently occurs especially during the baby’s first week of life. It happens when the baby does not get enough breast milk from the mother. It can occur due to nursing difficulties or perhaps because the milk hasn’t come in yet. Breastfeeding jaundice, however, may take a longer time to go.
Breast Milk Jaundice
It typically occurs one week after birth. The condition can sometimes last up to 12 weeks, but it rarely causes complications in healthy, breast-fed infants.
The exact cause of breast milk jaundice is not yet known. However, it may due to a substance in breast milk that prevents certain proteins in the infant’s liver from breaking down bilirubin. The condition may also be hereditary.
What are the Lab tests to run for jaundiced babies?
- Serum bilirubin – total and conjugated
- Full blood count and blood culture
- Assay of G-6-P-D.
- Direct and indirect coomb’s test
What is the treatment for neonatal jaundice?
- Provide binders by giving albumin
- Increased conjugation by giving Phenobarbitone or Phenytoin
- Treat infection with antibiotics
- Adequate nutrition
Phototherapy
This is the treatment with light. The baby is exposed to early morning light or the phototherapy light in the ward. The light source converts the bilirubin to photo bilirubin, which is excreted into the bile. Protect the eyes from the light source.
What are the effects of phototherapy?
- Dehydration
- Transient osmotic diarrhea and blindness
Exchange Blood Transfusion (EBT)
This is the piecemeal removal of the patient’s blood replacing it with fresh blood from a jaundiced-free patient. It’s advised that the blood for EBT should not be more than 5 years old. Preservatives used are Acid Citrate Dextrose(ACD), Citrate Phosphate Dextrose (CPO), and Heparin.
Complications of EBT
- Trauma to umbilical and vessels leading to bleeding
- Complications of blood transfusion
Neonatal Sepsis
This is an infection of the newborn within the first 28 days of life.
Predisposing Factors
- Prematurity
- Prolonged labor
- Prolonged premature rupture of the membrane with associated infection
- Infections in the mother such as gonorrhea
The infection gets to the baby by either team placental or acquired in the hospital. The latter source is called nosocomial infections.
Nosocomial infection can be due to hand contamination of babies in their cots by hospital workers or dirty mothers and by droplets of infections through inhalation.
Clinical Features In Babies With Neonatal Sepsis
- Fever of up to 39 degrees Celsius and above. While some may not have a fever
- Loss of appetite
- Vomiting and diarrhea
- Dyspnea (difficult breathing) and tachypnoea (abnormal or rapid breathing )
- Lethargy and irritable
What is the Lab. test to run for neonatal sepsis?
- Full blood count: The total white blood cell (WBC) count is usually high but may be low in some cases. The hemoglobin is low.
- Blood culture to isolate the offending organism
- Lumbar puncture may be necessary
What is the treatment for neonatal sepsis?
The treatment is according to clinical features. For fever, expose the baby. Do not tepid sponge to avoid rapid crash of temperature. Antipyretic analgesics are usually not necessary but can be given. Antibiotics in common uses are:
- Crystalline penicillin 0.25 m.u 6 hourly
- Gentamicin 5mg 8 hourly
Or,
- 1M Claforan 125mg daily x 5/7 or
- 1M Rocephin 125mg x 5/7
- 1M Oritaxim 125mg x 5/7
Either of these can be combined with 1M Gentamicin 20mg daily x 5/7
Neonatal Tetanus
This is an infection of the neonates by a bacterium called Clostridium tetani.
The infection is more common in the following conditions:
- Babies whose mothers were not immunized.
- Cutting the umbilical cord with an unhygienic razor.
The bacteria produce a toxin that affects neuromuscular transmission to produce spasms. It also affects the autonomic nervous to produce hyperpyrexia and salivation.
Clinical Features In Babies With Neonatal Tetanus
- Spasms
- Trismus – inability to open mouth
- Ophithotonus – arching of the spring.
Management Regimen
- Nurse your baby in a quiet and dark room to avoid provoking spasms. Keep a close watch
- Maintain airway and give oxygen where necessary
- Control spasms by sedating the patient with valium, paraldehyde, and phenobarbitone
- Eliminate the organism with IV Crystalline penicillin 0.25mg .u. 6 hourly
- Clean any possible wound source
- Neutralize the toxin
- Good nutrition
Preventions
- Good personal hygiene for mother and baby
- Immunize mother during pregnancy
- Actively immunize baby after birth by giving OPT.
~ Dr Anthony A. Ufere
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