Neonatal Jaundice (Newborn Jaundice)

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NICU guide

- Neonatal Jaundice

Neonatal jaundice is a common condition observed during the first week of an infant's life. It affects approximately 80% of preterm infants and more than 50% of full-term newborns. In many cases, treatment is simple and effective. However, the condition can become dangerous if bilirubin levels rise significantly, reaching the brain and potentially causing damage to sensory and motor centers.

Neonatal jaundice is defined as an increase in bilirubin levels in the newborn’s blood exceeding 5-7 mg/100 ml (Indirect bilirubin), which results from the breakdown of red blood cells. It manifests as a yellowish discoloration of the newborn’s skin and the whites of the eyes, gradually spreading downward towards the chest, abdomen, and eventually the feet.

Types of Indirect Hyperbilirubinemia:

• Physiological jaundice
• Pathological jaundice
• Breastfeeding-related jaundice (due to insufficient milk intake)

A. Physiological Jaundice

This type affects around 50% of newborns and appears between the second day and the tenth day of life, usually resolving by 14 days after birth. It generally does not reach dangerous bilirubin levels and does not require treatment except in certain cases as determined by a doctor after medical evaluation and laboratory tests.

Physiological jaundice occurs equally in both male and female newborns and is considered a normal condition due to the natural breakdown of red blood cells. Normally, the liver processes the excess bilirubin, converting it into direct bilirubin, which is then eliminated through stool. However, in newborns, particularly preterm infants, liver function is not yet fully developed. This immaturity makes it difficult for the liver to process bilirubin efficiently, leading to elevated indirect bilirubin levels in the blood.

Preterm infants are more susceptible to physiological jaundice due to their underdeveloped liver. For these infants, treatment is usually required when bilirubin levels reach 14–16 mg/100 ml.

B. Pathological Jaundice (Non-Physiological Jaundice)

This type is less common but far more dangerous than physiological jaundice, as bilirubin levels can rise to over 25 mg/100 ml, potentially leading to brain damage, hearing loss, cerebral palsy, mental retardation, and motor impairment.

Causes of Pathological Jaundice:

• Blood incompatibility between mother and infant, such as:
• Rh incompatibility (Rh–incompatibility)
• ABO blood group incompatibility (ABO–incompatibility)
• This results in the mother's immune system attacking the newborn’s red blood cells, leading to severe hemolysis and dangerously high bilirubin levels. This condition often occurs within the first 24 hours after birth and requires urgent medical treatment.
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency (Favism)
• Neonatal sepsis (blood infection)
• Cephalhematoma (bleeding under the scalp) or bruising under the skin
• Hypothyroidism (low thyroid hormone levels)
• Polycythemia (high red blood cell count), often seen in infants of diabetic mothers or cases of delayed cord clamping
• Liver enzyme deficiency (Glucuronyl transferase enzyme deficiency)
• Prematurity and low birth weight

C. Breastfeeding-Related Jaundice (Not-Enough Breast Milk Jaundice)

This occurs in the first days after birth due to inadequate milk intake, either because of insufficient breastfeeding frequency or the newborn’s difficulty in latching onto the breast properly.

Treatment:
Increasing breastfeeding frequency helps to enhance stool output, thereby eliminating bilirubin more quickly.

Nurse's Assessment of Jaundice:

1. Medical History Collection:

• Mother’s blood type and Rh factor
• Family history of genetic red blood cell disorders (e.g., G6PD deficiency)
• History of jaundice in previous siblings due to blood incompatibility
• Maternal diabetes, infections, or medication use during pregnancy
• Gestational age at birth
• Difficult or prolonged labor, signs of fetal distress (asphyxia)
• Timing of jaundice onset and parental observations
• Associated symptoms (e.g., lethargy, poor feeding, decreased activity)

2. Newborn Examination:

Skin Examination:

• Yellowish or orange discoloration (indicative of indirect bilirubin increase)
• Presence of bruising, scalp bleeding (cephalhematoma), or skin infections
• Areas affected by jaundice indicate bilirubin levels:

Signs of Red Blood Cell Hemolysis:

• Pale skin
• Rapid heartbeat
• Dark urine color

Signs of Bilirubin Deposits in the Brain (Kernicterus):

• Poor sucking and feeding
• Abnormal crying
• Stiff or abnormal body posture
• Altered consciousness (lethargy, stupor)
• Seizures or abnormal movements

Laboratory Tests:

• Total & direct bilirubin levels
• Blood type & Rh factor (mother and infant)
• Direct Coombs test
• Complete blood count (CBC) & red blood cell morphology
• Reticulocyte count
• G6PD enzyme deficiency test

Treatment

• Ensure adequate hydration by:
• Breastfeeding every 1-2 hours
• Administering IV fluids if necessary

• Do not stop breastfeeding
• Do not give glucose solutions orally
• Use phototherapy or exchange transfusion as prescribed by the physician

Direct Hyperbilirubinemia (Conjugated Jaundice):

This occurs due to biliary obstruction, bacterial or viral infections, or metabolic disorders. The newborn may appear greenish-yellow, and stools may be pale-colored (as seen in biliary atresia).

- Phototherapy Treatment

Objective:
To reduce indirect bilirubin levels by exposing the newborn to blue/white light with a wavelength of 425-475 nm, preventing brain damage.

- Exchange Transfusion

Objective:
To remove excess bilirubin and replace damaged red blood cells covered with antibodies.

Blood Requirements:

• Fresh whole blood (not packed red cells)
• Free from infectious diseases
• Less than 48 hours old
• Compatible with the mother’s blood

Post-Exchange Transfusion Procedures