Jaundice (hyperbilirubinemia)

Hyperbilirubinemia refers to an excessive accumulation of bilirubin in the blood and is characterized by jaundice or yellowish discoloration of the skin and other organs.

Causes of Hyperbilirubinemia

• Physiological jaundice
• Pathological jaundice associated with liver disease
• Rh and ABO incompatibility
• Inherited cause of hemolytic disease
• Erythroblastosis fetalis
• Breast milk jaundice
• Jaundice due to sepsis
• Hemolysis due to drugs like quinine, poisons
• Congenital biliary atresia

Physiological jaundice in newborn

Jaundice

Yellowish discoloration of the mucous membrane due to increased serum bilirubin level of more than 4- 5 mg/dl in the blood of the newborn baby. Jaundice, also called icterus or hyperbilirubinemia, is a very common condition in newborn babies.

Physiological jaundice

Neonates develop visible jaundice due to an elevation of un-conjugated bilirubin during their first week of life is called physiological jaundice. More than half of all full-term newborns and 80% of a premature babies will develop physiological jaundices within the first few days of life. In a newborn, bilirubin level must exceed 5 mg/ dl to develop the clinical features of jaundice (yellowish discoloration of the skin, mucous membrane, and nails.)

Causes of Physiological jaundice

• Hemolysis of fetal RBC
• Immature hepatic function
• Increased enterohepatic circulation of bilirubin

Mechanism of physiological jaundice

A newborn produces twice much bilirubin as an adult. They have a higher concentration of erythrocytes with a shorter lifespan (60- 80 days) so a profound change in hepatic circulation after delivery impaired the ability of the liver to conjugate bilirubin due to deficiency of enzymes i.e. glucuronyl transferase. That ultimately decreased plasma concentration level results in low plasma binding for bilirubin. Besides these, the newborn's bowel is sterile and prevents the conversion of bilirubin by intestinal flora and exertion of urobilin in feces. Now the bilirubin is back in circulation through enterohepatic circulation and jaundice becomes visible clinically.

Sign and Symptoms

• Jaundice appears within 24 hours of birth
• Serum bilirubin is more than 15mg/dl
• Pallor, serious jaundice
• Generalized edema
• The bilirubin is increased to 5mg/dl
• There is a positive coomb’s test if it is associated with ABO or RH factor incompatibility.
• Positive G6PD test if it is associated with G6PD deficiency
• Jaundice persists for more than 14 days

Management

• Explain findings, diagnosis, and plan of care to mother and family using good communication/counseling.
• Start phototherapy if it exceeds more than normal according to age and body weight
• If the hemoglobin is less than 10gm/dl (hematocrit less than 30%) give a blood transfusion of 20ml/kg body weight over four hours.
• If the serum bilirubin level is increasing though the above measures are taken, and the comb’s test is positive, refer the baby for exchange transfusion
• If a baby has a G6PD deficiency, advise the mother about which substances to avoid to prevent hemolysis in the baby (e.g. anti-malarial drugs, sulfa drugs, aspirin, etc).
• If jaundice persists for 2 weeks or longer in a term baby or three weeks or longer in a small baby, treat for prolonged jaundice.