Newborn Jaundice

Something to share. Kenapa anak kita terkena jaundis?

Neonatal jaundice is extremely common. As a practicing pediatrician, I get many questions about what it is and how it should be treated.

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What is Jaundice?

Jaundice -- a yellow coloring of the skin and eyes -- occurs in approximately 60 percent of full-term newborns.

It is generally a temporary condition that does not cause babies harm and does not require any treatment. However, a few babies do require treatment -- both when they are in the newborn nursery and for a short period after they return home.

Jaundice is caused by a pigment that we all have in our blood called bilirubin. Bilirubin is released into the blood by the normal breakdown and turnover of red blood cells, which naturally occurs all the time. It is then processed by the liver into a form that can be removed in the digestive tract.

Newborns typically develop higher bilirubin levels than adults over the first few days of life because they have higher levels and faster turnover of red blood cells -- and produce more bilirubin. Their livers are also immature and less able to remove the bilirubin from their bodies. These factors lead to physiologic jaundice.

The yellow coloring of a baby with physiologic jaundice will often be noticeable around two days of life, will peak at three to five days, and will then resolve within two weeks. Physiologic jaundice poses no danger to the newborn.
Jaundice can develop when red blood cells break down and bilirubin is left. It is normal for some red blood cells to die every day. In the womb, the mother's liver removes bilirubin for the baby, but after birth the baby's liver must remove the bilirubin. In some babies, the liver might not be developed enough to efficiently get rid of bilirubin. When too much bilirubin builds up in a new baby's body, the skin and whites of the eyes might look yellow. This yellow coloring is called jaundice. 
Jaundice usually appears first on the face and then moves to the chest, belly, arms, and legs as bilirubin levels get higher. The whites of the eyes can also look yellow. Jaundice can be harder to see in babies with darker skin color. Your baby's doctor or nurse can test how much bilirubin is in your baby's blood.

Risk Factors for Pathologic Jaundice

Pathologic jaundice, however, involves a higher level of bilirubin and requires treatment to hasten the removal of bilirubin. This can occur in any newborn who has an exaggerated form of physiologic (normal) jaundice. There are also risk factors that can help guide clinicians as to which babies must be followed more carefully.

• One risk factor is prematurity -- babies born more than two weeks before their due date are more likely to develop higher levels of bilirubin. The more premature a child is, the less mature their liver is at the time of birth, and the harder it is for them to start eliminating the bilirubin.

• A blood type incompatibility between the mother and baby is also a reason to track the newborn’s jaundice more closely. This exists when a mother has the blood type O (and therefore has antibodies against A and B cells) and her newborn is of blood type A or B. This may cause the newborn’s red blood cells to break down more quickly due to maternal antibodies that have leaked into the baby’s bloodstream.
  
  Remember that there are three main blood types, including types A, B, and O. Since babies inherit their blood type from each parent, it is possible for a mother and baby to have different blood types. For example, a mother who is type O and a father who is type A could have a baby who is type A.
  With an ABO incompatibility, a mother makes antibodies against her baby's blood type. It doesn't happen if the mother and baby have the same blood type or if the baby is type O, since in that case, there is usually nothing to make antibodies against.
  
  These antibodies, if the mother is type O, can cross the placenta and can break down the baby's red blood cells after she is born, leading to jaundice and anemia. This condition is called Hemolytic Disease of the Newborn or erythroblastosis fetalis, and it can also be caused by having an Rh incompatibility between a baby and mother.
  
  If a mother is type A or B and the baby has a different blood type other than type O, she can still make antibodies against the baby's red blood cells. These antibodies are too large to cross the placenta though, and so don't usually lead to any problems.
  
  Although many children with an ABO incompatibility do not need any treatment at all, some do require extensive phototherapy if the baby is very jaundiced. This is usually continued until the mother's antibodies are cleared from the baby's body, which happens on its own after a few days.
  An ABO incompatibility that leads to jaundice, anemia, and the need for transfusions can definitely happen if the mother is type O and the baby is either type A or B.
  
  A-B-O incompatibility occurs when: 
  
  1. the mother is type O and the baby is B, A, or AB
  2. the mother is type A and their baby is B or AB 
  3. the mother is type B and their baby is A or AB

• A blood type incompatibility also exists if the mother has a Rh (Rhesus) factor negative blood type and the newborn is Rh factor positive. This had been a common cause of severe neonatal jaundice, but is now very uncommon because Rh immune globulin (Rhogham) is given to mothers at risk before delivery.
  Rh incompatibility occurs when a mother has Rh-negative blood and the baby has Rh-positive blood. The mother’s body will produce an auto-immune response that attacks the fetus or newborn’s blood cells as if they were a bacterial or viral invader. This immune response is fairly slow to develop and is rarely a serious issue in first pregnancies. However, subsequent pregnancies with an Rh incompatibility are a significantly higher risk.
  
  Blood type incompatibility can be prevented with a blood test early in pregnancy. If an Rh incompatibility is found, an Rh-immune globulin treatment is administered about 28 weeks into the pregnancy. If the incompatibility is not detected, the newborn can develop severe jaundice leading to brain damage. While it can have serious consequences, jaundice in newborns is common and treatable; medical attention is necessary at the first sign of yellowish discoloration in the skin or eyes.

• Although breastfeeding is also considered a risk factor, it is actually lack of effective breastfeeding that is the risk factor. The likelihood of problems with nursing are minimized by nursing the newborn as soon after birth as possible and to continue nursing eight to 12 times per day for the first several days. Breast milk is an ideal food for babies, and jaundice is usually not a reason to add formula to the diet. Breastfeeding jaundice is seen in breastfed babies during the first week of life, especially in babies who do not nurse well or if the mother's milk is slow to come in. Breast milk jaundice may appear in some healthy, breastfed babies after day 7 of life. It usually peaks during weeks 2 and 3. It may last at low levels for a month or more. It may be due to how substances in the breast milk affect how bilirubin breaks down in the liver. Breast milk jaundice is different than breastfeeding jaundice.

• Other risk factors for pathologic jaundice include excessive bruising of the newborn, having a sibling that required treatment for jaundice, and being of East Asian race.

• Jaundice in the first 24 hours of life is never physiologic and always merits an evaluation.

• Things that make it harder for the baby's body to remove bilirubin may also lead to more severe jaundice, including: 

1. Certain medications
2. Congenital infections, such as rubella, syphilis and others
3. Diseases that affect the liver or biliary tract, such as cystics fibrosis or hepatitis
4. Low oxygen level (hypoxia)
5. Infections (such as sepsis)
6. Many different genetic or inherited disorders.

Are some babies more likely to be jaundiced?

About 60% of all babies have jaundice. Some babies are more likely to have severe jaundice and higher bilirubin levels than others. Babies with any of the following risk factors need close monitoring and early jaundice management:

• Sibling: A baby with a brother or sister that had jaundice is more likely to develop jaundice.
• Bruising: A baby who has bruises at birth is more likely to have jaundice. A bruise forms when blood leaks out of a blood vessel and causes the skin to look black and blue. Then, when the bruise begins to heal, red blood cells die. Bilirubin is made when red blood cells break down. The healing of large bruises may cause high levels of bilirubin, and the baby may become jaundiced.
• Preterm babies: Babies born before 37 weeks, or 8 ½ months, of pregnancy may become jaundiced because their liver may not be fully developed. The young liver may not be able to get rid of so much bilirubin. If too many red blood cells break down at the same time, the baby can become very yellow or may even look orange.
• Feeding difficulties: A baby who is not eating, wetting, or stooling well in the first few days of life is more likely to get jaundice.
• Early jaundice: A baby who is yellow in the first 24 hours of life may get dangerously jaundiced.
• Heredity A: baby born to an East-Asian or Mediterranean family is at a higher risk of becoming very jaundiced. Also, jaundice is harder to see in babies with darker skin tones. Some families inherit conditions (such as G6PD), and their babies are more likely to become jaundiced.
• Blood type: Women with an O blood type or Rh negative blood factor might have babies with higher bilirubin levels. A mother with Rh incompatibility should be given Rhogam.

Detection

A physical exam is always important in assessing the level of jaundice. Jaundice causes a yellow color of the skin, first appears on the face, and, as the bilirubin level rises, spreads down the body, to the chest, belly area, legs, and soles of the feet. The yellow color is best appreciated in natural light, so doing the exam by a window is helpful. Sometimes, infants with significant jaundice have extreme tiredness and poor feeding.

Estimation of the level of jaundice by exam alone, however, is difficult and prone to errors. By obtaining blood though a prick of a newborn’s heel, an exact bilirubin level can be obtained.

How do you measure bilirubin?
Before leaving the hospital with your newborn, ask your doctor or nurse about a jaundice bilirubin test.
A doctor or nurse may screen your baby's bilirubin using a light meter that is placed on the baby's head (as pictured). This results in a transcutaneous bilirubin (TcB) level. If it is high, a blood test will likely be ordered.
The best way to accurately measure bilirubin is with a small blood sample from the baby's heel.
This results in a total serum bilirubin (TSB) level. If the level is high, based upon the baby's age in hours and other risk factors, treatment will likely follow. Repeat blood samples will also likely be taken to ensure that the TSB decreases with the prescribed treatment.

The American Academy of Pediatrics has provided guidelines as to which newborns should be treated for jaundice (“Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation,” Pediatrics, July 2004).

The necessity of treatment depends upon the bilirubin level, the newborn’s age in hours and the babies gestation. In general, the older the newborn, the higher the bilirubin level can be and not require treatment. For newborns with particular risk factors, such as prematurity, treatment is started at lower bilirubin levels for a given age in hours.

Complications of Extreme Jaundice

Extremely high levels of bilirubin can lead to the rare but serious condition of kernicterus, a form of brain damage that causes athetoid cerebral palsy and hearing loss. It also causes problems with vision and teeth and sometimes can cause mental retardation. . This is now a very rare condition with most cases occurring in premature or very ill babies. Treatment for jaundice starts at levels that are far lower that those that could cause kernicterus.

Who can develop kernicterus?

Any baby with untreated jaundice is at risk for kernicterus. This does not mean that every baby with yellow skin will have brain damage. Most babies with jaundice get better by themselves. If their skin is very yellow, they might need phototherapy treatment. If phototherapy does not lower the baby's bilirubin levels, the baby may need an exchange transfusion.

Ask your pediatrician to see your baby the day you call, if your baby:

• Is very yellow or orange (skin color changes start from the head and spread to the toes)
• Is hard to wake up or will not sleep at all
• Is not breastfeeding or sucking from a bottle well
• Is very fussy
• Does not have at least 4 wet or dirty diapers in 24 hours

No baby should develop brain damage from untreated jaundice. If a baby gets too jaundiced, the baby can be treated with phototherapy. That is, the baby can be put under blue lights most of the day. The blue lights do not bother the baby. They are warm and probably feel good. If the baby gets very, very jaundiced, the doctor can do an exchange transfusion.

Treatment

Your child will need treatment if the bilirubin level is too high or is rising too quickly.
Keep the baby well hydrated with breast milk or formula. Frequent feedings (up to 12 times a day) encourage frequent bowel movements, which help remove bilirubin through the stools. Ask your doctor before giving your newborn extra formula.
Some newborns need to be treated before they leave the hospital. Others may need to go back to the hospital when they are a few days old. Treatment in the hospital usually lasts 1 to 2 days. Jaundice is generally treated before brain damage is a concern. Putting your baby in sunlight is not recommended as a safe way of treating jaundice. 

Light therapy (phototherapy) is the most common treatment for jaundice. The baby may be placed under ultraviolet light or on top of a fiber-optic blanket (“bili-blanket”) -- or both. The ultraviolet light converts the bilirubin into a form that can be removed from the body in the urine. These lights work by helping to break down bilirubin in the skin. The infant is placed under artificial light in a warm, enclosed bed to maintain constant temperature. The baby will wear only a diaper and special eye shades to protect the eyes. The American Academy of Pediatrics recommends that breastfeeding be continued through phototherapy, if possible. Rarely, the baby may have an intravenous (IV) line to deliver fluids.
Since bili-blankets are available for home use, many newborns can be treated for jaundice at home. Whether a baby is a candidate for home phototherapy depends on the level of the bilirubin and the reasons for the jaundice. Treatment generally takes several days.
When being treated for high bilirubin levels, your baby will be undressed and put under special lights. The lights will not hurt the baby. This can be done in the hospital or at home. The baby's milk intake may also need to be increased.

Rarely, an exchange blood transfusion may be performed to treat extremely high levels of bilirubin. This is done in a neonatal intensive care unit and involves removing small amounts of the baby’s blood at a time and replacing it with fresh blood repeatedly over several hours.

• You must keep the light therapy on your child's skin and feed your child every 2 to 3 hours (10 to 12 times a day).
• A nurse will come to your home to teach you how to use the blanket or bed, and to check on your child.
• The nurse will return daily to check your child's weight, feedings, skin, and bilirubin levels.
• You will be asked to count the number of wet and dirty diapers.

In the most severe cases of jaundice, an exchange transfusion is required. In this procedure, the baby's blood is replaced with fresh blood. Treating severely jaundiced babies with intravenous immunoglobulin may also be very effective at reducing bilirubin levels.

Prevention

As discussed above, physiologic jaundice is not a process that can or should be prevented. The likelihood of developing pathologic jaundice, or jaundice that requires treatment, can be minimized by frequent feedings. A newborn should feed at least eight to 12 times per 24 hours. A doctor or nurse should see your newborn between three to five days of age as this is when the bilirubin level usually peaks. You should certainly call your child’s physician if your newborn appears more jaundiced or if he or she is especially sleepy, fussy, or feeding poorly.

It is essential that a newborn’s jaundice be monitored closely by a health care professional. As most healthy newborns require only a brief hospital stay, prompt follow up in the primary care physician’s office is recommended.

In newborns, some degree of jaundice is normal and probably not preventable. The risk of significant jaundice can often be reduced by feeding babies at least 8 to 12 times a day for the first several days and by carefully identifying infants at highest risk.
All pregnant women should be tested for blood type and unusual antibodies. If the mother is Rh negative, follow-up testing on the infant's cord is recommended. This may also be done if the mother's blood type is O+, but it is not needed if careful monitoring takes place.
Careful monitoring of all babies during the first 5 days of life can prevent most complications of jaundice. Ideally, this includes:

• Considering a baby's risk for jaundice
• Checking bilirubin level in the first day or so
• Scheduling at least one follow-up visit the first week of life for babies sent home from the hospital in 72 hours

  

source:

http://pediatrics.about.com/od/weeklyquestion/a/04_abo_incmplty.htm

http://www.dukehealth.org/health_library/advice_from_doctors/your_childs_health/newbornjaundice

http://cerebralpalsy.org/about-cerebral-palsy/cerebral-palsy-risk-factors/blood-type-incompatibility-or-jaundice/

http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm

-- Joanne F. Band, MD, is a Duke pediatrician in charge of the Duke Full-term Nursery.
Dr. Joanne Band, a pediatrician in charge of the Duke Full-term Nursery at Duke, discusses jaundice -- its physiological and pathological features and treatments.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

It is important to note that this condition is usually transient and rarely causes significant medical problems.

-- Dennis Clements, MD, PhD