Infant Jaundice and Birth Injuries

Newborn jaundice is a well-known and exceedingly common health condition experienced by infants during the first weeks of life.

Jaundice is observed in 2.4% to 15% of otherwise healthy newborns during the first two weeks after birth. (You can also find data suggesting that 60% of term newborns and 80% of preterm newborns will become clinically jaundiced, so it is hard to know what to believe.)Typically, jaundice is of little clinical significance and is considered physiologic.

Most babies with newborn jaundice are breastfed. Although not completely harmless, newborn jaundice is typically not cause for alarm. Jaundice usually resolves in days or a few weeks and often resolves with even limited sunlight exposure.

While breastfeeding is great, his kind of jaundice is rarely seen in formula-fed infants, affecting only .1% of newborns taking formula. Breastfed infants are far more likely to develop jaundice.  Infants with non-physiologic jaundice may appear normal and grow as expected during the first weeks after birth.

The risk is biliary atresia which impedes the flow of bile from the liver to the small intestine. This is the most common cause of cholestatic (non-physiologic) jaundice in this population. It is rare, impacting somewhere between 1 in 10,000 to 19,000 newborns, depending upon who you ask.

How do you tell the difference between physiologic and pathological jaundice? The careful doctor will simply plot hour-specific bilirubin on a graph. This is the kind of plan and diligence that protects newborn babies.

Ideally, the patient is identified as at-risk and is give something called RhoGAM and phototherapy. If that window passes, treatment of biliary atresia is surgical - called a Kasai procedure -- during the critical window of 8-10 weeks of age.

Newborns with biliary atresia with correctable lesions typically have good outcomes with direct drainage. If the child does not have a correctable lesion, the outcome will less clear. The fear is portal hypertension and the need for a liver transplant.

The risk of jaundice has increased since the 2017 AGOG guidelines suggested delayed umbilical cord clamping for both term and preterm infants for at least 30-60 seconds after birth.  This has benefits to the child but increases the risk of jaundice. This means that doctors should be prepared to monitor and treat neonatal jaundice, most likely using phototherapy.

Infant jaundice still needs to be taken seriously and properly monitored and managed by both parents and pediatricians alike. If newborn jaundice is ignored and not treated, more serious cases occasionally develop into a very serious and even life-threatening situation. In the worst-case scenario, untreated infant jaundice can eventually progress into a rare but deadly condition called kernicterus resulting in permanent injury to the brain.

So while the risk of long-lasting harm is low, the risks are so grave that infant jaundice still needs to be taken seriously and properly monitored and managed by both parents and pediatricians alike. If newborn jaundice is ignored and not treated, more serious cases occasionally develop into a very serious and even life-threatening situation.

In the worst-case scenario, untreated infant jaundice can  progress into a deadly condition called kernicterus resulting in permanent injury to the brain. There is also fear that bilirubin, the toxin produced by jaundice, may cause brain alterations that can lead to autism (although there is disagreement).  There is even the risk of death with severe jaundice. So pediatricians mustn't dismiss newborn jaundice without fully understand its severity.

The medical condition known as jaundice occurs when levels of unprocessed bilirubin circulating in the bloodstream become too high.

Bilirubin is a natural waste of the body's red blood cell recycling system. Red blood cells are the most common type of cell in human blood. Red blood cells are very unique because unlike all other cells they have no nucleus. This allows them to be flexible and change shape which allowing blood to flow through narrow veins and blood vessels in the body.

While the lack of a nucleus makes red blood cells more flexible it also limits their cell life span. The life and death of a red blood cell only last about 4 months. This means that literally millions of red blood cells are dying off and being replaced by new ones inside the body every day.

When red blood cells die off they get broken down and the reusable leftovers are basically recycled and the non-reusable leftovers are disposed of through the urine. The process of red blood cell breakdown is called hemolysis.

The yellowish substance called bilirubin is one of the main byproducts that are leftover from the continuous breakdown of red blood cells (hemolysis). Unlike other byproducts of hemolysis, bilirubin is not reusable elsewhere in the body so it does not get recycled. In fact, bilirubin can be toxic to the body at high levels. This means that bilirubin leftover from the breakdown of red blood cells must be regularly disposed.

Bilirubin comes in two forms inside the body: unconjugated and conjugated. When dying red blood cells are first broken down the bilirubin that is left is in the unconjugated form. Unconjugated bilirubin is not water-soluble which means it cannot be disposed of through urination. Unconjugated bilirubin will continue to circulate and build up in the bloodstream. Normally the unconjugated bilirubin is filtered into the liver where it is converted to conjugated bilirubin. Conjugated bilirubin is water soluble which allows it to be disposed of through urination.

Jaundice occurs when the liver is not able to process bilirubin fast enough to keep pace with hemolysis. In adults jaundice typically occurs when the liver is damaged or impaired by disease. Jaundice in infants occurs so frequently because their liver is often underdeveloped or as efficient when they are firstborn.

In the first few days of life, the baby's new liver simply gets overworked and has trouble processing bilirubin fast enough to keep up with red blood cell breakdown. The result is a sudden backlog of unprocessed bilirubin that starts to build up in the newborn's bloodstream.

Jaundice in newborns is usually very easy to identify and diagnose. The first signs of newborn jaundice generally appear within the first 24 hours of life. The condition and outward symptoms will gradually increase in severity over the next several days. In most normal cases, jaundice will start to disappear the following week.

The hallmark symptom of jaundice in babies and adults is yellowing of the skin and eyes. Bilirubin has a strong yellow pigmentation so as levels of it in the blood increase it begins to alter the baby's color. The skin will begin to display a yellowish tint which is first noticeable in the face and chest. The white area in the eyes will also become noticeably yellow. Additional symptoms of babies with jaundice may include:

• General fatigue and poor feeding
• The baby seems jittery or abnormally cranky
• Intense crying with arched back
• High-pitch or abnormal sounding crying

Diagnosing infant jaundice is usually very easy. In most cases, the doctors at the hospital will confirm that a baby has jaundice before being discharged. The standard policy in most cases is to monitor the baby's condition to make sure the jaundice is progressing normally without signs of abnormality. Exposing the baby to direct sunlight is often the most simple treatment method to help speed up the processing of bilirubin.

For cases of jaundice that are more severe or which do not clear up on a normal time frame, doctors will need to intervene with additional levels of treatment. The second level of treatment for infant jaundice is phototherapy or light therapy.

This involves keeping the baby under a special light that emits the type of ultraviolet light waves that are known to stimulate the processing of bilirubin. If this is not successful the third level of treatment of very severe jaundice is blood replacement transfusion. Some of the baby's jaundiced blood is removed and replaced with a transfusion of non-jaundiced donor blood.

One management issue is making sure there is communication between the pedestrian, the emergency room, and the hospital.

• Abdellatif, Mohammed, et al. Massage therapy for the treatment of neonatal jaundice: A systematic review and network meta-analysis. Journal of Neonatal Nursing 26.1 (2020): 17-24. (This study looked at massage therapy’s effectiveness in treating infant jaundice. The researchers analyzed 27 studies. They found that massage therapy and phototherapy significantly reduced bilirubin levels compared to just phototherapy in infants ages three to four days. However, the researchers also found that the difference was insignificant after 14 days. They concluded that massage therapy helped reduce the phototherapy duration. However, they also concluded that it was not a phototherapy substitute.) 
• Ahmadipour, Shokoufeh, et al. Effect of synbiotic on the treatment of jaundice in full-term neonates: a randomized clinical trial. Pediatric Gastroenterology, Hepatology & Nutrition 22.5 (2019): 453-459. (This randomized clinical trial looked at how effective probiotics were at treating infant jaundice. The researchers split 83 full-term infants who underwent phototherapy into two groups. One group received synbiotics, while the other did not. The researchers found that the synbiotics group had lower serum bilirubin levels than the control group. They also found that they spent less time in the hospital. The researchers concluded that synbiotics were an effective treatment for jaundice.)
• Linder N, et al. Unexplained neonatal jaundice as an early diagnostic sign of septicemia in the newborn. J Perinatol 1988; 8:325-327. (This study looked at the association between hyperbilirubinemia and bacterial infections within a baby’s first weeks. The researchers’ data comprised 93 hyperbilirubinemic infants. They found that three of them developed septicemia. The researchers concluded that healthcare providers should consider bacterial infections a potential hyperbilirubinemia cause.) 
• Maisels MJ, Newman TB. Kernicterus in otherwise healthy, breast-fed term newborns. Pediatrics 1995; 96:730-733. (This study looked at the kernicterus occurrence among full-term, breast-fed infants who were born healthy. The researchers reviewed 22 medical malpractice cases involving infant hyperbilirubinemia-caused brain damage. They narrowed their data to six infants. All six underwent at least one exchange transfusion. Five of them showed no hemolysis signs. The researchers concluded that healthy, full-term babies with no hemolysis may occasionally suffer from kernicterus. They also concluded that there was no reliable way to timely detect and prevent hyperbilirubinemia.)
• Olusanya, Bolajoko O., et al. "Maternal detection of neonatal jaundice during birth hospitalization using a novel two-color icterometer." PLOS ONE 12.8 (2017): e0183882. (This study looked at whether Bilistrips could reliably detect significant jaundice within a baby’s first weeks. Over 2,400 mother-infant pairs participated in the 15-month study. The researchers found that Bilistrips detected significant jaundice with accuracy. It was able to detect over 95 percent of cases that required phototherapy. The researchers concluded that Bilistrips could help mothers detect significant jaundice in their babies.)