International Journal of Biomedical and Advance Research

NEONATAL JAUNDICE: A REIE!

Ba"ita A#ar$al %& Ashok Belde ,Pramod Sakpal , Rahul Khiste and Pramod Ingale
Marathwada Mitra Mandals College of Pharmac, !hergaon, Kalewadi, Pune"
##, Maharashtra, India$
E'mail of Corres(ondin# author% "a"ita)a)a#ar$al*+ahoo,co,in
A"stract
&aundice occurs in most new'orn infants$ Most (aundice is 'enign, 'ut 'ecause of the
potential to)icit of 'iliru'in, new'orn infants must 'e monitored to identif those who
might de*elop se*ere hper'iliru'inemia and, in rare cases, acute 'iliru'in encephalopath
or kernicterus$ !he focus of this article is to reduce the incidence of se*ere
hper'iliru'inemia and 'iliru'in encephalopath while minimi+ing the risks of unintended
harm such as maternal an)iet, decreased 'reastfeeding, and unnecessar costs or
treatment$ Although kernicterus should almost alwas 'e pre*enta'le, cases continue to
occur$ !his article pro*ides a framework for the pre*ention and management of
hper'iliru'inemia in new'orn infants of #, or more weeks of gestation$
-e+$ords: &aundice- .)trinsic causes- intrinsic causes- treatment
., Introduction
.'/
common cases, (aundice ma
A common condition in new'orns, indicate the presence of another
(aundice refers to the ellow color of the condition, such as an infection or a
skin and whites of the ees caused ' throid pro'lem$ !he American
e)cess 'iliru'in in the 'lood$ Biliru'in Academ of Pediatrics /AAP0
is produced ' the normal 'reakdown of recommends that all infants should
red 'lood cells$1ormall, 'iliru'in 'e e)amined for (aundice within a
passes through the li*er and is e)creted few das of 'irth$
as 'ile through the intestines$ &aundice 0, Causes
2-4, 8- 9
occurs when 'iliru'in 'uilds up faster In neonates, (aundice tends to
than a new'orn2s li*er can 'reak it down
de*elop 'ecause of two factors " the
and pass it from the 'od$ Reasons for
'reakdown of fetal hemoglo'in as it
this include% is replaced with adult hemoglo'in
1ew'orns make more 'iliru'in than
and the relati*el immature hepatic
adults do since the ha*e more turn
meta'olic pathwas which are una'le
o*er of red 'lood cells$
to con(ugate and so e)crete 'iliru'in
A new'orn 'a'2s still"de*eloping as 3uickl as an adult$ !his causes an
li*er ma not et 'e a'le to remo*e accumulation of 'iliru'in in the 'lood
ade3uate 'iliru'in from the 'lood$ /hper'iliru'inemia0, leading to the
!oo large an amount of 'iliru'in is smptoms of (aundice$
rea'sor'ed from the intestines If the neonatal (aundice does not clear
'efore the 'a' gets rid of it in the up with simple phototherap, other
stool$ causes such as 'iliar atresia, P4IC,
., 5igh le*els of 'iliru'in 6 usuall
'ile duct paucit, Alagille2s
sndrome, alpha 7 and other pediatric
a'o*e 8, mg 6 can cause deafness,
li*er diseases should 'e considered$
cere'ral pals, or other forms of
!he e*aluations for these include 'rain damage in some 'a'ies$ In less
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Revie$ Article A#ar$al et al #9:
'lood work and a *ariet of o Breast milk feeding$
diagnostic tests$ Prolonged neonatal
(aundice is serious and should 'e
2.3 Nonhemolytic
causes
followed up promptl$ Se*ere
neonatal (aundice ma indicate the Cephalohematoma
presence of other conditions Polcthemia
contri'uting to the ele*ated 'iliru'in Sepsis
le*els, of which there are a large 5pothroidism
*ariet of possi'ilities$ !hese should ;il'ert2s sndrome
'e detected or e)cluded as part of the
Crigler"1a((ar sndrome
differential diagnosis to pre*ent the
de*elopment of complications$ !he 2.4 Hepatic causes
can 'e grouped into the following
categories%
Infections
2.1 Intrinsic causes of
hemolysis o Sepsis
o 5epatitis B
Mem'rane conditions

o !<RC5 infections
o Spheroctosis
Meta'olic
o ;alactosemia o 5ereditar elliptoctosis
Sstemic conditions o Alpha"7"antitrpsin
o Splenomegal
o
deficienc
Cstic fi'rosis
o Sepsis
=rugs
o Arterio*enous malformation
!otal parenteral nutrition
.n+me conditions
Idiopathic o ;lucose">"phosphate
dehdrogenase deficienc
2.5 Posthepatic /also called ;>P=
o
deficienc0

Biliar atresia
Pru*ate kinase deficienc
;lo'in snthesis defect Bile duct o'struction
o Sickle Cell =isease 1on"organic causes
o Alpha"thalassemia 1, T+(es of 2aundice:
0.'0/
2.2 Extrinsic causes of
hemolysis The most common t+(es of 2aundice
All immunit /!he neonatal or cord
are:
1,.
3h+siolo#ical 4normal5 2aundice:
'lood gi*es a positi*e direct
<ccurring in most new'orns, this mild
Coom's test and the maternal 'lood
(aundice is due to the immaturit of the
gi*es a positi*e indirect Coom's
'a'2s li*er, which leads to a slow test0
processing of 'iliru'in$ It generall
o 5emoltic disease of the
appears at 8 to ? das of age and
new'orn /AB<0
o
disappears ' 7 to 8 weeks of age$
Rh disease
1,0 Jaundice of (rematurit+: <ccurs
o 5emoltic disease of the
fre3uentl in premature 'a'ies since
new'orn /anti"Kell0
o
the are e*en less read to e)crete
5emoltic disease of the
'iliru'in effecti*el$ &aundice in
new'orn /anti"Rhc0
o
premature 'a'ies needs to 'e treated at a
<ther 'lood tpe mismatches
lower 'iliru'in le*el than in full term
causing hemoltic disease of the 'a'ies in order to a*oid complications$
new'orn
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Revie$ ArticleA#ar$al et al #97
3.3 Breastfeedin# 2aundice: &aundice can
occur when a 'reastfeeding 'a' is not
getting enough 'reast milk 'ecause of
difficult with 'reastfeeding or 'ecause the
mother2s milk isnt in et$ !his is not caused
' a pro'lem with the 'reast milk itself, 'ut
' the 'a' not getting enough to drink$
3.4 Breast mil6 2aundice% In 7@ to 8@ of
'reastfed 'a'ies, (aundice ma 'e caused '
su'stances produced in their mother2s 'reast
milk that can cause the 'iliru'in le*el to rise$
!hese can pre*ent the e)cretion of 'iliru'in
through the intestines$ It starts after the first
# to , das and slowl impro*es o*er # to 78
weeks$
3.5 Blood #rou( incom(ati"ilit+ 4Rh or
ABO (ro"lems5: If a 'a' has a different
'lood tpe than the mother, the mother might
produce anti'odies that destro the infant2s red
'lood cells$ !his creates a sudden 'uildup of
'iliru'in in the 'a'2s 'lood$ Incompati'ilit
(aundice can 'egin as earl as the first da of
life$ Rh pro'lems once caused the most se*ere
form of (aundice, 'ut now can 'e pre*ented
with an in(ection of Rh immune glo'ulin to the
mother within A8 hours after deli*er, which
pre*ents her from forming anti'odies that
might endanger an su'se3uent 'a'ies$
/, 7+m(toms:
.8'.9
!he signs and smptoms will depend largel
on the cause$ .)tremel high le*els of
'iliru'in in infants ma cause kernicterus, a
form of 'rain damage$ Signs of se*ere
hper'iliru'inemia include listlessness,
high"pitched cring, apnea /periods of not
'reathing0, arching of the 'ack, and sei+ures$
If se*ere hper'iliru'inemia is not treated, it
can cause mental retardation, hearing loss,
'eha*ior disorders, cere'ral pals, or death$
In the phsiological group the (aundice is onl
noted on the second or third da$ !he 'a'
feeds well, 'eha*es normall and there is no
enlarged li*er or spleen
on e)amination$
!he urine ma
'e dark 'ut the
stools are
normal colour$
!he 'iliru'in
le*els are not
significantl
raised, 'elow
8A, BmolCl$ !he
(aundice
resol*es o*er
two to three
weeks$
Breastmilk
(aundice
'ecomes
apparent after a
few das- the
!SB rarel
e)ceeds 8A,
BmolCl 'ut it is a
cause of
prolonged
(aundice- the
'a' remains
completel well
and continues to
thri*e$ It is not a
reason to stop
'reastfeeding$
:, Dia#nosis
.:&
0;& 0/
:,. E<ams and
Tests
:& 9& ..
All new'orns
should 'e
e)amined for
(aundice at least
e*er D to 78
hours for the
first da of
life$An infant
who appears
(aundiced in the
first 8? hours
should ha*e
'iliru'in le*els
measured
immediatel$
!his can 'e done
with a skin or
'lood test$
Ba'ies should
'e assigned a
risk for later
de*eloping
(aundice 'efore
the lea*e the
hospital$ Ba'ies
are classified as
low risk, low
intermediate
risk, high
intermediate
risk, or high
risk$ Man
hospitals do this
' routinel
checking total
'iliru'in le*els
on all 'a'ies at
a'out 8? hours
of age$
4urther testing
*aries on the
infant2s specific
situation and
test results$ 4or
e)ample, the
possi'le cause
of the (aundice
should 'e
sought for
'a'ies who
re3uire
treatment or
whose total
'iliru'in le*els
are rising more
rapidl than
e)pected$
1 !esting " A
full range
of routine
and
specialt
diagnostic
testing is
a*aila'le,
including
MRI and
P.! scans,
e*oked
potentials /ABR, S.P, E.P0- .M;,
..;, *ideo ..;, sleep studies,
meta'olic and genetic testing,
auditor,and neuropschological testing
2 Complete
'lood
count
3 Coom'2s
test
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Revie$ Article A#ar$al et al #98
Measurement of le*els of specific e)cess 'iliru'in into a water"solu'le
tpes of 'iliru'in form that can 'e e)creted in 'ile and
Reticulocte count
urine$ !he infant recei*es treatment
usuall in an incu'ator, for
!he le*el of al'umin in the 'a'2s 'lood appro)imatel two to three das$
ma also 'e checked$ Fow al'umin
An old traditional her'al remedfor
le*els ma increas
neonatal (aundice with a newl
:,0 Non'invasive measurement of identified risk$ Gin"chen /Artemisia
2aundice
:'9
scoparia0 is a *er popular intra*enous
!his method is more accurate and less
her'al preparation used for the treatment
of neonatal (aundice in China$ Biliru'in"
su'(ecti*e in estimating (aundice$
protein titration studies with the horse
:,0,. In#ram icterometer% In this radish pero)idase method ha*e shown
method a piece of transparent plastic that the her' is highl effecti*e in
known as Ingram icterometer is used$ displacing 'iliru'in from its protein
Ingram icterometer is painted in fi*e 'inding$ 4ree 'iliru'in is li'erated in
trans*erse strips of graded ellow lines$ this process and this could increase the
!he instrument is pressed against the risk of 'rain damage in (aundiced
nose and the ellow colour of the infants$ Hith the present state of
'lanched skin is matched with the knowledge, the use of traditional her'al
graded ellow lines and 'iluri'in le*el is therapies should 'e strongl discouraged
assigned$ in neonates$
:,0,0Transcutaneous "iliru"inometer% 8,. 3hotothera(+
.& 1& 9
!his is hand held, porta'le and
recharga'le 'ut e)pensi*e and
sophisticated$ Hhen pressure is applied
to the photopro'e, a )enon tu'e
generates a stro'e light- and this light
passes through the su'cutaneous tissue$
!he reflected light returns through the
second fi'er optic 'undle to the
spectrophotometric module$ !he
intensit of the ellow color in this light,
after correcting for the hemoglo'in, is
=i#,.' Ne$"orn infant under#oin# measured and instantl displaed in
ar'itrar units$ 4$hite li#ht5 (hotothera(+ to treat
8, Treatment
.>& 0:& 0>
neonatal 2aundice
A ma(or concern with (aundice is the
Infants with neonatal (aundice
are
risk of *er high concentrations of treated with colored light called
'iliru'in reaching the 'rain and causing
phototherap$ Phsicians randoml
damage$ But studies show that most
assigned >> infants #, weeks
of
'a'ies who suffer such 'rain damage
gestation to recei*e phototherap$ After
ha*e underling illnesses or conditions,
7,I, the le*els of 'iliru'in, a ellowish
such as complete ina'ilit of the li*er to
'ile pigment that in e)cessi*e amounts
process 'iliru'in$
causes (aundice, were decreased down
=octors usuall use phototherap, or to :$8AI:$8, mgCdlCh in the 'lue light$
light treatment, to 'ring down 'iliru'in !his shows that 'lue light therap helps
le*els$ !he infant is placed under special reduce high 'iliru'in le*els that cause
fluorescent lamps that con*ert the
neonatal (aundice$ .)posing infants to
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Revie$ ArticleA#ar$al et al #9#
high le*els of colored light 'reaks down the
'iliru'in$ Scientists studied >7> capillar
'lood samples from (aundiced new'orn
infants$ !hese samples were randoml di*ided
into three groups$ <ne group contained 7##
samples and would recei*e phototherap with
'lue light$ Another group contained 8:8
samples would recei*e room light, or white
light$ !he final group contained 87, samples,
and was left in a dark room$ !he total 'iliru'in
le*els were checked at :, 8, ?, >, 8?, and ?D
hours$ !here was a significant decrease in
'iliru'in in the first group e)posed to
phototherap after two hours, 'ut no change
occurred in the white light and dark room
group$ After > hours, there was a significant
change in 'iliru'in le*el in the white light
group 'ut not the dark room group$ It took ?D
hours to record a change in the dark room
groups 'iliru'in le*el$ Phototherap is the
most effecti*e wa of 'reaking down a
neonates 'iliru'in$
Phototherap works through a process of
isomeri+ation that changes the 'iliru'in into
water"solu'le isomers that can 'e passed
without getting stuck in the li*er$
In phototherap, 'lue light is tpicall used
'ecause it is more effecti*e at 'reaking down
'iliru'in /Amato, Inae'nit, 79970$ !wo
matched groups of new'orn infants with
(aundice were e)posed to intensi*e green or
'lue light phototherap$ !he efficienc of the
treatment was measured ' the rate of
decline of serum 'iliru'in, which in
e)cessi*e amounts causes (aundice,
concentration after >, 78 and 8? hours of
light e)posure$ A more rapid response was
o'tained using the 'lue lamps than the green
lamps$ 5owe*er, a shorter phototherap
reco*er period was noticed in 'a'ies
e)posed to the green lamps$ ;reen light is
not commonl used 'ecause e)posure time
must 'e longer to see dramatic results$
Fight therap
ma increase the
risk of ne*i, or
skin moles$
Increased
feedings help
mo*e 'iliru'in
through the
neonates
meta'olic
sstem
!he light can 'e
applied with
o*erhead lamps,
which means that
the 'a'2s ees
need to 'e
co*ered, or with
a de*ice called a
Bili'lanket,
which sits under
the 'a'2s
clothing close to
its skin$
8,0
E<chan#e
transfusio
n:
.:& .?& .9

Indication
s
Fess fre3uentl,
when neonatal
(aundice is more
se*ere, and
fluorescent light
therap is una'le
to 'reak down all
circulating
'iliru'in,
e)change
transfusion is
often used$ 5igh
le*els of
'iliru'in in the
'lood can lead to
'rain damage
and other serious
pro'lems$ In
these cases,
e)change
transfusion is a
life"sa*ing
procedure
designed to
counteract the
effects of serious
(aundice,
infection, or
to)icit$ !he
procedure
in*ol*es the
staged remo*al
of the infant2s
'lood and
replacement
fresh donor
'lood or plasma$
=i#,0' 3icture
de(ictin#
transfusion in
Neonates
;uidelines for
an e)change
transfusion
include%
1 5emolti
c disease
of the
new'orn
/Rh
disease0
2 Fife"
threatening
infection
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1 Se*ere distur'ances in 'od
chemistr
2 !o)ic effects of drugs
3 Polcthemia
3rocedure
!he infant is laid on his or her 'ack, usuall
under a radiant warmer$ !he um'ilical *ein is
catheteri+ed with a fluid"filled catheter$ !he
catheter is connected to an e)change
transfusion set, incorporating lines to and from
a waste container and a pack of donor 'lood$
!hese are connected ' means of a four"wa
stopcock, to which is also attached the sringe
used to remo*e and replenish the infant2s
'lood$ !he e)change transfusion now goes
ahead in ccles, each of a few minutes
duration$ Slowl the infant2s 'lood is
withdrawn, and the fresh, pre"warmed 'lood
or plasma is in(ected$ After the e)change
transfusion, an um'ilical catheter ma 'e left
in place in case the procedure needs to 'e
repeated within a few hours$
6.3@ome Treatment
..'.0

2 Parents are often asked to watch their
new'orns for signs of (aundice, which
produces a ellow tint to the skin and ees$
Man mothers and their new'orns lea*e
the hospital within ?D hours of the 'a'2s
'irth, often 'efore signs of (aundice
de*elop$ It is recommended that our
infant ha*e a follow"up e)am with our
health professional within the first , das
after 'irth$
3 If our 'a' has (aundice 'ut does
not need phototherap, our 'a'2s
doctor will ask ou to watch for and
report an signs of increasing (aundice or
changes in 'eha*ior$ !o check for signs
of increasing (aundice%
4 Jndress our 'a' and look at his or
her skin closel twice a da$ 4or
dark"skinned
'a'ies, look
at the white
part of the
ees to
check for
(aundice$
Remem'er
that our
'a' will get
cold 3uickl
when
undressed$
Co*er our
'a' after
a'out 7
minute$
1 Check
our 'a' at
the same
time of da,
in the same
room, under
the same
lighting
conditions
each time$ If
ou think
that our
'a'2s skin
is getting
more ellow,
call our
health
professional$
2 !he 'est
home
treatment for
(aundice is
fre3uent
feedings,
whether
'reast"
feeding or
'ottle"
feeding$
4eeding our
'a'
fre3uentl
/a'out D to
78 times a
da0 will
pro*ide him
or her with
the fluids
needed to
get rid of the
e)tra
'iliru'in$
3 Ba'ies
with
(aundice
who are
otherwise
health ma
'e treated at
home with a
tpe of
phototherap
that uses a
fi'er"optic
wrap,
usuall a
'lanket or a
'and$ !hese
wraps
usuall
reduce 'lood
'iliru'in
le*els more
slowl than
standard
phototherap
, so
generall
the are
used onl
for mild
(aundice$
Sometimes
standard
therap and
fi'er"optic
wrap therap
are used
together$
4 If our
'a' is
'eing treated
at home for
(aundice, it
is important
that ou
understand
how to use
all of the
e3uipment$ Ask our 'a'2s doctor for
help if ou ha*e 3uestions or concerns$
Gou ma need to take our 'a' to a la'
each da to get his or her 'iliru'in
checked$ A home health nurse ma *isit
to make sure all is going well$
5 If our 'a' has 'een treated with
phototherap
, the ellow
tint to the
'a'2s skin
and ees
ma not
disappear
immediatel$
But if the
ellow tint
intensifies,
report it to
our health
professional$
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Revie$ Article A#ar$al et al #9,
Sometimes parents tr to treat their 'ecause uncon(ugated 'iliru'in is
(aundiced 'a'ies on their own neuroto)ic and can cause death in
without the proper e3uipment$ new'orns and lifelong neurologic
Placing a 'a' under lights at home, se3uelae in infants who sur*i*e
near a windowsill in the sunlight, or /kernicterus0$ 4or these reasons, the
outside in the sun will not lower the presence of neonatal (aundice fre3uentl
amount of 'iliru'in in his or her results in diagnostic e*aluation$
'lood$ Gour 'a'2s skin ma get .mphasis is gi*en on diagnostic
'urned ' the lights or the sun$ In techni3ues to detect the presence of
addition, our 'a' ma get too (aundice in neonates 'od$ 1eonatal
cold$ Special lights and controlled &aundice if diagnosed on time can 'e
surroundings are alwas needed to cured and the o*erall increase in death
treat (aundice safel$ rate of neonates due to this condition
Some mothers who 'reast"feed their
can 'e reduced$
Bi"lio#ra(h+:
'a'ies are concerned that the will
need to stop 'reast"feeding if their
., ;uton, Arthur, and &ohn 5all,
'a'ies de*elop (aundice$ !he
&ohn$ !e)t'ook of Medical
American Academ of Pediatrics
Phsiolog, Saunders, Septem'er
encourages women to continue
8::,
'reast"feeding new'orns with
0, ;ol(an, .dward 4$, Rapid Re*iew
(aundice who are otherwise health
Patholog
8nd edition$#>DK#>9$
and to focus on increasing the
8::A$
fre3uenc of feedings /a'out D to 78
1, <2Keefe, Fori /8::7":,":,0$
times e*er 8? hours0$ If our 'a'
LIncreased *igilance needed to
needs help getting enough milk, ou
pre*ent kernicterus innew'ornsL$
can use a lactation aid or ask our
American Academy of Pediatrics 7D
doctor or a lactation consultant to
/,0% 8#7$
help our 'a' latch on 'etter$
/, 4rom !he =ictionar of Cliches '
If our 'a' is hospitali+ed, ou &ames Rogers /Ballantine Books,
ma need to pump our 'reasts to 1ew Gork, 79D,0$
maintain our milk production$ Gou :, Maisels M&, ;ifford K$ 1ormal
can then take the milk to the hospital serum 'iliru'in le*els in the
for our 'a'2s feedings$ new'orn and the effect of 'reast"
Conclusion
feeding$ Pediatrics$ 1o* 79D>-
AD/,0%D#A"?#$
!his re*iew is a compilation of 8, Atkinson FR, .sco'ar ;&, !akama
information of neonatal (aundice with &I, 1ewman !B$ Phototherap use in
respect to its tpes, etiolog, smptoms, (aundiced new'orns in a large
diagnosis, treatment and pre*enti*e managed care organi+ation% do
measures$ &aundice is the most common clinicians adhere to the
condition that re3uires medical attention guidelineM Pediatrics$ 8::#-
in new'orns$ !he ellow coloration of
?,
777%e,,,$
the skin and sclera in new'orns with Moore F;, 1ew'err MA, 4ree'
(aundice is the result of accumulation of ;M, Crnic FS$ Increased incidence
uncon(ugated 'iliru'in$ In most infants, of neonatal hper'iliru'inemia at
uncon(ugated hper'iliru'inemia #,7:: m in
Colorado$
Am J Dis
reflects a normal transitional
>,
Child$ 4e' 79D?- 7#D/80%7,A">7$
phenomenon$ 5owe*er, in some infants, Sarici SJ, Serdar MA, Korkma+ A,
serum 'iliru'in le*els ma e)cessi*el et al$ Incidence, course, and
rise, which can 'e cause for concern
prediction of hper'iliru'inemia in
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Revie$ ArticleA#ar$al et al #9>
near"term and term new'orns$
Pediatrics$ 8::?- 77#%AA,"D:$
9. Finn S, Schoen'aum SC, Monson RR,
Rosner B, Stu''lefield P;, Ran K&$
.pidemiolog of neonatal
hper'iliru'inemia$ Pediatrics$ Apr
79D,- A,/?0%AA:"?$
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