JAUNDICE

While most children getting jaundice recover without much of a problem, some of them may need serious attention. Doctors get really concerned under the following circumstances:

• Jaundice appearing within 24 hours after birth.
• A child with jaundice who appears unusually sick, drowsy and anaemic or one who develops altered behaviour, or a bleeding tendency, or swelling of the body, or persistent vomiting with dehydration.

Physiological Jaundice In A Newborn Baby
Most jaundiced babies have what is known as normal or physiological jaundice. The jaundice normally appears after 30 hours of birth, gradually deepens and disappears on the 10th day. This happens due to slight immaturity of the baby’s liver. The child generally does not require any treatment. If the jaundice is severe, your doctor may like to rule out certain other causes of jaundice like an infection or rare causes like thyroid deficiency or galactosaemia — a rare inborn error of metabolism. Babies with galactosaemia are born with intolerance to galactose, one of the two sugars that make up the lactose present in milk.

The level of jaundice is known by estimating the level of serum bilirubin (the yellow pigment produced by the breakdown of red blood cells). In physiological jaundice, the bilirubin level usually does not exceed 20 mg./dl. In Indian and other Asian children, it may reach 25 mg./dl. without causing any problem to the child.

In case of high levels, your doctor may like to estimate the level of haemoglobin and may again test for bilirubin. A rise of 0.5 mg./dl. of bilirubin or more per hour or a falling haemoglobin level may need some intervention. Children who are born normally without any problem are usually quite safe, but those who are born prematurely or had lack of oxygen, low blood sugar or accumulation of acids in the body (acidoses) need extra care. 

Some jaundiced babies are sleepy and may not suckle too well or too often.

MANAGEMENT: Frequent suckling is the best way to reduce the incidence of jaundice and to treat it as well. Bilirubin is present in large amounts in the meconium — the baby’s first stools. If the meconium is not cleared, the bilirubin gets reabsorbed into the baby’s system. Colostrum (the first breast milk) helps to clear meconium and thus assists in the prevention of jaundice. If your baby gets enough breast milk, it helps to clear early jaundice. Giving glucose water, plain water or other supplements does not help. Such drinks interfere with breastfeeding and can increase the jaundice.

The best way you can help your baby with jaundice is by breastfeeding him frequently, whenever he is hungry (demand feeding) during the day or at night. If he is unusally sleepy, try to stimulate him every 2 hours. If he does not oblige, report to your doctor who may ask you to express your milk and give it to the baby with a small glass or bondla (paladai) every 3 hours.


Late Onset Jaundice In A Newborn Baby 
Sometimes, jaundice starts at the end of the first week of life in an otherwise healthy baby and may last up to 3 to 10 weeks of age. Often, this prolonged jaundice is not serious and is due to the presence of a harmless substance in the mother’s milk. That is why it is also sometimes labelled ‘breast milk jaundice’. It tends to recur in the next child. This jaundice is harmless and clears without any treatment. The baby continues to suckle well and gains weight normally. If the jaundice is very severe, especially if the baby looks unwell, your doctor may consider the possibility of the child having some other condition.

TREATMENT: The doctor may suggest temporary stoppage of breastfeeding to confirm the diagnosis of late onset jaundice. This would bring down the levels quickly, but do not agree to this suggestion too readily. In such a situation, you have the following options: 

• Express your milk. Boil it and give it to your baby by a bondla. Heating breast milk reduces the levels of bilirubin.
• Stop breastfeeding temporarily for 12 to 48 hours and give breast milk from another HIV-negative mother or from a breast milk bank*. Keep expressing your milk and discard it.
• Alternate artificial milk feeding and breastfeeding for 24 to 48 hours. I prefer this approach in anxious parents.
• Continue breastfeeding normally and give phototherapy (light therapy).
• Replace breastfeeding by artificial milk feeding for 12 to 48 hours while observing the reduction of bilirubin and the level of jaundice.

The moment the period of 12 to 48 hours is over, you must start breastfeeding normally again.

Very high levels of bilirubin can cause damage to the brain of a newborn baby. But no such damage has ever been reported due to late onset jaundice.

It is important to realise that even if a baby needs treatment (usually light therapy) for jaundice, you must continue to breastfeed your baby normally.


*Breast Milk Bank, C/o Head, Department of Neonatology, Lokmanya Tilak Municipal Medical College, Sion, Mumbai 400 022.


Light Therapy
Light therapy (phototherapy) is based on the principle that exposure of the skin to blue or fluorescent tube light, or daylight, converts bilirubin in a manner that it can be eliminated more easily from the body.

The baby is put under the light without clothes, with his eyes covered to prevent damage. The light is kept approximately 45 ems. above the infant. To avoid undue separation from your baby, you can request the nursing staff to bring the phototherapy unit next to your bed. If that is not possible, you should keep going to where the unit is kept and breastfeed your baby whenever he is hungry. Remove the cover from the baby’s eyes while breastfeeding.

Some babies may get loose motions while under the lights. This is normal. Others become a little irritable to begin with. Some may develop the so-called ‘dehydration fever’ due to loss of water from the body. You may be tempted to give water to the baby for this reason. This should be avoided. Frequent breastfeeding will provide the required amount of fluids in most cases.

For daylight, do not draw the curtains in your room. Direct sunlight can cause sunburn. But keeping the baby in the sun at about 10 a.m. for about 10 minutes, where possible, is advisable. This also helps in conversion of pro-Vitamin D in the baby’s skin to Vitamin D.


Jaundice Due To Blood Group Incompatibility
Rh incompatibility and ABO incompatibility between the mother and the foetus can result in jaundice in the newborn baby.

Your doctor will get your blood tested during pregnancy to find out if you are Rh-negative. If so, your baby will be observed closely for appearance of jaundice and for the rate of rise of bilirubin and his level of haemoglobin. Your doctor may also give you a special injection within 24 to 72 hours after delivery to prevent any trouble to your next baby.

ABO incompatibility is a relatively milder disease. The common combination is an 0 group mother and A or B group foetus.


Exchange Transfusion
An exchange transfusion is undertaken mostly in Rh incompatibility if the haemoglobin estimation of the cord blood of the baby is low or his cord bilirubin is high, or if the bilirubin levels after birth cross the safe levels.

It may also have to be undertaken in certain other situations like a whose bilirubin levels rise rather rapidly or babies with jaundice who also have added problems like infection, low blood sugar, etc.


Other Causes Of Jaundice In A Newborn Baby
Infections in a newborn baby are rare. Conditions like hypothyroidism and galactosaemia can also cause jaundice in the newborn.

Any jaundice that persists for over two weeks may need detailed investigations. If the child has white stools, it may be due to the flow of bile being obstructed. Such a child needs the urgent attention of a paediatric surgeon.


Jaundice In Older Children
CAUSES: The two common causes of jaundice in older children are infections or drugs affecting the liver. Certain drugs given for tuberculosis and epilepsy can cause jaundice. The common infections causing jaundice are hepatitis and malaria. In malaria, the child with jaundice may have very low haemoglobin. He is often very anaemic and may need blood transfusion.

11 February, 2013