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Neonatal jaundice is not the consuming concern it was a decade ago. We now recognize the vast majority of cases to be physiologic jaundice, unassociated with the dangerous rise in bilirubin characteristic of pathological types.
What causes physiologic jaundice? While in utero, the baby's need for oxygen is met by a high level of red blood cells in its circulation, higher than for most adults. Once the baby is born and breathing oxygen directly, excess red blood cells must be broken down and eliminated from its system. A byproduct of this breakdown is bilirubin, which imparts a yellow tinge to the baby's skin. This is physiologic jaundice. It generally manifests on the second or third day postpartum, and is remedied when the mother's milk comes in to flush the baby's system clean.
Another kind of jaundice that seldom requires treatment is due to ABO incompatibility. This phenomenon is similar to Rh sensitization: if blood from an O mother transfers to her A or B type baby during delivery, the baby may develop excess bilirubin.
Breast milk jaundice is yet another non-threatening condition caused by a hormone in mother's milk which can interfere with the baby's ability to break down bilirubin by inhibiting the enzyme glucuronyl transferase, which is needed for breaking down (conjugation) of bilirubin. Unlike most other varieties of jaundice, it is unique in that it manifests after the milk comes in. Breast milk jaundice incidence is less than 0.5% of full-term newborns. It occurs after the mature breast milk has come in and may last up to 6 weeks. The levels of unconjugated bilirubin rises beyond physiological limits (15 to 20 mg/dl) by the seventh day. If the nursing is discontinued for 12 to 24 hours. the levels will subside by 5 to 10 mg, and 3 to 5 days pass before the previous level is again reached. It is not necessary for the mothers to completely discontinue breastfeeding and women should not be made to feel that their milk is pathological to their babies.
In contrast, pathological jaundice is caused by obstructed bile duct, liver disease, infection, or Rh hemolytic disease. This is easy to differentiate from physiologic jaundice as it generally manifests within the first 24 hours. However, jaundice from ABO incompatibility may also appear at this time. To be on the safe side, refer any jaundice on day one to a pediatrician. If jaundice is pathological, high levels of bilirubin may be nearly impossible for the baby to eliminate and may seep into the basal ganglia of the brain, leading to kernicterus, or permanent brain damage.
Although physiologic, ABO, and breast milk jaundice are essentially normal and self-correcting, they can occasionally cause the baby to become lethargic and disinterested in nursing. If the characteristic yellow tinge is noted on the baby's face and neck but runs no lower than the nipple line, encourage the mother to nurse often and expose the baby to sunshine (with its body naked and eyes protected) for 30 minutes twice daily. If the baby's extremities appear jaundiced, consult a pediatrician.
Depending on the degree and type of jaundice, the baby may be hospitalized for treatment. The most commonly used treatment is ultraviolet light exposure, in which the infant is placed under an ultraviolet lamp for a few hours each day. The ultraviolet light breaks down bilirubin into a form which the infant liver can process and excrete. If the baby is placed under bili-lights, it will have blood drawn periodically to assess bilirubin levels. If the bili-lights are used, it is crucial that the baby's treatment be properly supervised, as dehydration, burning, and possible genetic damage can occur with excessive exposure. Jaundiced babies also have increased risks of infections.
Babies kept in darkened rooms for the first few days tend to have higher bilirubin levels than those liberally exposed to sunlight. Lack of light is probably a more significant factor in extreme physiological jaundice than the favored theoretical cause, late cord clamping. Most midwives clamp the cord after it has ceased pulsing, and after placing the baby on the mother's belly or chest. They have very rarely had problems with severe jaundice except when lack of light has been a determining factor.
Cold stress (it is important to keep newborns warm), asphyxia neonatorium (newborn respiratory distress syndrome or respiratory failure), and neonatal hypoglycemia contribute to pathological levels of bilirubin by interfering with albumin binding of bilirubin. Babies born to mothers whose labors have been induced or augmented with pitocin must be watched carefully. Pitocin competes with bilirubin for binding sites, rendering elimination difficult. The same is true of certain drugs, such as diazepam, sulphonamides, steroids, and salicylates.
PHYSIOLOGIC JAUNDICE
(Total Serum bilirubin levels)
Up to 24 hours 2 to 5 mg/dl Nose: 3 mg
Face: 5 mgUp to 48 hours 9 mg/dl Chest: 7 mg Up to 3 to 5 days Less than 12 mg/dl Abdomen: 10 mg
Legs: 12 mgUp to 7 days Usually less than 15 mg Palms: 20 mg
Neonatal Hepatic System
Conjugated bilirubin (direct, soluble bilirubin):The conjugated form of bilirubin is excreted from liver cells. Along with other components of bile, direct bilirubin is thus excreted into the biliary tract system, beginning with the smallest of these ducts (the bile canaliculi) and ultimately ending at the common bile duct, which inserts into the duodenum. There, by the action of the bacterial flora, bilirubin is converted to urobilirubinogen and stercobilin and eliminated by way of the urine and feces.
Unconjugated bilirubin (indirect):The unconjugated bilirubin circulates bound to plasma albumin. Unbound bilirubin leaves the vascular bed and is deposited in body tissues (e.g., all organs, the skin, the sclera, oral mucous membranes), the resultant yellow coloring is termed jaundice.
Total serum bilirubin is the sum of conjugated and unconjugated bilirubin.
Hepatic immaturity, increased erythocyte (red blood cell) destruction, or the availability of inadequate serum albumin binding sites can result in hyperbilirubinemia (high bilirubin levels)
POSTPARTUM VISITS
PostPartum Visit - Day One
PostPartum Visit - Day Three
PostPartum Visit - Day Seven
Postpartum Baby Care & Concerns
MDBS Birthing Guidelines: Newborn Jaundice
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or your family member has questions about postpartum care and newborn jaundice.
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