Review on Neonatal Jaundice

Neonatal jaundice is a term for elevated total serum bilirubin in newborns and infants less than one month of age. In other words, neonatal Jaundice is the yellowish coloration of the skin and the white part of the eye (the sclera). 1 Neonatal jaundice occurs in 60 % of term healthy neonates and 80 % of preterm neonates.2 It results from having too much of substance called bilirubin in the blood. Bilirubin is formed when the body breaks down old red blood cells. The liver usually processes and removes the bilirubin from the blood. Neonatal jaundice in babies usually occurs because of a normal increase in the red blood cell break down and the fact that their immature livers are not efficient at removing bilirubin from the bloodstream.

There are mainly two types of neonatal jaundice.

• Physiological jaundice

• Pathological jaundice

PHYSIOLOGICAL JAUNDICE is due to the physiologic immaturity, immaturity in steps results in the occurrence of in the first few days of life.

CHARACTERS OF PHYSIOLOGIC JAUNDICE: First appears between 24-72 hours of age, Maximum intensity seen on the 4-5th day in term neonates, Does not exceed 15 mg/dl and clinically undetected after 14 days.

PATHOLOGICAL JAUNDICE: Bilirubin levels that deviate from Normal range and require intervention i.e. presence of any of the following signs denotes that jaundice is pathological. Treatment is required in the form of phototherapy. Clinical jaundice detected before 24 hours of age, Rise in serum bilirubin by more than 5 mg/ dl/ day, Serum bilirubin more than 15 mg/dl, Jaundice persisting beyond 14 days of life and direct bilirubin >2 at any time.

Jaundice comes from the French word “jaune”, which means yellow. When it is said that a baby is jaundiced, it simply means that the color of his skin appears yellow. Jaundice in the infant appears first in the face and upper body and progresses downward toward the toes. Premature infants are more likely to develop jaundice than full-term babies. 3

In neonates, jaundice tends to develop because of two factors - the breakdown of fetal hemoglobin as it is replaced with adult hemoglobin and the relatively immature hepatic metabolic pathways which are unable to conjugate and so excrete bilirubin as quickly as an adult. This causes an accumulation of bilirubin in the blood, leading to the symptoms of jaundice.4

Each year in India over one million newborns die before they complete their first month of life, accounting for 30% of the world's neonatal deaths. India’s current neonatal mortality rate of 20 per 1000 live births. Asian male babies and Native American ones are reported to be most affected by Neonatal Jaundice13.4 million babies need treatment for jaundice every year.

Amongst all age group, neonates are most susceptible to mortality and morbidity. According to UNICEF newsletter on April 24, 2008, out of every four, a child dies under the age of one in the world, one is an Indian child. The infant mortality rate in the country is 67% per thousand live births, in which neonatal mortality contributes 43.4 /1000 against the annual death of 9 /1000 (2008). In India neonatal jaundice, contributes 4.55% death in the neonatal period. 6

According to the All India Institute of Medical Sciences protocol in neonatology, neonatal jaundice is the commonest morbidity in the neonatal period and 5-10% of all the newborns require interventions for pathological jaundice. Neonates on exclusive breastfeeding have a different pattern of physiological jaundice as compared to artificially fed babies. Separate guidelines have been provided for the management of jaundice in sick term babies, preterm and low birth weight babies for jaundice secondary to hemolysis and for prolonged neonatal jaundice. 7

Delayed initiation of breastfeeding or insufficient feeding result in poor mobility of the gut, that leads to poor excretion of bilirubin, resulting in accumulation of bilirubin leading to hyperbilirubinemia. Inadequate milk leads to delay the passage of meconium. Passage of baby through the vagina during birth helps stimulate milk production in the mother. When the baby is born by caesarian section the milk secretion is slightly delayed and the mothers will also be in pain and in sedation, so the feeding is delayed, these babies are at higher risk for this condition. Mothers should be aware of initiating breastfeeding as early as possible, either she had a caesarian section or had a normal delivery. 8

The complication of hyperbilirubinemia is kernicterus. It is due to the severe accumulation of unconjugated bilirubin. According to a study by Nasrin Khalesi, kernicterus causes 10% of mortality and 70% of morbidity among neonates. However, the correct use of phototherapy and timely blood exchange will control serum bilirubin level which can prevent complications. 9

Many cases of neonatal jaundice pass unnoticed or are identified late by mothers making them present to hospitals late. 10 This can lead to complications such as bilirubin encephalopathy and even death. Interventions to stop the progression of neonatal jaundice will reduce the morbidity and mortality associated with this condition. It is therefore important for mothers to recognize neonatal jaundice so as to seek for therapy early and prevent complications that arise due to neonatal jaundice. 10 This study is therefore designed to assess the knowledge, attitude, and practice of expectant mothers on NNJ with respect to their awareness, recognition, knowledge of risk factors/ causes, complications, treatment modalities, and initial step to take when it is noticed.