What Causes Hyperbilirubinemia In Newborns

What Are The Causes Of Pediatric Hyperbilirubinemia

Jaundice occurs because your babys blood has more bilirubin than it can get rid of. This can happen because an infants red blood cells have a shorter lifespan and so are broken down at a higher rate. Bruising that occurs during the birth can lead to higher levels of bilirubin. Finally, the babys liver may just not be mature enough to filter bilirubin from the bloodstream to avoid the yellowish tint.

For the most part, jaundice is not a cause for concern. Physiologic jaundice is harmless and usually is seen at 2 to 4 days old. It goes away within 1 to 2 weeks.

In addition, this can be a side effect of some medications or infections present at birth. Other diseases that affect the liver such as cystic fibrosis or hepatitis can also lead to jaundice.

Should Breastfeeding Be Modified For Infants With Jaundice

• References

Breastfed infants are three times more likely to have a TSB level greater than 12 mg per dL and six times more likely to have a level greater than 15 mg per dL .31 The exact mechanism for breastfeeding-related jaundice is unknown, but may involve decreased caloric intake, inhibition of hepatic bilirubin excretion, and increased intestinal bilirubin resorption. One study compared neonates who were exclusively breastfed with those who received supplemental formula if they had significant weight loss, and others who were formula fed.32 The results suggest that caloric deprivationnot necessarily breastfeedingincreases the risk of hyperbilirubinemia. Increasing the frequency of breastfeeding decreases the likelihood of significant hyperbilirubinemia.5 Signs of adequate intake in breast-fed infants include four to six thoroughly wet diapers per day, three to four stools per day by the fourth day of life, and a transition to seedy, mustard-colored stools by the third or fourth day of life.5

What Is Jaundice In Newborns

Jaundice is a yellow tint to a newborn’s skin and the white part of the eyes. It is a sign that there’s too much bilirubin in the baby’s blood. The word for having too much bilirubin in the blood is hyperbilirubinemia .

Jaundice usually appears in the first 5 days of life. Babies born in Canada are routinely checked for jaundice within 72 hours after birth. If your baby is at risk for jaundice, your doctor may want to do a follow-up examination.

Most babies have mild jaundice. It usually gets better or goes away on its own within a week or two without causing problems. But jaundice should be taken seriously. In rare cases, if the bilirubin level stays high and isn’t treated, it can cause brain damage called kernicterus. This can lead to serious lifelong problems.

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What Causes Infant Jaundice

Jaundice is caused when too much bilirubin builds up in your babys body. Bilirubin is a yellow substance made when the body breaks down old red blood cells. The liver filters it from the blood, and it leaves the body through the stool . This is a normal process that happens all through life. However, babies sometimes get a buildup of bilirubin in their bodies. Your babys liver might not yet be developed enough to filter out the bilirubin. Or your baby may have a condition that increases the number of red blood cells that need to be replaced. These can cause the bilirubin to build up in your babys body, causing jaundice.

There are several common types of jaundice:

• Physiological jaundice:Many newborns have this jaundice. Most of the time it isnt severe. It doesnt cause any problems and goes away on its own within 2 weeks.
• Prematurity jaundice:Premature babies livers often arent developed enough to break down bilirubin effectively. Theyre often treated, even if their bilirubin levels arent as high.
• Breastfeeding jaundice:Babies can get this when they dont get enough breast milk. This can happen because of difficulties with breastfeeding or because the mothers milk hasnt come in yet.
• Breast milk jaundice:Sometimes substances in breast milk cause bilirubin levels to rise. They can also make it harder for the babys body to get rid of bilirubin through the stool. This type starts after 3 to 5 days and slowly gets better over a number of weeks.

What Are Jaundice And Kernicterus

Jaundice is the yellow color seen in the skin of many newborns. Jaundice happens when a chemical called bilirubin builds up in the babys blood. During pregnancy, the mothers liver removes bilirubin for the baby, but after birth the babys liver must remove the bilirubin. In some babies, the liver might not be developed enough to efficiently get rid of bilirubin. When too much bilirubin builds up in a new babys body, the skin and whites of the eyes might look yellow. This yellow coloring is called jaundice.

When severe jaundice goes untreated for too long, it can cause a condition called kernicterus. Kernicterus is a type of brain damage that can result from high levels of bilirubin in a babys blood. It can cause athetoid cerebral palsy and hearing loss. Kernicterus also causes problems with vision and teeth and sometimes can cause intellectual disabilities. Early detection and management of jaundice can prevent kernicterus.

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Jaundice: In: Newborn: Babiesdoc

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What Are The Symptoms Of Newborn Jaundice

The first sign of jaundice is a yellowing of a babys skin and eyes. The yellowing may begin within 2 to 4 days after birth and may start in the face before spreading down across the body.

Bilirubin levels typically peak between 3 to 7 days after birth.

If a finger lightly pressed on a babys skin causes that area of skin to become yellow, its likely a sign of jaundice.

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Complications Of Extreme Jaundice

Extremely high levels of bilirubin can lead to the rare but serious condition of kernicterus, a form of brain damage. This is now a very rare condition with most cases occurring in premature or very ill babies. Treatment for jaundice starts at levels that are far lower that those that could cause kernicterus.

After I Leave The Hospital When Should I Call My Doctor

• refuses breastfeeding or bottle feeding,
• is very sleepy all the time,
• has lost a lot of weight ,
• is extremely jaundiced , or
• jaundice that seems to be getting worse.

If your baby is having trouble with breastfeeding, there are many hospital- or community-based programs that support breastfeeding families, such as the La Leche League Canada. Call their toll-free breastfeeding line for a referral to someone in your community: 1-800-665-4324.

You may also contact a lactation consultant, public health nurse, and/or breastfeeding coordinator.

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Who Should Have Their Bilirubin Concentration Measured When And How

The peak TSB concentration usually occurs between three and five days of life, at which time the majority of babies have already been discharged from hospital. At the usual age of discharge, TSB concentrations that are in a high-risk zone on the nomograms cannot be reliably detected by visual inspection, especially in infants with darker skin colours. To predict the occurrence of severe hyperbilirubinemia, it is therefore recommended that either TSB or TcB concentration be measured in all infants between 24 h and 72 h of life if the infant does not require immediate treatment, the results should be plotted on the predictive nomogram to determine the risk of progression to severe hyperbilirubinemia. The TSB concentration and the predictive zone should be recorded, a copy should be given to the family at the time of discharge, and follow-up arrangements should be made for infants who are at higher risk .

Measurement of bilirubin

Measurement of free bilirubin

Measurement of conjugated bilirubin

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How Is Hyperbilirubinemia Diagnosed

The timing of the appearance of jaundice helps with the diagnosis. Jaundice appearing in the first 12-24 hours can be serious and may require early treatment. When jaundice appears on the second or third day, it is usually “physiologic” or related to dehydration. The physician will usually rely on a bilirubin tool or graph to decide when the level of bilirubin becomes dangerous as infants who are a few days old can tolerate higher levels of bilirubin compared to an infant who is less than 48 hours old. When jaundice appears toward the end of the first week, it may be due to an infection. Later appearance of jaundice in the second week, is often related to breast milk feedings, but may have other causes.

Diagnostic procedures for hyperbilirubinemia may include:

• Direct and indirect bilirubin levels. A blood test can determine if the bilirubin is bound with other substances by the liver so that it can be excreted , or is circulating in the blood circulation .

• Red blood cell count may be used to determine if the baby has too many or too few red blood cells.

• Reticulocyte count determines the number of young red blood cells, which is an indication of red blood cell production.

• Blood type and testing for ABO or Rh incompatibility

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How Is Newborn Jaundice Diagnosed

The hospital discharges most mothers and newborns within 72 hours of delivery. Its very important for parents to bring their babies in for a checkup a few days after birth because bilirubin levels peak between 3 to 7 days after birth.

A distinct yellow coloring confirms that a baby has jaundice, but additional tests may be needed to determine the severity of the jaundice.

Babies who develop jaundice in the first 24 hours of life should have bilirubin levels measured immediately, either through a skin test or blood test.

Additional tests may be needed to see if a babys jaundice is due to an underlying condition. This may include testing your baby for their complete blood count , blood type, and Rhesus factor incompatibility.

Additionally, a Coombs test may be done to check for increased red blood cell breakdown.

How Do I Know If My Babys Bilirubin Levels Are Too High

There is a blood test to measure the amount of bilirubin in your babys body. In many hospitals, bilirubin levels are routinely checked before you take your baby home. To minimize blood tests, non-invasive devices are also used to monitor jaundice.

Your health care provider can plot your babys result on a graph if they know exactly how many hours old your baby was when the test was performed. The information should be given to you when you and your baby leave the hospital. If the test shows that your baby is at risk for reaching a level of bilirubin that needs treatment, your doctor will arrange a follow-up visit and will do another test.

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What Are The Symptoms Of Jaundice

Jaundice is very common in newborn babies. It makes a babys skin and the whites of the eyes turn a yellow colour. You may notice it between 1 and 4 days after your baby is born. It will first appear on your babys face and chest.

Babies who have higher levels of bilirubin may seem very tired and cranky, and feed poorly because they are too hard to wake up.

What Are The Symptoms Of Hyperbilirubinemia

Elevated bilirubin is evident by yellow discoloration of the baby’s eyes, mucosa and skin, usually starting from the head and moving downward. Prior to discharge in the hospital, most babies will have their bilirubin level checked, either by a skin probe or a blood test. Other symptoms of jaundice may include poor feeding or lethargy.

The symptoms of hyperbilirubinemia may resemble other conditions or medical problems. Always consult your baby’s primary care provider for a diagnosis.

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How Do You Know If Your Baby Has Jaundice

When a baby has jaundice, a yellowish color usually first appears on his face. It then may spread to his chest, belly, arms, legs and white parts of his eyes. The best way to see jaundice is in good light, like in daylight or under fluorescent lights. Jaundice can be harder to see in babies with darker skin.

• Looks very yellow, orange or greenish-yellow
• Is hard to wake up or wont sleep at all
• Has trouble breastfeeding or sucking from a bottle
• Is very fussy
• Has too few wet or dirty diapers

• Wont stop crying or has a high-pitched cry
• Arches backward
• Has a stiff, limp or floppy body
• Has strange eye movements

These may be warning signs of dangerously high levels of bilirubin that need quick treatment to prevent kernicterus. This is a kind of brain damage caused by high bilirubin levels. Kernicterus isnt common because babies usually are treated before jaundice becomes severe. If untreated, kernicterus can cause:

• Athetoid cerebral palsy. Babies with this condition have uncontrollable movements in the arms, legs, face and other body parts.
• Intellectual disabilities

Can Severe Hyperbilirubinemia Be Accurately Predicted

Timed TSB measurements

Therefore, the best available method for predicting severe hyperbilirubinemia appears to be the use of a timed TSB measurement analyzed in the context of the infants gestational age. Infants of less than 38 weeks gestation whose TSB concentration is greater than the 75th percentile have a greater than 10% risk of developing severe hyperbilirubinemia similarly, infants of 39 to 40 weeks gestation whose TSB concentration is above the 95th percentile have a greater than 10% risk .

Umbilical cord blood TSB

A TSB concentration greater than 30 µmol/L in umbilical cord blood is statistically correlated with a peak neonatal TSB concentration greater than 300 µmol/L, but the positive predictive value is only 4.8% for the term infant, rising to 10.9% in the late preterm infant, and the specificity is very poor .

Universal hemoglobin assessment

Although bilirubin is derived from the breakdown of hemoglobin, routine umbilical cord blood hemoglobin or hematocrit measurement does not aid in the prediction of severe hyperbilirubinemia .

Blood group and Coombs testing

A version of this graph

A version of this graph

Glucose-6-phosphate dehydrogenase deficiency

End-tidal carbon monoxide

Exhaled carbon monoxide is increased during hemolysis however, prediction of severe hyperbilirubinemia is not improved by measuring the end-tidal carbon monoxide concentration in addition to a timed TSB measurement .

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