NEONATAL JAUNDICE – FACTS or MYTHS
As more than 70% of newborn will develop jaundice in the first few days of life, parents will be frantically finding for answers from the web or listen to hearsay to cure their baby’s jaundice.
Congratulations on the arrival of your bundle of joy!!! Having a newborn can be both very exciting and challenging period of time for new parents. As more than 70% of newborn will develop jaundice in the first few days of life, parents will be frantically finding for answers from the web or listen to hearsay to cure their baby’s jaundice. Below are some of the commonly heard myths regarding jaundice in newborn babies:
- Goat’s milk can be given to treat jaundice.
- Grape water can be given to treat jaundice.
- Untreated jaundice can cause death in newborn babies.
- Exposing babies to the sunlight can reduce the jaundice level.
- Breastfed babies should be fed with water in order to prevent dehydration.
HOW DOES JAUNDICE HAPPEN?
Once baby is born, their body needs to breakdown the fetal red blood cell (hemoglobin). The waste product of the breakdown is bilirubin (a yellow pigment). Bilirubin will be processed by the liver to form conjugated bilirubin and then stored as bile salts in gallbladder. These bile salts will be transported to the intestine whenever baby is breastfed (presence of fat in milk) for fat absorption before it is eliminated in the stool.
However, due to excessive fetal hemoglobin breakdown (hemolysis) baby’s immature liver cannot fully metabolize the bilirubin. Thus, some of the bilirubin will remain unconjugated and are in high concentration in blood circulation. This unconjugated bilirubin will be deposited on the skin causing yellow discoloration on the baby and can enter the brain if the level is very high.
OTHER CAUSES OF JAUNDICE
In rare cases, an underlying condition can cause jaundice and it often appears much earlier or much later than does the more common form of infant jaundice. Diseases or underlying conditions that can cause jaundice include:
- ABO & rhesus incompatibility between mother and baby
- Neonatal alloimmune hemolytic anemia
- G6PD deficiency
- Urinary tract infection
- Neonatal hepatitis
- Cephalohaematoma
- Biliary tract obstruction
- Polycythemia (in baby with gestational diabetes mother)
- Congenital hypothyroidism
- Intrauterine infections (Toxoplasmosis, CMV, Herpes & etc.)
- Gilbert/Criglar Najar syndrome
- Alpha fetoprotein deficiency
WHEN SHOULD YOU BE CONCERNED ABOUT JAUNDICE?
You should contact your pediatrician if:
- Baby’s jaundice appear less than 24 hours of life.
- Prolonged jaundice for more than 14 days for term baby or 21 days for preterm baby.
- Amount of conjugated bilirubin is more than 20 percent of total bilirubin.
- Total bilirubin is more than 15mg/dL.
- Rapid increase in bilirubin level in the blood (>5mg/dL per day).
- Baby passing clay/pale colored stool.
FACTORS THAT CONTRIBUTE TO JAUNDICE IN BREASTFED BABIES
Breastfed babies can be at risk of jaundice due to failure to establish proper breastfeeding technique. Though breastfeeding is a natural physiological way of feeding a baby, the learning process especially during the first few weeks of baby’s life may not be easy. Mothers who did not attend antenatal class may not have enough breastfeeding knowledge and are not given proper support to breastfeed. In order for the baby to be able to remove the milk effectively from the breast, baby must be positioned correctly and have good attachment at the breast. When baby isn’t getting enough milk from the breast, this will exaggerate the physiological jaundice.
Secondly, the presences of beta glucuronidase enzymes are higher in breast milk. Beta glucuronidase breakdown conjugated bilirubin causing more reabsorption of bilirubin to be returned to liver instead of elimination. Thus ,more bilirubin are available in the bloodstream causing breast milk jaundice.
TREATMENT OF NEONATAL JAUNDICE
The first step of treatment for jaundice in newborn is to ensure that baby is breastfed correctly and on demand. When baby is getting enough milk from the breast by having correct breastfeeding technique (correct positioning and latching), breastmilk will act as laxative which increase bowel movement and reduce reabsorption of bilirubin in the gut. Thus, breastmilk helps to get rid of unwanted bilirubin. If the baby is too sleepy due to jaundice, mother can use breast compression during feeding to encourage baby to feed more actively.
When the bilirubin level in baby exceeds threshold, phototherapy is use in the hospital to breakdown the unconjugated bilirubin that is stored in the skin so that the body can excrete it readily. Baby will be placed under a special light in the cot with the eyes covered for a day or two. Once, the bilirubin level fall within safe level, baby can be discharge home.
OTHER TREATMENTS WHICH ARE NOT RECOMMENDED
- Fresh goat’s milk
Fresh goat’s milk are not recommended for children below 12 months old because it does not meet babies nutritional needs. It lacks of folic acid, iron, vitamin c, lactose but contains high concentration of protein. Higher protein versus fat ratio can also lead to metabolic acidosis in baby. Fresh goat’s milk can burden baby’s immature kidney as it contain higher amount of sodium and chloride. - Water and honey
Babies should be breastfed exclusively till the age of 6 months. No other liquid including water should be introduced before 6 months as it will interfere the process of mother establishing her breast milk supply. Mothers need to breastfeed regularly in order to regulate her supply. As the baby’s stomach is small, giving even small amount of water will quickly fill it up, thus reducing baby’s need to breastfeed. Besides that, giving water to baby can slow down baby’s weight gain as water contain no calories and nutritional value. When water is given in bigger amount, baby can suffer from water intoxication due to dilution of sodium level in their blood leading to seizure and death.
Giving pure honey as “tahnik” is “Sunnah”. However, it should not be given frequently as treatment for jaundice. Babies who are exposed to sweet taste early in their life can cause them to be picky eater later on. Unprocessed raw honey that is contaminated with Clostridium botulinum bacteria can pose a risk of botulism toxicity in baby.
- Sunlight exposure
Sunlight therapy no longer recommended as treatment for jaundice as it is less reliable because it is made up of wide range of wavelength from 10-400nm (UV) , 400-700 nm ( visible light) and above 700nm (infrared). For bilirubin to be broken down, they typically absorb light wavelength around 450-460nm. Direct exposure to sunlight can cause sunburn and dehydration in baby if not properly monitored. However, sunlight exposure around 7 to 11 am is good for production of vitamin D under the skin.
- OTHERS
Herbal bath and application should be avoided in baby as there is no safety study. Mothers can still take herbs, ginger and turmeric in small amount without additional risk of jaundice in breastfed baby. However, mothers should avoid unknown herbs as metabolisms of the herbs are unknown and if it is secreted into breast milk. Herbs that are passed through breast milk may compete with the bilirubin metabolism in the liver which further reduces the liver capacity to conjugate the bilirubin.
BREAST MILK JAUNDICE
Prolonged breast milk jaundice often makes mother feel guilty and blame their breast milk. However, the presence of bilirubin below the threshold level does not harm the baby. Therefore, it is not recommended to stop breastfeeding for 24 hours to diagnose breast milk jaundice.
TAKE HOME MESSAGE
- Approximately 70% newborn babies will develop physiological jaundice.
- Risks of severe jaundice in all babies are usually low as most cases have mild jaundice.
- Physiological jaundice will resolve before 14 days with or without giving other liquid other than breast milk.
- Giving other liquids such as water, fresh goat’s milk, honey will cause more harm to baby.
- Helping mother to breastfeed to ensure baby gets breast milk will help to reduce jaundice in newborn.
Source:
Dr.Hairin Anisa (Consultant Pediatrician, IBCLC & BCNP founder)
By:
Carrie Foo Hwei Yi
