Jaundice in Newborns

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Introduction

Do you know that, according to a report, 35% of all NICU admissions were made for Neonatal Jaundice? A global survey estimates that each year, 1.1 million newborns experience severe jaundice, with the bulk of those cases occurring in sub-Saharan Africa and South Asia. In Africa, particularly in West Africa, neonatal jaundice is the major condition that affects and kills newborns. Hence, it requires priority attention from the international community. In these areas, newborn mortality due to jaundice complications occurred in almost 75% of cases. There are a lot of misconceptions about neonatal jaundice in developing countries, and it is imperative we talk about it. Nigeria is one of the nations with one of the highest neonatal mortality rates, with almost one-third (32%) of the estimated 1 million children under the age of five who pass away each year dying during the newborn period. Between 5 and 14% of these neonatal deaths, severe neonatal jaundice (SNNJ) is to blame. The prevalence of neonatal jaundice in Africa is partially caused by a genetic predisposition brought on by a high prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency, system flaws, and delays in the care of newborns who have jaundice. Infants with severe neonatal jaundice who survive develop varying neurological problems, including sensory-neural hearing loss, language processing issues, and cerebral palsy, now known as a kernicterus spectrum disorder (KSD). Nigeria and the entire of Africa have insufficient research on the prevalence and regional characteristics linked to newborn jaundice. However, we have put together some pertinent information regarding neonatal jaundice as it concerns us in West Africa. Let’s go on this ride, shall we?

Outlook of Neonatal Jaundice in Low and Middle-Income Countries

Numerous studies conducted throughout the years have identified newborn jaundice as a significant cause of infant morbidity and mortality. It has been challenging to compare jaundice across different regions due to the absence of standardised guidelines for the care and classification of the condition in low- and middle-income nations.

The high prevalence of acute bilirubin encephalopathy (ABE) or kernicterus in low- and middle-income countries (LMICs) has been linked to three levels of delay in the pathway to care for neonates with neonatal jaundice. Specifically, a delay in seeking care, a delay in showing up at the proper facility, and a delay in receiving sufficient and appropriate care at a medical facility. Due to these delays, bilirubin levels can rise to risky levels, and the newborn's brain is exposed to high bilirubin levels over an extended period, which results in both acute and chronic neurotoxicity. In many LMICs, parents of newborns who fail to seek immediate and appropriate care for a sick newborn outside the home setting may do so due to poverty, a lack of access to medical care, sociocultural perceptions and practices related to newborn illness, such as the use of traditional medicine, and living in rural areas. 

In Nigeria and Africa as a whole, septicemia and prematurity were the main aetiological causes of NNJ. Significantly more outborn than inborn babies experienced substantial bilirubinemia, septicemia, and contact with clothing contaminated by naphthalene balls. Also, unbooked women were more likely to use herbal pregnancy remedies than mothers of unborn children.

What is Jaundice

Jaundice is defined as the yellowish discolouration of the skin and sclera (the white part of the eye) due to high levels of a pigment known as bilirubin in the skin and mucous membranes. Neonatal Jaundice, aka NNJ, is jaundice in a neonate (a child 28 days old and less). Neonatal jaundice is one of the most prevalent illnesses that require medical attention in newborns. It is a liver condition that causes the yellowing of a newborn baby’s skin and eyes. 60% of term and 80% of preterm newborns experience neonatal jaundice worldwide. Neonatal jaundice occurs because of an imbalance between bilirubin production and its removal from the bloodstream. The mother assists in the placenta's function throughout pregnancy to help the foetus excrete its bilirubin. Following delivery, the infant must self-adjust and eliminate blood bilirubin. Bilirubin is a by-product of the breakdown of haemoglobin(a pigment in red blood cells). Because newborns have more red blood cells, which also have a short lifespan and an immature liver, there’s usually an imbalance in the rate at which bilirubin is produced and removed from the bloodstream. It is important to know that when this pigment (bilirubin) crosses the barrier separating the blood from the brain, it causes what we call bilirubin encephalopathy or kernicterus.  Kernicterus results in permanent brain damage in which the child will have a delay in development, stiffness of the body, and affectation of social interaction. Kernicterus specifically happens in the first 14 days of a newborn (as the blood-brain barrier is most easily penetrated at this time). It is important to know that the damage to the brain is permanent, and no treatment can reverse it. The child can only be managed to limit challenges and complications. 

How do I know my child has jaundice?

• Baby’s skin becomes more yellow.
• The skin on the baby’s abdomen, arms, or legs looks yellow
• The whites of the baby’s eyes look yellow
• Baby seems listless, sick, or is difficult to awaken
• Baby isn’t gaining weight or is feeding poorly
• Baby makes high-pitched cries.

Jaundice: What Could Be the Cause?

The appearance of jaundice in a newborn could be a result of certain factors. Below are some of the common causes of jaundice.

• Hyperbilirubinemia (excess bilirubin): An excessive amount of bilirubin in the blood results in a condition called hyperbilirubinemia. When red blood cells, which carry oxygen throughout the body, are broken down, bilirubin, a yellow material, is created. The bilirubin is transported to the liver by the bloodstream. Bilirubin is transformed by the liver so that it can be eliminated from the body in feces. However, if there is too much bilirubin in the blood or the liver is unable to eliminate it, it will produce jaundice.
• Internal bleeding (hemorrhage): Red blood cell disintegration and the subsequent release of unconjugated bilirubin into the bloodstream can cause jaundice. Therefore, this breakdown of blood cells outside of blood vessels (extravascular hemolysis) will lead to an increase in the amount of unconjugated bilirubin presented to the liver cells (hepatocyte). Thus, unconjugated bilirubin will build up in plasma, increasing total and indirect bilirubin if the hepatocyte's capacity to absorb and conjugate this bilirubin is exceeded. 
• Infection in baby’s blood (sepsis): Sepsis is a condition in which there is both an infection and a systemic inflammatory reaction. Jaundice is one of the many symptoms of sepsis. When the body fights an infection due to sepsis, among other reactions, cytokines are released. The regulation of bilirubin by our body is interfered with by these cytokines, which are also the cause of inflammation in sepsis. As a result, bilirubin cannot be properly processed by our bodies, which causes a buildup and jaundice or yellowing of the skin. Both the drugs used to treat sepsis or direct liver damage from sepsis can result in jaundice.
• Incompatibility between the mother’s blood and the baby’s blood: While a mother is pregnant, it is possible for her red blood cells to enter the placenta or fetus. When this happens, the mother's blood cells produce antibodies that can target the newborn's blood cells, resulting in jaundice.
• Liver malfunction Inflammation, various issues involving the liver cells, or clogged bile ducts may all be associated with high levels of bilirubin. In newborns, the early symptoms of liver illness frequently include jaundice.
• Biliary atresia: The flow of bile from the liver to the gut is obstructed in infants who have biliary atresia. The newborn develops jaundice as a result of the bile becoming trapped inside the liver. Babies' trapped bile can damage and scar their livers very quickly (cirrhosis). This typically leads to liver failure, and jaundice often develops in infants with biliary atresia between the ages of 3 and 6 weeks.

Myths and Truths Surrounding the Treatment of Neonatal Jaundice in Africa 

People are wrongly informed about treatment options regarding neonatal jaundice. Some of the myths and truths about jaundice are listed below.

Myths

In Africa, some of the myths and wrong narratives or pieces of advice prevalent and surrounding the treatment of neonatal jaundice include:

• Putting the child under sunlight 
• Putting breast milk in the eyes
• Giving any form of traditional medications
• Giving any form of oral (mouth) medications.
• Wearing yellow clothes causes jaundice.
• Unripe pawpaw/leaf cures jaundice.
• Abidec/ampiclox drops cure/prevent jaundice.
• Untreated malaria in pregnancy causes jaundice. 

Truths

The perfect advice to parents and health workers of every sort is to always make sure to refer newborns with jaundice or suspected case of jaundice to a paediatrician.  In doing so, you could just be guaranteeing a normal life! 

How Long Does Jaundice Last In A Baby?

If your baby is fed formula, jaundice usually goes away within two weeks. In breastfed babies, it can last longer, up to three weeks or more. If your baby's jaundice persists beyond three weeks, it's best to speak to your healthcare provider.

What Jaundice Treatment Options Are Available?

At birth, jaundice can be discovered by running an SB (serum bilirubin) test. Clinically, jaundice can be discovered in a neonate between 1 and 7 days of birth. The treatment option to be used is dependent on the level of the bilirubin as measured in the lab. In some cases, no intervention is required. The mother would just be counselled to go home, continue breastfeeding and come back for a recheck later. In situations where bilirubin levels are still high after a recheck, the paediatrician decides on any of the following treatment options:

• Phototherapy: This is a medical treatment that uses a specific type of light, which is not sunlight. It is commonly used to treat newborn jaundice by helping the liver to break down and eliminate bilirubin from the baby's blood. Any level above 15 mg/dL or more calls for immediate phototherapy within the first 72hrs after birth.
• Exchange Blood Transfusion: In some cases, when a person has a serious case of jaundice, or when phototherapy hasn't been effective, a procedure known as a complete blood transfusion or an exchange transfusion may be necessary. The process involves the gradual removal of the individual's blood and replacing it with fresh donor blood or plasma to counteract the high levels of bilirubin in their blood.

Complication Of Jaundice

The major/most worrisome complication of jaundice is kernicterus. Kernicterus causes irreversible (permanent) brain damage. 

What is the way forward?

To considerably lower newborn morbidity and mortality, social factors that affect health must be taken into consideration. These factors are at the heart of the problems that underlie both of these outcomes. Furthermore, to reduce the prevalence of severe neonatal jaundice, there is a need for continuous education of the general public on the importance of routine antenatal observation of pregnancy and delivery in competent healthcare facilities.

In conclusion, always follow the doctor’s recommendation when your child has jaundice. Also, the best thing you can do for your newborn who is jaundiced is to make sure they are getting enough breastmilk. Do not listen to old wives’ fables of alternate methods of ‘curing’ jaundice. Remember, it is your baby and therefore, it is your responsibility to give the best care.