Neonatal Jaundice: Evaluation, Management, and Complications

Neonatal jaundice classified as the yellowing of the skin, sclera, and mucous membranes, stems from elevated total serum bilirubin, known as neonatal hyperbilirubinemia. It’s a prevalent condition, affecting approximately 2/3^rd of healthy infants.

Timely identification and treatment are crucial to prevent bilirubin encephalopathy and other neurological complications.

Neonatal jaundice is classified into four categories:

• Physiological Jaundice
• Pathological Jaundice
• Breastfeeding Jaundice
• Breast Milk Jaundice

Evaluation of Neonatal Jaundice:

1. The American Academy of Pediatrics (AAP) recommends assessing bilirubin levels in infants between 24 to 48 hours post-birth, with measurement before discharge if leaving earlier.
2. Primary evaluation utilizes transcutaneous measurement or serum bilirubin levels. While transcutaneous bilirubin estimation can reduce blood tests, its utility is limited in dark-skinned infants and post-phototherapy cases.
3. Serums should be measured if transcutaneous levels exceed certain thresholds. However, transcutaneous measurements cannot detect the direct bilirubin fraction crucial for diagnosing neonatal cholestasis.
4. Radiographic imaging is generally unnecessary in most cases. Brain MRI findings, notably in the globus pallidus, are sensitive to bilirubin encephalopathy, showing signal changes over time.
5. Magnetic resonance spectroscopy (MRS) can reveal biochemical changes, through their absence doesn’t exclude risk.
6. Hepatic ultrasonography can identify biliary abnormalities. Hepatobiliary scintigraphy distinguishes obstructive from non-obstructive cholestasis, with liver biopsy being the gold standard histopathologic diagnosis in most cases.

Treatment and management for Neonatal Jaundice

1. Phototherapy and exchange transfusion are primary treatments for newborns with unconjugated hyperbilirubinemia. The treatment approach considers neurotoxicity risk factors, gestational age, and hour-specific total serum bilirubin (TSB) levels.
2. Phototherapy is the first-line treatment, reducing TSB to safe levels and lowering bilirubin toxicity risk. Phototherapy effectiveness depends on the light dose, wavelength, and the infant’s exposed surface area.
3. Exchange transfusion is a secondary treatment for severe cases unresponsive to phototherapy or exceeding the exchange threshold. Indications for ET include failure to respond to PT to TSB reaching the exchange threshold.
4. ET rapidly removes bilirubin and hemolytic antibodies. Monitoring vital signs during ET is crucial with post-procedure TSB, CBC, and electrolyte checks warranted due to potential complications. Phototherapy should resume post-ET until safe phototherapy discontinuation levels are reached.

Complications in Neonatal Jaundice

1. Newborns with severe hyperbilirubinemia face the risk of bilirubin-induced neurologic dysfunction, where bilirubin binds to various brain regions, including the globus pallidus and hippocampus, causing neurotoxicity.
2. Acute bilirubin encephalopathy presents with lethargy, hypotonia, and reduced sucking, and potential reversibility at this stage.
3. Progression to irreversible chronic bilirubin encephalopathy or kernicterus can occur, leading to choreo-athetoid cerebral palsy, seizures, arching and gaze abnormalities, dental enamel defects, and sensorineural loss.

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