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'''For patient information, click [[Neonatal jaundice (patient information)|here]]'''
'''For patient information, click [[Neonatal jaundice (patient information)|here]]'''


{{DiseaseDisorder infobox |
{{Neonatal jaundice }}
  Name          = Neonatal jaundice |
{{CMG}} '''Assosciate Editor(s)-In-Chief:''' [[User: Prashanthsaddala|Prashanth Saddala M.B.B.S]], {{AEL}},  
  Image          = |
  Caption        = Infant undergoing home phototherapy for jaundice using a [[bili light|bili blanket]] |
  ICD10          = {{ICD10|P|58||p|50}}, {{ICD10|P|59||p|50}} |
  ICD9          = {{ICD9|773}}, {{ICD9|774}} |
  OMIM          = |
  MedlinePlus    = 001559 |
  eMedicineSubj  = |
  eMedicineTopic = |
  DiseasesDB    = 8881 |
}}
{{SI}}
{{CMG}}


==Overview==
'''''Synonyms and Keywords:''''' Jaundice of the newborn; Neonatal hyperbilirubinemia
'''Neonatal jaundice''' is a yellowing of the [[skin]] and other tissues of a newborn [[infant]] caused by increased levels of [[bilirubin]] in the [[blood]].


A [[bilirubin]] level of more than 85 umol/l (5 mg/dL) manifests clinical [[jaundice]] in [[neonates]] whereas in adults a level of 34 umol/l (2 mg/dL) would look [[icteric]]. In newborns jaundice is detected by blanching the skin with digital pressure so that it reveals underlying skin and subcutaneous tissue.  Jaundice newborns have an apparent icteric [[sclera]], and yellowing of the face, extending down onto the chest.
==[[Neonatal jaundice overview|Overview]]==


In neonates the dermal [[Icterus (medicine)|icterus]] is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities.<ref name="ReferenceA">Madlon-Kay, Diane J. Recognition of the Presence and Severity of Newborn Jaundice by Parents, Nurses, Physicians, and Icterometer Pediatrics 1997 100: e3</ref>
==[[Neonatal jaundice historical perspective|Historical Perspective]]==


Neonatal jaundice can be '''physiological''' or '''pathological'''. Neonatal physiological jaundice is usually harmless: this condition is often seen in [[infants]] around the second day after birth, lasting until day 8 in normal births, or to around day 14 in [[premature birth]]s. Serum [[bilirubin]] normally drops to a low level without any intervention required: the jaundice is presumably a consequence of metabolic and physiological adjustments after birth. In extreme cases, a brain-damaging condition known as [[kernicterus]] can occur; there are concerns that this condition has been rising in recent years due to inadequate detection and treatment of neonatal hyperbilirubinemia. Neonatal jaundice is a risk factor for hearing loss.<ref>{{cite web|url=http://aapnews.aappublications.org/cgi/content/full/18/5/231 |title=Increased vigilance needed to prevent kernicterus in newborns --O�Keefe 18 (5): 231 -- AAP News |accessdate=2007-06-27 |format= |work=}}</ref>
==[[Neonatal jaundice classification|Classification]]==


All [[jaundice]] should be medically evaluated before treatment can be given.
==[[Neonatal jaundice pathophysiology|Pathophysiology]]==
==Epidemilogy and Demographics==
This condition is common in newborns affecting over half (50 -60%) of all babies in the first week of life.<ref>{{Cite conference
  | title = Neonatal Jaundice
  | booktitle = Intensive Care Nursery House Staff Manual
  | publisher = UCSF Children's Hospital
  | date = 2004
  | url = http://www.ucsfbenioffchildrens.org/pdf/manuals/41_Jaundice.pdf
  | accessdate = 26 July 2011}}</ref>
==Causes==


In neonates, benign jaundice tends to develop because of two factors - the breakdown of [[fetal hemoglobin]] as it is replaced with [[Hemoglobin|adult hemoglobin]] and the relatively immature hepatic metabolic pathways which are unable to conjugate and so excrete bilirubin as fast as an adult.  This causes an accumulation of bilirubin in the body ([[hyperbilirubinemia]]), leading to the symptoms of jaundice.
==[[Neonatal jaundice causes|Causes]]==


Severe neonatal jaundice may indicate the presence of other conditions contributing to the elevated bilirubin levels, of which there are a large variety of possibilities (see below).  These should be detected or excluded as part of the [[differential diagnosis]] to prevent the development of complications.  They can be grouped into the following categories:
==[[Neonatal jaundice differential diagnosis|Differentiating Neonatal jaundice from other Diseases]]==


{{familytree/start}}
==[[Neonatal jaundice epidemiology and demographics|Epidemiology and Demographics]]==
{{familytree | | | | | | | | | | | | | A01 | | | | |A01=Neonatal jaundice}}
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.|}}
{{familytree | | | | | | | | B01 | | | | | | | | B02|B01=[[Unconjugated bilirubin]]|B02=[[Conjugated bilirubin]]}}
{{familytree | | | | | |,|-|-|^|-|-|.| | | |,|-|-|^|-|-|.| |}}
{{familytree | | | | | C01 | | | | C02 | | C03 | | | | C04 | |C01=[[pathology|Pathologic]] |C02=[[Physiologic]] |C03=[[Hepatic]] |C04=Post-hepatic}}
{{familytree | | |,|-|-|^|-|-|.| | | | | | | | | | | |}}
{{familytree | | C01 | | | | C02 | | | | | | | | | | | |C01=[[hemolysis|Hemolytic]]|C02=Non-hemolytic}}
{{familytree | | |)|-|-|-|-|-|.| | | | | | | | | | | |}}
{{familytree | | C01 | | | | C02 | | | | | | | | | | | |C01=Intrinsic causes|C02=Extrinsic causes}}
{{familytree/end}}


===Intrinsic causes of hemolysis===
==[[Neonatal jaundice risk factors|Risk Factors]]==
*Membrane conditions
**[[Spherocytosis]]
**[[Hereditary elliptocytosis]]
*Systemic contitions
**[[Splenomegaly]]
**[[Sepsis]]
**[[Arteriovenous malformation]]
*Enzyme conditions
**[[Glucose-6-phosphate dehydrogenase deficiency]] (also called G6PD deficiency)
**[[Pyruvate kinase deficiency]]
*Globin synthesis defect
**[[Alpha-thalassemia]]


===Extrinsic causes of hemolysis===
==[[Neonatal jaundice screening|Screening]]==
*[[Alloimmunity]] (The neonatal or [[cord blood]] gives a positive [[Coombs test#Direct Coombs test|direct Coombs test]] and the maternal blood gives a positive [[Coombs test#Indirect Coombs est|indirect Coombs test]])
**[[Hemolytic disease of the newborn (ABO)]]
**[[Rh disease]]
**[[Hemolytic disease of the newborn (anti-Kell)]]
**[[Hemolytic disease of the newborn (anti-Rhc)]]
**Other blood type mismatches causing [[hemolytic disease of the newborn]]


===Non-hemolytic causes===
==[[Neonatal jaundice natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
*[[Cephalohematoma]]
*[[Polycythemia]]
*[[Sepsis]]
*[[Hypothyroidism]]
*[[Gilbert's syndrome]]
*[[Crigler-Najjar syndrome]]


===Hepatic causes===
*Infections
**[[Sepsis]]
**[[Hepatitis B]], [[TORCH syndrome|TORCH infections]]
*Metabolic
**[[Galactosemia]]
**[[Alpha-1-antitrypsin deficiency]]
**[[Cystic fibrosis]]
*Drugs
*[[Total parenteral nutrition]]
*Idiopathic
===Post-hepatic===
*[[Biliary atresia]]
*[[Bile duct]] obstruction
===Breast feeding jaundice===
"Breastfeeding jaundice" is caused by insufficient milk intake resulting in dehydration, and can be prevented by frequent breastfeeding sessions of sufficient duration to stimulate adequate milk production.
===Breast milk jaundice===
Very rarely, "breast milk jaundice" occurs during the second or third week of life, and may be caused by high levels of [[beta-glucuronidase]] in [[breast milk]]. Neither condition is a reason to stop nursing, though caregivers may advise IV or other fluid administration to ensure the baby is not dehydrated.
==Natural history, Complications and Prognosis==
===Complications===
With high doses of bilirubin (severe hyperbilirubinemia) there can be a complication known as [[kernicterus]].  This is the chief condition that treatment of jaundice is aimed at preventing. The effects of kernicterus range from fever, seizures, and a high-pitched crying to mental retardation. This is due to a staining effect on the [[basal ganglia]] leading to neuronal damage. With aggressive treatment such as exchange transfusion to lower very high bilirubin levels, the neurological effects are almost always transient.
==Diagnosis==
==Diagnosis==
===Physical Examination===
[[Neonatal jaundice diagnostic study of choice|Diagnostic Study of Choice]] | [[Neonatal jaundice history and symptoms| History and Symptoms]] | [[Neonatal jaundice physical examination | Physical Examination]] | [[Neonatal jaundice laboratory findings|Laboratory Findings]] | [[Neonatal jaundice electrocardiogram|Electrocardiogram]] | [[Neonatal jaundice x ray|X Ray]] | [[Neonatal jaundice CT|CT]] | [[Neonatal jaundice MRI|MRI]] | [[Neonatal jaundice ultrasound|Echocardiography or Ultrasound]] | [[Neonatal jaundice other imaging findings|Other Imaging Findings]] | [[Neonatal jaundice other diagnostic studies|Other Diagnostic Studies]]
Notoriously inaccurate [[rules of thumb]] have been applied to the [[physical exam]] of the jaundiced infant.  Some include estimation of serum [[bilirubin]] based on appearance. One such rule of thumb includes infants whose jaundice is restricted to the face and part of the trunk above the [[Navel|umbilicus]], have the [[bilirubin]] less than 204&nbsp;umol/l (12&nbsp;mg/dL) (less dangerous level). Infants whose palms and soles are yellow, have serum bilirubin level over 255&nbsp;umol/l (15&nbsp;mg/dL) (more serious level)
===Non-invasive measurements of jaundice===
'''Clinical Assessment'''
This method is more accurate and less subjective in estimating jaundice.
 
'''Ingram icterometer''': In this method a piece of transparent plastic known as '''Ingram icterometer''' is used. Ingram icterometer is painted in five transverse strips of graded yellow lines. The instrument is pressed against the nose and the yellow colour of the blanched skin is matched with the graded yellow lines and biluribin level is assigned.
 
'''Transcutaneous bilirubinometer''': This is hand held, portable and rechargeable but expensive and sophisticated. When pressure is applied to the photoprobe, a xenon tube generates a strobe light, and this light passes through the subcutaneous tissue. The reflected light returns through the second fiber optic bundle to the spectrophotometric module. The intensity of the yellow color in this light, after correcting for the hemoglobin, is measured and instantly displayed in arbitrary units.


==Treatment==
==Treatment==
Infants with neonatal jaundice are often treated with [[bili light]]s, exposing them to high levels of colored light to break down the bilirubin. This works due to a photo oxidation process occurring on the bilirubin in the subcutaneous tissues of the neonate. Light energy creates isomerization of the bilirubin and consequently transformation into compounds that the new born can excrete via urine and stools.  Blue light is typically used for this purpose.  Green light is more effective at breaking down bilirubin, but is not commonly used because it makes the babies appear sickly, which is disturbing to observers.  A recent study has shown that light therapy may increase the risk of skin moles (or "[[nevi]]") in childhood which in turn also increases the risk of [[melanoma]] (skin cancer).<ref>{{cite web |url=http://www.medpagetoday.com/HematologyOncology/SkinCancer/tb/4730 |title=Childhood Moles Linked to Neonatal Jaundice Treatment - CME Teaching Brief� - MedPage Today |accessdate=2007-06-30 |format= |work=}}</ref><ref>{{cite web |url=http://www.medicinenet.com/script/main/art.asp?articlekey=78650 |title=Infant Jaundice Treatment May Encourage Moles - Skin diseases, conditions and procedures on MedicineNet.com |accessdate=2007-06-30 |format= |work=}}</ref>
[[Neonatal jaundice medical therapy|Medical Therapy]] | [[Neonatal jaundice surgery|Surgery]] | [[Neonatal jaundice primary prevention|Primary Prevention]] | [[Neonatal jaundice secondary prevention|Secondary Prevention]] | [[Neonatal jaundice cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Neonatal jaundice future or investigational therapies|Future or Investigational Therapies]]


Brief exposure to '''indirect''' sunlight each day and increased feeding are also helpful. A newborn should not be exposed to direct [[sunlight]] because of the danger of [[sunburn]], which is much more harmful to a newborn's thin skin than that of an adult.
==Case Studies==
[[Neonatal jaundice case study one|Case#1]]


If the neonatal jaundice does not clear up with simple [[phototherapy]], other causes such as [[biliary atresia]], PFIC, bile duct paucity, Alagille's syndrome, alpha 1 and other pediatric liver diseases should be considered.  The evaluation for these will include blood work and a variety of diagnostic tests.  Prolonged neonatal jaundice is serious and should be followed up promptly.
==Related Chapters==
 
==See also==
* [[Jaundice]]
* [[Jaundice]]
==References==
{{reflist|2}}
{{Certain conditions originating in the perinatal period}}
{{SIB}}
[[de:Neugeborenengelbsucht]]
[[es:Ictericia del recién nacido]]


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Latest revision as of 22:56, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Assosciate Editor(s)-In-Chief: Prashanth Saddala M.B.B.S, Ahmed Elsaiey, MBBCH [2],

Synonyms and Keywords: Jaundice of the newborn; Neonatal hyperbilirubinemia

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Neonatal jaundice from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies

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Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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