Physiologic jaundice of a newborn baby: what causes it, when it passes, consequences

Physiological jaundice of the newborn is the appearance of a yellow tint of the skin of a newborn baby three days after birth, which can occur in a healthy baby. The main thing to understand about this pathology is that physiological jaundice is not a disease. However, the manifestations of physiological and pathological jaundice can be similar, so you need to carefully monitor all the symptoms.

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Epidemiology

Statistics on physiological jaundice show that it occurs in 80% of premature babies and about 60% of full-term babies. This shows a higher frequency of this condition in premature babies, which is associated with a higher level of immaturity of liver enzymes.

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Causes physiologic jaundice of the newborn

Almost all newborn babies have an increase in the level of bilirubin in the blood, which is transient and does not manifest itself clinically. This suggests that the spread of jaundice is more significant than it is thought at first glance. Speaking about jaundice, you must first find out what the concept of physiological jaundice means. The main thesis of this concept is the normal state of the child, which does not require any external interventions, that is, a physiological state. If we talk about this concept in more detail, physiological jaundice is a change in the color of the child's skin and mucous membranes to yellow, which is caused by a transient increase in the level of bilirubin in the blood. Such a yellow color of the child's skin appears no earlier than 36 hours after birth, then we can say that this is physiological jaundice. If it appears earlier, then these are already signs of a pathological condition.

The causes of physiological jaundice directly depend on the pathogenetic features of the development of this condition. The pathogenesis of jaundice is based on the pathology of bilirubin metabolism. Newborns have a number of features of bilirubin metabolism, which determine the high frequency of this pathology. The source of bilirubin formation under normal conditions is the hemoglobin of erythrocytes. This hemoglobin circulates in the blood and after three months is destroyed in the spleen. In newborns, the lifespan of erythrocytes is less than in adults and is about one month. And thus, it is quickly destroyed in the spleen, forming a large amount of free bilirubin. Considering that newborns have more erythrocytes than adults, which is necessary to ensure oxygen respiration in utero, this increases the amount of hemoglobin itself.

Bilirubin, which is released during the breakdown of a large amount of hemoglobin, is released into the blood. This is indirect bilirubin, which has affinity for lipid-rich tissues, insolubility in water, and toxic properties. In plasma, indirect bilirubin combines with albumin and is transported to liver cells.

Newborns have a lower level of blood protein, so the bilirubin particle remains in a free state and diffuses into tissues, primarily into the subcutaneous tissue. The jaundice that occurs in this case is physiological.

There is another peculiarity of pathogenesis - this is that the liver of newborns has a certain degree of immaturity, therefore the processes of conjugation of indirect bilirubin in the first days of life are slow. Only on the 5-7th day of life the enzymatic function of the liver becomes active, which enables it to normally neutralize bilirubin.

The transformation of indirect bilirubin into direct bilirubin occurs with the participation of glucuronic acid and the enzymes UDPG dehydrogenase, glucuronyl transferase, cytochrome P-450. The activity of enzymes is greatly influenced by drugs used during childbirth, as well as components of breast milk. Part of the unconjugated bilirubin enters the intestine, from where it is actively absorbed into the blood, maintaining hyperbilirubinemia. In addition, newborns have narrow bile ducts, a low concentration of bile acids. Delayed elimination of meconium leads to the accumulation of bilirubin in the digestive tract, the transformation of direct bilirubin into indirect with the help of intestinal beta-glucuronidase, an increase in its toxic effect on the body. Therefore, it is important to limit when jaundice is still physiological, and when it is already pathological.

Therefore, the main cause of physiological jaundice is the immaturity of liver cells in the active neutralization of bilirubin.

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Risk factors

But not all newborns have physiological jaundice. There are children who have risk factors for developing such a pathology. These include:

1. Premature babies have an even greater degree of underdevelopment of hepatocytes and liver function;
2. complicated pregnancy and maternal illnesses during pregnancy;
3. birth conditions and external interventions during childbirth increase the level of stress in the child’s body and disrupt the normal function of organs, including the liver;
4. circulatory disorders in the placenta can cause an increase in the number of red blood cells and, accordingly, an increase in the level of bilirubin breakdown;
5. children with hemorrhages - cephalohematoma or hemorrhagic disease;
6. children with malnutrition or vomiting, losing weight - there is a risk of more serious damage to the central nervous system even with less significant bilirubin levels;
7. neonatal asphyxia;
8. generalized fetal infection.

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Symptoms physiologic jaundice of the newborn

The first signs of physiological jaundice appear no earlier than 36 hours after birth. Then the mother may notice that the baby's skin, mucous membranes and sclera are turning yellow. The yellowness of the skin extends to the face and to the level of the nipple line. In this case, we can say that this is physiological jaundice. When does physiological jaundice pass in newborns? By the end of the seventh day of the child's life, such jaundice should decrease, and by the end of the 14th day it should disappear. As for a premature baby, his jaundice should pass by the 21st day of life. Prolonged physiological jaundice is a manifestation of jaundice after the specified period, which is not manifested by other pathological symptoms. Then this concept also fits into the term "physiological" jaundice, but it is necessary to carefully monitor the child's condition in this case. In newborns who are exclusively breastfed, jaundice can have two peaks of bilirubin (between days 4-5 and 14-15). In such cases, there is a slow decrease in the intensity of yellowish coloration of the skin and jaundice can remain until the 12th week of the child's life. This jaundice is diagnosed by exclusion in healthy full-term children in the absence of general health disorders. This jaundice does not require drug therapy and cessation of breastfeeding. This is called "breast milk jaundice", which also refers to physiological.

The stages of jaundice can be traced precisely by the increase in symptoms. In the first three days, the yellow color of the skin increases and spreads from the face to the shoulders. Then, closer to the seventh day, the intensity of jaundice decreases and there is no spread below the shoulder level, and the third stage is characterized by reverse involution of jaundice.

The types of jaundice that need to be differentiated are physiological and pathological. They have different levels of bilirubin in the blood and different risks of complications.

Other symptoms are not typical for physiological jaundice, since such a level of bilirubin does not affect the nervous system and other tissues. If any symptoms of the child's inhibition, refusal to breastfeed appear, then one should think about serious pathologies.

Complications and consequences

The consequences of jaundice can be very serious, because indirect bilirubin, which is formed during the development of jaundice, is toxic to the central nervous system. Therefore, an excess of a certain level of bilirubin in the blood serum allows it to enter the brain cells and disrupt their work. What is dangerous about physiological jaundice of a newborn? One of the complications of physiological jaundice can be considered nuclear jaundice - this is damage to the nervous system under the influence of the maximum permissible level of bilirubin. For full-term babies, this level is 320 micromoles, and for premature babies 250. If the increase in bilirubin levels occurs sharply, then bilirubin encephalopathy develops. This is characterized by damage to the nuclei of the brain and disruption of the further development of the child. Clinically, this is manifested by the appearance of impaired consciousness, focal symptoms, convulsions, and impaired thermoregulation.

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Diagnostics physiologic jaundice of the newborn

Physiological jaundice should be diagnosed with a thorough examination of the child, which allows for an 80% diagnosis. First of all, you need to carefully examine the child. Examination for the presence of yellowish skin coloring should be carried out when the child is completely undressed, provided there is sufficient (optimally daylight) lighting. To do this, lightly press on the child's skin to the level of subcutaneous tissue. This allows you to more accurately assess the degree of coloring of the child's skin. It is imperative to pay attention to the sclera and mucous membranes, they should also be yellow, then we are talking about jaundice. In order for the doctor to be able to assess the oriented bilirubin level and the degree of jaundice, there is a special assessment scale of Kramer. It is based on the fact that the amount of bilirubin in the child's body is equal to the level of coloring of his skin. For example, if the bilirubin level is about 50 micromoles per liter, then in this case there will be jaundice only on the face, and if the bilirubin level is about 250, then the heels and palms will be colored, which is already very dangerous. Thus, one can assume the degree of jaundice and the level of bilirubin.

When jaundice appears, the child’s clinical condition should be assessed:

1. The child's level of adequacy, activity of reflexes.
2. Adequacy of breastfeeding, which should occur at least 8 times a day.
3. The state of skin turgor and moisture of mucous membranes.
4. Liver and spleen sizes.
5. Frequency of urination and the nature of urine.

A child with physiological jaundice is active with good reflexes, eats normally and has no signs of pathology in the liver and spleen.

To more accurately determine the degree of jaundice and predict the risk of complications, it is necessary to conduct tests. Tests can be carried out when jaundice progresses or dangerous symptoms appear. If the clinic has the necessary equipment, then a non-invasive method of research is considered to be transcutaneous measurement of the bilirubin level. But more often, bilirubin is determined in serum or umbilical blood. The bilirubin norm for physiological jaundice does not exceed 200 micromoles in serum blood, then we can talk about the benign course of this pathology. If, when determining the bilirubin level in umbilical blood, the result is more than 50 micromoles per liter, then an additional analysis of serum blood is carried out. It should be noted that routine measurement of any indicators in newborns is not carried out, since this is an invasive intervention.

Physiological jaundice does not require any instrumental diagnostic methods, but if there is a tendency to prolonged jaundice, then an ultrasound examination of the internal organs, the liver in particular, can be performed to study the condition of the bile ducts. Sometimes jaundice can be caused by pathology of the bile outflow, so for the purpose of differential diagnostics, an ultrasound can be performed. If there are signs of complications and damage to the nervous system, then there is a need for ultrasonography. This will allow differential diagnostics between pathology caused by hyperbilirubinemia and hypoxic damage to the central nervous system.

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Differential diagnosis

Differential diagnostics of physiological jaundice should be carried out first of all with pathological jaundice. The difference between physiological jaundice and pathological jaundice is the time of appearance. Pathological jaundice appears from the end of the second day and spreads to areas below the umbilical line and limbs (zones 3-4 on the Cramer scale). In the laboratory, this is characterized by an increase in the bilirubin level of more than 150 micromoles per liter. Clinically, there are clear differential signs. The child's condition may be disturbed in the form of flabbiness, inhibition, impaired reflexes (including the sucking reflex). The liver and spleen may be enlarged. Urine is light, the number of urinations corresponds to age, the stool is colored.

No less serious pathology should be considered hemolytic disease, which also requires clear differential diagnosis already at the stage of the first examination. Hemolytic disease occurs in a child when the blood groups of the mother and baby are incompatible by the Rh factor, which causes severe hemolysis of red blood cells. Therefore, a huge amount of free bilirubin is formed. Hemolytic disease has several forms, but a comparison of hemolytic disease of the newborn and physiological jaundice can be carried out in the icteric form, when this is the main symptom. The main differential signs can be considered the appearance of jaundice in the first day with hemolytic disease and severe anemia in the blood test. It is also important to take into account the mother's blood group and what pregnancy it is in order.

Differential diagnostics should also be performed with other liver pathologies that are characterized by jaundice syndrome. There are many disorders of liver enzymes that manifest as jaundice syndrome. Such pathologies include Crigler-Najjar syndrome and Gilbert syndrome. Crigler-Najjar syndrome is a genetic pathology of the enzyme glucuronyl transferase. This enzyme is one of the main ones that participate in the conversion of indirect bilirubin and its excretion. With this disease, the enzyme is completely absent or its amount is insignificant, so bilirubin is not neutralized at all. Therefore, jaundice in a child appears from the first day and progresses greatly. Complications arise quickly.

Gilbert's syndrome is characterized by a decrease in the activity of a similar enzyme, so the jaundice is less intense. This is also a genetic pathology, so it is very important to find out the family history, how many children there were in the family, how they were born and whether there were any fatal cases.

Hepatitis in a newborn can also cause jaundice syndrome. Hepatitis is usually caused by an intrauterine infection, so it is very important to know the pregnancy data and all the mother's studies to exclude such a pathology. As for the symptoms, with physiological jaundice, the child has no symptoms and he develops normally. With hepatitis, jaundice is caused by a violation of the cell wall of the hepatocyte, so both indirect and direct bilirubin increase, whereas with physiological jaundice only indirect. Hepatitis is accompanied by severe intoxication of the child, since there is an active inflammatory process in the liver and destruction, which is the main criterion for a dangerous condition.

All these criteria are very important for correct and timely diagnosis, because the consequences of the pathology can be serious.

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Treatment physiologic jaundice of the newborn

Treatment of physiological jaundice today has many controversial issues and different clinics can practice different methods of treatment. But in Ukraine the effectiveness of certain drugs has not been proven, although their use is nevertheless very widespread. The most effective and recommended method of treatment today is considered to be phototherapy. It is very important in treatment to organize not only the correct treatment regimen, but also the baby's nutrition and care.

The frequency of breastfeeding of a child with jaundice should be at least 8-12 times a day without a night break, which reduces the risk of developing a calorie deficit or dehydration of the child and, thus, increasing hyperbilirubinemia. At the same time, oral administration of water or glucose to newborns with jaundice does not prevent the development of hyperbilirubinemia and does not reduce the bilirubin level. Therefore, nutrition should be breastfeeding, if possible, or artificial. If it is impossible to ensure adequate breastfeeding, it is advisable to supplement the child with expressed breast milk. In the event that the amount of breast milk received cannot provide the required daily volume of fluid, intravenous fluid administration is possible.

Phototherapy is certainly the most effective method of reducing bilirubin levels. The effect of phototherapy is due to three phenomena – photoisomerization, photodegradation and photooxidation. That is, bilirubin, under the influence of direct monochromatic light rays of 450 nanometers in length, is broken down into more non-toxic water-soluble compounds. Thus, it is quickly excreted from the body.

The technique of phototherapy involves round-the-clock treatment with breaks only for feeding. The child lies under a source of artificial color for several days until the symptoms disappear. The child is naked to ensure maximum irradiation and special glasses are put on for protection, and the genitals are also protected. This therapy is accompanied by a decrease in the bilirubin level by 20-30 units, which is a good indicator.

During phototherapy, it is very important to monitor the child's condition. After all, intense radiation can cause overheating, increased body temperature, dehydration. Therefore, the doctor must monitor the child's condition and his reaction to treatment.

As for the use of drugs in the treatment of physiological jaundice, it is quite common to see them used for prolonged jaundice already at the stage of treatment in outpatient settings. It cannot be said that this is a completely wrong approach, because many drugs have different mechanisms of action. The following drugs are most often used:

1. Hofitol is often used for physiological jaundice as a drug that has a choleretic and hepatoprotective effect. This helps to accelerate the maturation of hepatocytes in newborns and at the same time accelerates the metabolism of bilirubin. The main active ingredient of the drug is artichoke extract, so the herbal composition of the drug contributes to its wide use. The method of using the drug for children in the form of tablets, since the syrup has a significant amount of alcohol. The dosage of the drug for children is one tablet per day with breast milk. Side effects - most often diarrhea is observed in a child, there may also be vomiting, spasmodic colic in the abdomen and allergic reactions.
2. Galstena is a complex drug that has an antispasmodic effect on the bile ducts and improves the outflow of bile, and also improves the function of hepatocytes. The active substance of the drug is Carduus, Taraxacum, Chelidonium, Natrium sulfuricum and Phosphorus. This composition of the drug allows it to be used for jaundice in a dosage of one drop of solution per day. Side effects can also be in the form of action on the intestines.
3. The use of probiotics is widely used in the treatment of jaundice, since the restoration of normal intestinal microflora in a child allows for the normalization of metabolic processes and the elimination of bilirubin.

Acidolak is a drug that contains lactobacilli, which form lactic acid and prevent pathogenic bacteria from multiplying. Due to this, the drug creates favorable conditions for the development of beneficial intestinal microflora. Lactobacillus reuteri, which is part of the drug, is a priority "resident" of the child's intestines, so it takes an active part in the exchange of bilirubin and its excretion with feces. The dosage sufficient to restore microflora in children is half a sachet per day in two doses. The powder can be dissolved in milk and given to the child before feeding. Side effects - diarrhea, stool color change, rumbling in the intestines.

1. Sorbents are also widely used in the treatment of physiological jaundice and the main principle of the drug is the absorption of toxic metabolic products in the intestine. This allows part of the bilirubin to be excreted in the intestine, and against the background of normal excretory function of the intestine, jaundice quickly passes.

Smecta is a drug that is an active sorbent due to the content of many bonds capable of binding pathological products in the intestine. The dosage of the drug is one sachet per day. Considering that the drug has an antidiarrheal effect, it is necessary to ensure normal feeding of the child to improve the removal of metabolic products with feces. Method of application of the drug - you can dilute a sachet with the medicine in boiled water. Side effects may be constipation in susceptible children.

Traditional treatment of physiological jaundice

Traditional methods of treatment are not used for newborn babies, since additional introduction of liquid can be dangerous for them. Therefore, among traditional methods, herbs are used that help improve liver function and thus accelerate the excretion of bilirubin. Such traditional methods are used in the form of herbal teas and infusions for intake by a mother who breastfeeds a child.

1. Artichoke leaf extract is a natural herbal remedy for protecting liver cells and improving their function. In addition, artichoke leaves have a choleretic effect and enhance bilirubin metabolism in the intestines by excreting it with bile. A medicinal infusion can be prepared by steeping 60 grams of artichoke leaves in a liter of water. Mom should take this tea twice a day, 50 milliliters each time.
2. Corn silk is also one of the most effective natural hepatoprotective agents. An infusion of it accelerates the exchange of bile acids, promotes the excretion of bile into the ducts and duodenum, which allows bilirubin to be broken down in the liver and also excreted with bile. To prepare the infusion, you need to take corn silk (these are corn hairs) or buy already packaged tea from a pharmacy and brew it. You need to take one hundred grams of this tea every six hours.
3. Milk thistle shows its effect in the treatment of jaundice by improving the synthesis of bile acids, which help remove toxic metabolic products of bilirubin. To prepare tea, take twenty grams of the herb and brew it in 750 milliliters of boiled water. Take a glass of this tea at night.

Vitamins can be used by the mother after the child has fully recovered. As for physiotherapeutic methods of treatment, they are not used for newborns. Considering the positive effect of sunlight, it is recommended that mothers walk in the open sun after discharge with residual effects of jaundice. Rickets prevention according to the scheme is mandatory for such children.

Homeopathy can be used in the treatment of jaundice, because many hepatoprotective drugs are based on homeopathic products.

1. Chole-gran is a homeopathic complex preparation of plant origin. It is used to treat jaundice, which is accompanied by significant anxiety in the child and problems with stool. Due to its complex composition, the drug eliminates spasms and normalizes metabolism in the liver. The method of using the drug in drops. The dosage of the drug for a child is one drop twice a day in the acute period. Side effects can only be in the form of allergic reactions.
2. Lycopodium is a homeopathic remedy of inorganic origin. This remedy acts by increasing bile formation and removing the end products of bilirubin metabolism. It is used to treat jaundice in children when adding the medicine to a nursing mother. The dosage of the drug is two drops every four hours. Side effects are possible in the form of allergic reactions. Precautions - the drug should not be used if there is a suspicion of organic brain damage or severe pathological jaundice.
3. Sodium sulphur is an organic homeopathic preparation used in 200 dilution. It is used to treat jaundice in children of any genesis, as a fast-acting drug. The method of administration of the drug is oral in the form of drops for the baby. The dosage in case of taking drops is one drop twice a day during feeding. Side effects are possible in the form of increased salivation.
4. Mercurius solubilis is a homeopathic medicine used to treat chronic jaundice. The drug is most effective in lethargic and underweight babies who have poor bowel movements, which further contributes to the retention of bilirubin. For treatment, the dosage is two drops for the baby once a day. Side effects may include constipation.

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Prevention

Prevention of complications in a child with physiological jaundice is very important, since damage to the nervous system with improper or untimely treatment is irreversible. Therefore, the main thing is to assess the extent of jaundice and determine the level of bilirubin if there are any doubts about this. Monitoring is also very important after the child is discharged from the hospital. In case of discharge of the child on the 3rd day of life, it is necessary to examine the child at home until the child reaches 120 hours of life (5 days). In case of uncomplicated course of physiological jaundice, prevalence of yellowish coloration of the skin not below the umbilical line, good clinical condition of the child and established breastfeeding - the child can be discharged home under the supervision of a local pediatrician or family doctor. And further monitoring of the child's condition is an important part of the prevention of further complications.

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Forecast

The prognosis for recovery of a child with physiological jaundice is favorable, since the bilirubin level is not critically high for the development of complications. If phototherapy is successfully performed, the issue of discharging the child from the medical institution can be decided no earlier than 24 hours after the completion of phototherapy and in the case of a satisfactory clinical condition of the child, the absence of an increase in yellowish coloration of the skin after the end of phototherapy. Thus, after two days, children are discharged home.

Physiological jaundice of the newborn is the appearance of a yellow color of the skin and mucous membranes in the child, which is caused by the immaturity of liver enzymes, which cannot inactivate high concentrations of bilirubin so quickly. This condition does not threaten the life of the child as long as it is physiological. But the mother should carefully monitor the condition of the child and the extent of the jaundice in order to consult a doctor in a timely manner.

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