Physiological jaundice of a newborn: what is conditioned, when it passes, the consequences

The physiological jaundice of a newborn is the appearance of a yellow skin tone in a newborn child three days after birth, which can be 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.

[1], [2], [3], [4], [5], [6]

Epidemiology

Statistics of physiological jaundice suggests that it manifests itself in 80% of premature babies and about 60% of full-term babies. This shows a higher incidence of this condition in prematurity, which is associated with a higher level of immaturity of liver enzymes.

[7], [8], [9], [10], [11], [12], [13], [14]

Causes of the physiological jaundice of the newborn

Almost all newborn babies have an increase in the level of bilirubin in the blood, which is transient in nature and does not appear clinically. This suggests that the distribution of jaundice is more significant than is considered at first glance. Speaking of jaundice, it is necessary first of all to 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 condition. If we talk in more detail about this concept, then physiological jaundice is a change in the color of the skin of the child and mucous membranes to yellow, which is caused by a transient increase in the level of bilirubin in the blood. This yellow color of the child's skin appears not earlier than 36 hours after birth, then we can say that it is physiological jaundice. If it appears earlier, it is already signs of a pathological condition.

The causes of physiological jaundice directly depend on the pathogenetic features of the development of this condition. At the heart of the pathogenesis of jaundice is the pathology of bilirubin metabolism. Newborn children are characterized by a number of features of bilirubin metabolism, which cause a high frequency of this pathology. The source of bilirubin in 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 life expectancy of red blood cells is less than in adults and is about one month. And thus, it quickly collapses in the spleen, forming a large amount of free bilirubin. Given that the number of erythrocytes in newborn babies is greater than that of an adult, which is necessary to provide oxygen breath in utero, this increases the amount of hemoglobin itself.

Bilirubin, which is released during the decay of large amounts of hemoglobin, is released into the blood. This is an indirect bilirubin, which is inherent in tropism to tissues rich in lipids, insolubility in water and toxic properties. In the 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 the tissues, primarily into the subcutaneous tissue. The jaundice that occurs while doing this is physiological.

There is one more peculiarity of pathogenesis - the fact 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 5th-7th day of life does the enzyme function of the liver become active, which enables it to normally neutralize bilirubin.

Transformation of indirect bilirubin in the direct line occurs with the participation of glucuronic acid and enzymes of UDPG-dehydrogenase, glucuronyltransferase, cytochrome P-450. The activity of enzymes is greatly influenced by drugs that are used during childbirth, as well as components of breast milk. Part of unconjugated bilirubin enters the intestine, from where it is actively absorbed into the blood, supporting hyperbilirubinemia. In addition, newborns have narrow bile ducts, low concentrations of bile acids. The retention of meconium elimination leads to the accumulation of bilirubin in the digestive canal, the transformation of direct bilirubin into the indirect bilirubin using intestinal beta-glucuronidase, and the enhancement of its toxic effect on the body. Therefore it is important to limit when jaundice is still physiological, and when already pathological.

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

[15], [16]

Risk factors

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

1. premature babies have an even greater degree of underdevelopment of hepatocytes and liver function;
2. complicated pregnancy and mother's diseases during pregnancy;
3. the conditions of childbirth and external interventions at birth increase the level of stress in the child's body and disrupt the normal function of organs, including the liver;
4. impaired circulation in the placenta can cause an increase in the number of red blood cells and, correspondingly, an increase in the level of bilirubin decay;
5. children with hemorrhages - cephalomatoma or hemorrhagic disease;
6. Children with malnutrition or with vomiting, losing body weight - this is a risk of a more serious lesion of the central nervous system, even with bilirubin numbers less significant;
7. asphyxia of the newborn;
8. generalized fetal infection.

[17], [18], [19], [20], [21], [22], [23]

Symptoms of the physiological 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 has a yellow color of the skin, mucous membranes and sclera. The yellowness of the skin extends to the face and up to the level of the teat line. In this case, you can say that this is physiological jaundice. When does physiological jaundice pass in newborns? Until the end of the seventh day of the child's life, such jaundice should decrease, and until the end of the 14th day it should disappear. As for the premature baby, he must have jaundice before 21 days of life. Prolonged physiological jaundice is a manifestation of jaundice after a 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 closely monitor the condition of the child at the same time. In newborns who are exclusively breastfed, jaundice can have two peaks of bilirubin (between 4-5 and 14-15 days). In such cases, a slow decrease in the intensity of icteric staining 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 infants in the absence of general disorders. Such jaundice does not require medical therapy and stop breastfeeding. This is called "jaundice from breast milk", which also applies to the 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 grows and spreads from face to shoulder. Further closer to the seventh day, the intensity of jaundice decreases and there is no spread below the level of the shoulders, 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 a different risk of complications.

Other symptoms for physiological jaundice are not peculiar, since such a level of bilirubin does not affect the nervous system and other tissues. If there are any symptoms of child retardation, rejection of the breast, 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, exceeding a certain level of bilirubin in the blood serum allows it to enter the brain cells and disrupt their work. What is dangerous physiological jaundice of a newborn? One of the complications of physiological jaundice can be considered nuclear jaundice - this is the defeat of the nervous system under the influence of the borderline permissible level of bilirubin. For term infants, this level is 320 micromolar, and for premature babies 250. If bilirubin levels rise sharply, bilirubin encephalopathy develops. This is characterized by damage to the brain nuclei and a violation of the child's further development. Clinically, this manifests itself as a violation of consciousness, focal symptoms, seizures, a violation of thermoregulation.

[24], [25], [26]

Diagnostics of the physiological jaundice of the newborn

Diagnosis of physiological jaundice should be carried out with a careful examination of the child, which allows 80% to establish a diagnosis. First of all, you need to carefully examine the child. An examination for the presence of icteric skin coloration should be performed when the child is completely stripped, provided that there is sufficient (optimally daytime) illumination. To do this, lightly pressing the skin of the child to the level of subcutaneous tissue. This allows you to more accurately assess the degree of coloration of the baby's skin. Be sure to pay attention to sclera and mucous membranes, they must also be yellow, then it's about jaundice. In order for the doctor to evaluate the level of bilirubin and the degree of jaundice, there is a special Cramer score. It is justified by the fact that the amount of bilirubin in a child's body is equal to the level of coloring of his skin. For example, if the bilirubin level is about 50 micromolar per liter, then there will be jaundice only on the face, and if the bilirubin level is about 250, then heels and palms will be painted, which is very dangerous. Thus, one can assume the degree of jaundice and the level of bilirubin.

When jaundice occurs, the clinical state of the child should be assessed:

1. The degree of adequacy of the child, the activity of reflexes.
2. Adequacy of breastfeeding, which should occur at least 8 times a day.
3. Condition of skin turgor and moisture of mucous membranes.
4. Dimensions of the liver and spleen.
5. The frequency of urination and the nature of urine.

A child with physiological jaundice is active with good reflexes, normally eats and without signs of pathology on the part of the liver and spleen.

To more accurately determine the degree of jaundice and predict the degree of risk of complications, it is necessary to conduct analyzes. Analyzes can be conducted with the progression of jaundice or the appearance of dangerous symptoms. If the clinic has the necessary equipment, then a non-invasive method of investigation is a transcutaneous measurement of the level of bilirubin. But more often determine bilirubin serum or umbilical cord blood. The norm of bilirubin in physiological jaundice does not exceed 200 micromolar in serum, then we can speak about the benign course of this pathology. If the result is greater than 50 micromolar per liter in determining the level of bilirubin in the umbilical cord, then an additional serum blood test is performed. It should be noted that the 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 protracted jaundice, ultrasound examination of the internal organs, the liver in particular, for the purpose of studying the state of the bile ducts can be performed. Sometimes jaundice can be caused by the pathology of outflow of bile, so for the purpose of differential diagnosis it is possible to perform ultrasound. If there are signs of complications and lesions of the nervous system, then there is a need for ultrasonography. This will allow for differential diagnosis between the pathology caused by hyperbillirubinemia and hypoxic damage to the central nervous system.

[27], [28], [29], [30], [31]

Differential diagnosis

Differential diagnosis of physiological jaundice should be carried out primarily 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 extends to areas below the umbilical line and limb (zones 3-4 on the Cramer scale). This is characterized in laboratory by an increase in the level of bilirubin more than 150 micromolar per liter. Clinically, there are obvious differential signs. The condition of the child can be violated in the form of flabbiness, inhibition, reflexes (including the sucking reflex). The liver and spleen can be enlarged. Urine is light, the amount of urination corresponds to age, stool stained.

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

Differential diagnostics should also be performed with other liver pathologies that are characterized by jaundice. There are many violations of the liver enzymes that manifest the syndrome of jaundice. Such pathologies include the Kriegler-Nayar syndrome and Gilbert's syndrome. The Kriegler-Nayar syndrome is a genetic pathology of the enzyme glucuronyltransferase. 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 generally absent or its insignificant amount, so bilirubin is not neutralized at all. Therefore, jaundice in a child appears already from the first day and greatly progresses. Complications quickly appear.

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

Hepatitis in a newborn can also cause jaundice. Hepatitis is usually caused by intrauterine infection, so the data on pregnancy and all the research of the mother is very important to know in order to exclude such pathology. As for the symptomatology, with physiological jaundice, the child has no symptoms and it develops normally. In hepatitis, jaundice is caused by a violation of the cell wall of the hepatocyte, so both indirect and direct bilirubin increases, whereas in physiological jaundice, only indirect. Hepatitis is accompanied by severe intoxication of the child, as there is an active inflammatory process in the liver and destruction, which is the main criterion of the dangerous state.

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

[32], [33], [34], [35], [36], [37], [38]

Treatment of the physiological jaundice of the newborn

The treatment of physiological jaundice today has many debating issues and different clinics can practice different methods of treatment. But in Ukraine the effectiveness of these or other medications is not proven, although their use, despite this is very broad. The most effective and recommended method of treatment is phototherapy today. It is very important in the treatment to organize not only the correct treatment regimen, but also the baby's nutrition and caring for it.

The frequency of breastfeeding 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, increased hyperbilirubinemia. At the same time, oral administration to newborns with jaundice of water or glucose does not prevent the development of hyperbilirubinemia and does not reduce the level of bilirubin. Therefore, the diet should be thoracic if possible or artificial. If it is not possible to provide adequate breastfeeding, it is advisable to supplement the baby with expressed breast milk. In the event that the amount of breast milk received can not provide the required daily volume of fluid, intravenous fluid may be administered.

Phototherapy is certainly the most effective method of lowering the level of bilirubin. The effect of phototherapy is due to three phenomena - photoisomerization, photodegradation and photo-oxidation. That is, bilirubin under the action of direct monochromatic light rays with a length of 450 nanometers splits into more nontoxic water-soluble compounds. Thus, it is quickly excreted from the body.

The technique of phototherapy involves a round-the-clock treatment with interruptions only for feeding. The child lies under a source of artificial color for several days until the symptomatology disappears. At the same time, the child is naked to ensure maximum radiation and he is given special glasses for protection, and also protects the genitals. Such therapy is accompanied by a decrease in the level of bilirubin by 20-30 units, which is a good indicator.

It is very important to monitor the child's condition during the phototherapy. After all, intense irradiation can cause overheating, fever, dehydration. Therefore, the doctor must monitor the condition of the child and his reaction to treatment.

With regard to the use of drugs in the treatment of physiological jaundice, it is often possible to see their use in prolonged jaundice already at the stage of treatment in policlinic conditions. It can not be said that this is a completely wrong approach, because many drugs have a different mechanism of action. The most commonly used drugs are:

1. Hofitol with physiological jaundice is often used as a drug that has a cholagogic and hepatoprotective effect. This helps to accelerate the maturation of hepatocytes in newborns and, at the same time, speeds up the metabolism of bilirubin. The main active ingredient of the preparation is an artichoke extract, therefore the plant composition of the preparation contributes to its wide application. The way the drug is used for children in the form of tablets, since the syrup has a significant amount of alcohol. Dosage of the drug for children one tablet per day with breast milk. Side effects - the most commonly observed diarrhea in a child, can also be vomiting, spasmodic colic in the abdomen and allergic manifestations.
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. Such a composition of the drug allows you to use it for jaundice in the dosage of one drop of solution per day. Side effects can also be in the form of an action on the intestines.
3. The use of probiotics is widely used in the treatment of jaundice, since the restoration of normal microflora of the intestinal tract of the child allows to normalize the processes of metabolism and excretion of bilirubin.

Acidolac - a drug that has in its composition lactobacilli, which form lactic acid and do not allow the reproduction of pathogenic bacteria. Due to this, the preparation forms favorable conditions for the development of useful intestinal microflora. Lactobacillus reuteri, which is a part of the medicine, is a priority "resident" of the intestine of the child, therefore it takes an active part in the exchange of bilirubin and its excretion with feces. The dosage sufficient to restore the microflora in children is half the packet per day in two divided doses. The powder can be dissolved in milk and given to the baby before feeding. Side effects are diarrhea, stool color disorder, rumbling in the intestine.

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 parts of bilirubin to be excreted in the intestine, and against a background of normal excretory function of the intestinal jaundice quickly passes.

Smecta is a drug that is an active sorbent due to the content of many bonds that can bind pathological products in the intestine. Dosage of the drug - one packet per day. Given that the drug has an antidiarrheal effect, it is necessary to ensure the normal feeding of the child to improve the excretion of metabolic products even with feces. The way of using the drug - you can dilute the sachet of medicine in boiled water. Side effects can be in the form of constipation in prone children.

Alternative treatment of physiological jaundice

Alternative therapies are not applied to newborn babies, since additional fluid administration may be dangerous for them. Therefore, among the alternative methods used herbs, which contribute to the improvement of liver function and thus accelerate the excretion of bilirubin. Such alternative methods are used in the form of herbal teas and infusions for taking a mother who is breastfeeding.

1. Artichoke leaves extract is a natural herbal remedy for the protection of liver cells and improving their function. In addition, artichoke leaves have a choleretic effect and increase the metabolism of bilirubin also in the intestine by excretion with bile. Therapeutic infusion can be prepared by infusing 60 grams of artichoke leaves in a liter of water. Mom should take such tea twice a day for 50 milliliters.
2. Corn stigmas are also one of the most effective natural hepatoprotective agents. Infusion of them speeds up the exchange of bile acids, promotes the excretion of bile into the ducts and duodenum, which allows bilirubin to be split in the liver and also excreted with bile. To prepare the infusion, you need to take corn stigmas (this is the hair of corn) or buy in the pharmacy already packaged tea and fume. Take every six hours for a hundred grams of tea.
3. Milk thistle has its effect in the treatment of jaundice by improving the synthesis of bile acids, which contribute to the elimination of toxic metabolic products of bilirubin. To make tea, you need to take twenty grams of grass and fry in 750 milliliters of boiled water. Take a night for a glass of tea.

Vitamins can be used by the mother even when the child is 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, after discharge for residual effects of jaundice, walk in the open sun. Prevention of rickets 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. The chole-gran is a homeopathic complex preparation of plant origin. It is used to treat jaundice, which is accompanied by significant child anxiety and problems with stool. Due to the complex composition, the drug eliminates spasms and normalizes the metabolism in the liver. Method of application of the drug in droplets. Dosage of the drug for a child - one drop twice a day in an acute period. Side effects can only be in the form of allergic manifestations.
2. Likopodium - a homeopathic remedy of inorganic origin. This drug acts by increasing bile formation and removing the final products of bilirubin metabolism. Used in the treatment of jaundice in children with the addition of a drug to a nursing mother. Dosage of the drug is two drops every four hours. Side effects are possible in the form of allergic reactions. Precautions - do not use the drug in case of suspected organic brain damage or with severe pathological jaundice.
3. Sodium sulfur is an organic homeopathic preparation that is used in 200 dilutions. It is used to treat jaundice in children of any genesis, as a quick-acting drug. The way of application of the preparation is oral in the form of drops for the baby. Dosage in case of taking drops - one drop twice a day during feeding. Side effects are possible in the form of increased salivation.
4. Mercurius solubilis is a homeopathic medicine that is used to treat prolonged jaundice. The drug is most effective in sluggish and low-fat children, which are poorly emptied, which further contributes to the delay of bilirubin. For treatment, the dosage is two drops for the baby once a day. Side effects can be in the form of constipation.

[39], [40], [41], [42], [43], [44], [45]

Prevention

Prophylaxis of complications in a child with physiological jaundice is very important, since the damage to the nervous system in case of incorrect or untimely treatment is irreversible. Therefore, the main thing is to assess the extent of jaundice and determine the level of bilirubin if there is any doubt about this. Very important monitoring and after the discharge of the child from the hospital. In case of a child's discharge 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, the prevalence of icteric staining of the skin is not lower than the umbilical line, a good clinical condition of the child and well-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 preventing further complications.

[46], [47], [48], [49], [50], [51], [52], [53]

Forecast

The prognosis for recovery of the child with physiological jaundice is favorable, since the level of bilirubin is not critically high for the development of complications. With successful phototherapy, the issue of discharging a child from a medical institution can be resolved 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 jaundice staining of the skin after the termination of phototherapy. Thus, after two days the children are discharged home.

The physiological jaundice of the newborn is the appearance of the yellow color of the skin and mucous in the child, which is caused by the immaturity of the liver enzymes, which can not so rapidly inactivate high concentrations of bilirubin. This condition does not threaten the child's life until it is physiological. But the mother must carefully monitor the state of the child and the extent of the spread of jaundice, in order to contact the doctor in a timely manner.

[54], [55], [56], [57], [58], [59], [60], [61]