Jaundice in Children

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Jaundice in children, particularly newborns, refers to the yellowing of the skin and eyes due to elevated levels of bilirubin in the blood. Neonatal jaundice is common, especially in the first week of life, and is usually benign. However, in some cases, it may indicate an underlying health issue requiring medical intervention.

Aetiology

There are different causes of jaundice in children, categorised as physiological or pathological:

• Physiological jaundice: Occurs in most newborns due to the immaturity of the liver, which is less efficient in processing bilirubin.
• Breastfeeding jaundice: Inadequate breastfeeding in the first few days of life may lead to dehydration, reducing the elimination of bilirubin.
• Breast milk jaundice: Some breastfed babies may develop jaundice later due to substances in breast milk that interfere with bilirubin breakdown.
• Pathological causes: Includes haemolytic diseases (e.g., Rh or ABO incompatibility), infections, liver diseases, or metabolic disorders.

Pathophysiology

Bilirubin is a byproduct of the breakdown of red blood cells. In newborns, their red blood cells are broken down more rapidly than in adults, leading to increased bilirubin production. The immature liver in neonates has a reduced ability to conjugate and eliminate bilirubin, leading to a buildup in the blood. This unconjugated bilirubin is deposited in the skin and sclera, causing the characteristic yellow colour seen in jaundice.

Risk Factors

• Prematurity (babies born before 37 weeks).
• Inadequate breastfeeding or feeding difficulties.
• Family history of jaundice.
• Blood type incompatibilities (e.g., ABO or Rh incompatibility).
• Bruising or cephalohaematoma at birth (increased breakdown of red blood cells).
• Sepsis or infections.
• Metabolic disorders such as G6PD deficiency.
• Congenital infections (e.g., TORCH infections).

Signs and Symptoms

• Yellowing of the skin and sclera, starting from the face and spreading downwards.
• Poor feeding or lethargy in severe cases.
• Dark urine or pale stools (may indicate liver or biliary tract pathology).
• Excessive drowsiness or irritability in cases of severe jaundice.
• High-pitched crying (may indicate neurological involvement due to severe jaundice).

Investigations

• Bilirubin levels: Measure serum bilirubin levels to assess the severity of jaundice. Transcutaneous bilirubinometry may also be used.
• Blood group and Coombs test: To check for blood group incompatibilities and haemolysis.
• Full blood count (FBC): To evaluate haemoglobin levels and signs of haemolysis.
• Liver function tests (LFTs): To assess for liver dysfunction or cholestasis.
• Sepsis screen: If infection is suspected, especially in babies with fever or prolonged jaundice.

Management

Management depends on the severity of the jaundice and the underlying cause. Early detection and treatment are crucial to prevent complications such as kernicterus (bilirubin-induced brain damage).

Phototherapy:

• First-line treatment: Phototherapy is the mainstay of treatment for neonatal jaundice. The light breaks down bilirubin in the skin, allowing it to be excreted in the urine.
• Duration and review: The baby will be regularly monitored by midwives and health visitors to assess bilirubin levels and adjust treatment as needed.

Exchange Transfusion:

• In severe cases of jaundice where bilirubin levels are dangerously high or there is evidence of haemolysis, exchange transfusion may be necessary to quickly reduce bilirubin levels.

Support for Feeding:

• Ensuring adequate feeding, whether through breastfeeding or formula feeding, is crucial to help eliminate bilirubin. Midwives and health visitors play a key role in supporting breastfeeding mothers and identifying feeding difficulties early.
• Breastfeeding support: Midwives and health visitors can offer breastfeeding support to ensure the baby is feeding effectively and regularly.

When to Be Concerned:

• If jaundice appears within the first 24 hours of life (this is more likely to be pathological and requires urgent evaluation).
• Jaundice lasting longer than 14 days in term babies or 21 days in preterm babies (prolonged jaundice may indicate an underlying problem such as liver disease).
• If the baby is not feeding well, is excessively sleepy, or has dark urine and pale stools.
• If there are signs of kernicterus, such as high-pitched crying, poor feeding, muscle rigidity, or seizures (medical emergency).

References

1. NICE (2024). Jaundice in Newborns: Diagnosis and Management Guidelines. Available at: NICE Guidance
2. NHS (2023). Neonatal Jaundice. Available at: NHS
3. British Medical Journal (2023). Neonatal Jaundice: A Clinical Guide. Available at: BMJ