Jaundice or yellow characteristic is often found in newborns within normal limits on the second day to the third day. Normally, it will disappear on the tenth day. Therefore, towards the returning home of the baby, jaundice must get attention. Regarding, it may be pathological. Physiological jaundice is a kind of Jaundice experienced by most of these newborns. Bilirubin is the result of hemoglobin metabolism contained in red blood cells.
These red blood cells have a certain age, 120 days in adults and about 70-90 days in neonates. The shortage of red blood cells occurs because of the condition of immature neonates red blood cells, the cells have large nuclei so it is very easy to experience hemolysis. When it reaches its time, these red blood cells will undergo destruction.
As an illustration, it can be said that the bilirubin indirect levels of term infants are around 15 mg%. While the early babies are 10 mg%. However, the case above this normal level is considered as hyperbilirubinemia. Later, it can cause kern-icterus.
Why is jaundice important?
Jaundice can be a sign of an actual disease. Also, it becomes a clue in diagnosing etiology. Besides, jaundice that does not handle quickly and precisely causing kern-icterus, we can call it as encephalopathy. This appears due to excessive bilirubin indirect levels in the basal ganglia and brain stem nuclei. This was marked by visible irritability in infants, lethargy, lazy drinking, fever, convulsions, coma, and even death.
In general, physiological jaundice occurs due to 2 processes, they are:
- Production of bilirubin increases:
- High hemoglobin concentration at birth and rapidly decreases during the first few days of life
- The age of red blood cells in newborns is shorter
- Excretion of decreased bilirubin:
- A decrease in liver cells decreases
- the conjugation in the liver decreases due to the immaturity of liver enzymes
- Enterohepatic circulation increases
Signs and Symptoms of Physiological Jaundice
- Letargi and lazy
- The white part of the baby’s eyeball looks yellow
- Babies who do not want to suckle or sleep continuously
- If the skin is pressed for a few seconds it will look yellowish. The trick: press the index finger slowly in places where the bones stand out like the bones of the nose, chest, and knees
- High-pitched cry
- Yellow skin
Therefore, midwives need to know well when the occurrence of jaundice prolonged or the level of intensity increases, so later it can conduct consultations or recommend the patients to the hospital.
How to prevent physiological jaundice
- Prevention of infection in newborns
- Good antenatal supervision
- Avoid drugs that can increase jaundice in infants during pregnancy and birth. Provision of drinking as early as possible with a sufficient amount of fluid and calories. Early drinking will increase intestinal motility and cause bacteria to be introduced into the intestine.
Management of Physiological Jaundice
- Provision of early food (breast milk) with the amount of fluid and calories according to the needs of newborns.
- Tell mothers how to properly care for newborns. Example: bathing the baby and cord care.
- The act of sunbathing a yellow baby, bilirubin will absorb light with a wavelength of 450-460 nm. Here are how to do it: Do it between 7:00 a.m. until 9:00 a.m. and the baby is dried for about ½ hour with the position ¼ hour in the supine condition and ¼ hour again face down.
Babies who get exclusive breastfeeding can also experience jaundice. Jaundice is caused by the production of breastmilk which is not yet abundant on the first day. Babies experience a lack of food intake. As a result, direct bilirubin that has reached the intestine is not bound by food and not released through the rectum with food.
In the intestine, direct bilirubin is converted into indirect bilirubin.
This is later absorbed back into the blood. Later, it increases enterohepatic circulation. This situation does not require treatment and should not be given water or sugar water. To reduce the occurrence of early jaundice need to do these following actions:
- Babies within 30 minutes are placed on the mother’s chest about 30-60 minutes
- The position and attachment of the baby to the breast must be correct
- Give the colostrum because it can help to clean meconium immediately. Meconium contains high bilirubin and recommended to release immediately. Its bilirubin can be reabsorbed to increase the level of bilirubin in the blood.
- Babies are breastfed according to their wishes (at least 8 times a day).
- Do not give water, sugar water or anything else before the milk comes out because it will reduce milk intake.
- Check the adequacy of breastmilk production by seeing babies urinating at least 6-7 times a day and defecating at least 3-4 times a days
Jaundice due to breast milk
Characteristics of jaundice due to breast milk are bilirubin indirect levels still increasing after the first 4 – 7 days. It lasts longer than physiological jaundice which is up to 3-12 weeks. Jaundice of breast milk is related to breastfeeding from a particular mother. Further, usually, jaundice will occur in each baby who is breastfed. Besides, jaundice because breast milk also depends on the ability of the baby to conjugate indirect bilirubin (for example premature babies will be more likely to occur jaundice).
The cause of jaundice due to breast milk is unclear but here are several factors thought related to the case:
- There is a result of the metabolism of the hormone progesterone (pregnane3-Î ± 20 betadiol) in breast milk which inhibits uridine diphosphoglucoronic acid (UDPGA)
- An increased concentration of nonesterified free fatty acids that inhibits the function of glucuronide transferase in the liver
- Increased enterohepatic circulation due to an increase in ŸŸ glucuronidase activity in breast milk while in the baby’s intestine.
- Defecation of uridine diphosphate-glucoronyl transferase (UGT1A1) activity in homozygous or heterozygous infants for the variant of Gillbert syndrome.
Diagnosis of jaundice due to breast milk
All causes of jaundice must be removed. Parents can be asked if their previous child has jaundice. About 70% of newborns who were siblings previously had jaundice because the milk will also experience jaundice. The severity of jaundice depends on the maturity of the heart to conjugate the advantages of this indirect billirubin. For certainty diagnosis, especially if the bilirubin level has reached above 16 mg / dl for more than 24 hours is to check the level of billirubin 2 hours after breastfeeding and then stop breastfeeding for 12 hours (of course the baby gets fluids and calories from other foods in the form of milk from donor or breastmilk substitute and the mother is still milked so the milk production is not reduced). After 12 hours the level of billirubin is re-examined, if the decrease is more than 2 mg / dl then the diagnosis can be confirmed.
If the bilirubin level has reached <15 mg / dl, then the milk can be given back. The billirubin level is checked to see if there is an increase again. In most cases the termination of breast milk for a long time will give the heart a chance to conjugate excessive indirect billirubin, so that when the ASI is given back the increase will not be much and then gradually decrease. If the billirubin level does not decrease, the termination of breastfeeding is continued until 18-24 hours by measuring the level of billirubin every 6 hours. If the level of billirubin continues to increase after the cessation of breastfeeding for 24 hours then the cause is clearly not because of breast milk. ASI may be given again while looking for other causes of jaundice. There is still controversy to continue breastfeeding or to be stopped temporarily in jaundice due to breast milk. Usually the bilirubin level will decrease dramatically if the milk is stopped temporarily.