Early Human Development, 22 (1990) 23-28 23

Elsevier Scientific Publishers Ireland Ltd.

EHD 01039

The cephalocaudal progression of jaundice in

newborns in relation to the transfer of bilirubin
from plasma to skin

Aage Knudsen
Department of Obstetrics and Gynaecology, County Hospital of Hjbrring (Denmark)

Accepted for publication 20 November 1989

Summary

The cephalocaudal progression of jaundice was studied in 136 mature, clinically

well newborns. The yellow colour of the skin was measured with the transcutaneous
bilirubinometer. Significant positive correlation was found between the yellow col-
our of the skin in four regions and the plasma bilirubin concentration (forehead: rho
= 0.83, abdomen: rho = 0.89, knee: rho = 0.82, and foot: rho = 0.65, all P <
0.00001). The values obtained from the forehead were significantly higher than the
values obtained from the abdomen (P < O.OOOl),the knee (P < O.OOOOl),and the
foot (P < O.oooOl). The cephalocaudal progression of jaundice correlated positively
with the plasma bilirubin concentration (rho = 0.58, P < 0.00001) and inversely
with the gestational age (rho = - 0.28, P < 0.01). The results support a proposed
hypothesis explaining the cephalocaudal progression of jaundice in newborns.
According to the hypothesis, the cepholocaudal colour difference may be caused by
the presence of young bilirubin-albumin complexes in the blood undergoing confor-
mational changes.

neonatal jaundice; transcutaneous bilirubinometry; bilirubin-albumin binding.

Introduction

The cephalocaudal progression of dermal jaundice in newborns has been known

since Porak observed the phenomenon in 1878 [14]. Later investigators have con-
firmed his findings and demonstrated a direct relationship between plasma bilirubin

Correspondence to: Aage Knudsen, Kattegatsvej 38, DK-9700 BrQnderslev, Denmark.

0378-3782/90/$03.50 0 1990 Elsevier Scientific Publishers Ireland Ltd.

Published and Printed in Ireland
24

concentration and the cephalocaudal progression of the jaundice [3,7,11,14]. While

the phenomenon is well recognised, the mechanism explaining its occurrence
remains to be satisfactorily elucidated. Differences in skin vascularity, exposure of
skin to light and different content of epidermal surface lipid in various body sites
have been proposed as possible explanations [7].
Recently, a theory concerning the mechanisms involved in the transfer of biliru-
bin from blood plasma to skin tissue has been proposed [lo]. Based on that theory
and the knowledge of the albumin-bilirubin binding mechanisms, we hypothesise
that the cephalocaudal progress of jaundice in newborns can be explained by confor-
mational changes in the bilirubin-albumin complex. The present work was carried
out to present the hypothesis and to confirm the existence of the cephalocaudal pro-
gression of jaundice in newborns.

Hypothesis

The formation of bilirubin takes place in the reticuloendothelial system, which is

primarily located in the liver, spleen, and bone marrow. Once bilirubin reaches the
plasma, the bilirubin is bound tightly to plasma albumin. The binding process
involves a fast bimolecular combination of bilirubin and plasma albumin (within 10
ms) followed by a train of slow relaxational changes of conformation of the biliru-
bin-albumin complex. Major conformational changes in the bilirubin-albumin com-
plex are seen from 1 to 30 seconds and the final conformation reached 8 minutes
after binding [9]. Such conformational changes affect the binding equilibrium
between albumin and bilirubin, and a lower bilirubin binding affinity to albumin
can be expected until the stage of final conformation. Therefore, a gradient with
increasing bilirubin affinity to albumin exists in the blood circulation with the lowest
bilirubin affinity to albumin just after the blood leaves the reticuloendothelial sys-
tem. As the circulation time from the reticuloendothelial system to the distal parts of
the body is longer than to the proximal parts of the body, we may expect a
cephalocaudal increase in bilirubin affinity to albumin in the blood stream.
It has been shown that the transfer of bilirubin from plasma to skin can be
explained by two different mechanisms, by leakage of bilirubin-albumin complexes
into extravascular spaces, and by precipitation of bilirubin acid in phospholipid
membranes [lo]. According to the theory, the yellow colour of the skin in the icteric
newborn is determined by a contribution due to its content of bilirubin-albumin
complexes, a contribution from precipitated bilirubin acid and a contribution from
the basic yellow colour of the skin at birth. The first of these mechanisms would
probably not be influenced by the conformational changes occurring in the young
bilirubin-albumin complexes. The second of these mechanisms would, on the other
hand, be affected by the conformational changes in the young bilirubin-albumin
complexes. The plasma of the icteric newborn infant is supersaturated with bilirubin
acid. Experiments in vitro have shown that when phospholipid membranes are in
contact with plasma supersaturated with bilirubin acid, precipitation of bilirubin
acid takes place through the process [ 1,4]:

AB*- + 2H’ .Z BH, + A

 25

The bilirubin-albumin complex, AB2-, in which the bilirubin is present as the

dianion, combines with two hydrogen ions in the plasma and bilirubin acid, BH,, is
precipitated in phospholipid membranes. One molecule of albumin is released and
remains in the blood stream. If the bilirubin binding affinity to albumin is reduced
due to the presence of young bilirubin-albumin complexes in the blood, the process
will tend to proceed towards the right. Thus, in the presence of a cephalocaudal
increase in bilirubin affinity to albumin, we may expect a cephalocaudal colour gra-
dient as precipitation of bilirubin acid would be favoured in the proximal parts of
the body.
The plasma bilirubin concentration is determined by the balance between biliru-
bin production and removal of bilirubin from the circulation. The neonatal bilirubin
metabolism is characterized by a high production of bilirubin (two to three times
greater than in normal adults when expressed per kilogram of body weight) and
impaired removal of bilirubin from the circulation as the activity of the glucuronyl
transferase enzyme is low and as an unknown amount of bilirubin is reabsorbed by
way of the enterohepatic circulation [5,12]. However, we may expect that the higher
the plasma bilirubin concentration, the higher the plasma concentration of young
bilirubin-albumin complexes, and thus a positive correlation between the cephalo-
caudal progression of jaundice and the plasma bilirubin concentration is compre-
hensible.
It is noted that the cephalocaudal progression of jaundice seems more extended in
premature when compared to mature infants with equal plasma bilirubin concentra-
tions [3]. This phenomenon might be explained by the present hypothesis. At birth,
the placental circulation is cut off, the ductus arteriosus constricts, the foramen
ovale closes and the adult circulatory pattern is established. It is well known that this
process takes longer in the premature than in the mature infant. Especially in
prematures, therefore, a fraction of the blood from the liver and spleen could be
expected to follow the fetal pattern and be directed mainly to the head. This mecha-
nism could explain the negative correlation between gestational age and the cephalo-
caudal colour difference.
In summary, it is proposed that the cephalocaudal progression of jaundice in
newborn infants be explained by the conformational changes in the bilirubin-albu-
min complex in the first minutes following its formation.

Subjects and Methods

The study comprised 136 mature clinically healthy, icteric newborns without rhe-
sus immunisation or hemolytic anemia. In the days after birth the infants were care-
fully observed for the development of jaundice. If jaundice was observed, a blood
sample was drawn by heel prick. The plasma bilirubin concentration was determined
by a standard diazo method [2]. Immediately before the blood sample was taken, the
yellow colour of the skin was measured at four body sites: namely, forehead, umbili-
cus, knee and foot. Two readings were taken at each site and the average value was
used in the calculations.
The measurements of the yellow colour of the skin were performed with the Air
Shields Jaundice Meter (Minolta Camera Co.). The jaundice meter momentarily illu-
minates the skin and then spectrophotometrically analyses the reflected light and
measures the yellow intensity of the skin. The meter was tested daily and treated as
recommended by the manufacturer [ 131.

Results and Discussion

The median gestational age of the infants in the study was 40.0 (37.0-42.0)
weeks. The median birth weight was 3470 (2440-4400) g. The median plasma biliru-
bin concentration was 170 (62-248) PM. The values in the brackets are 95% percen-
tiles.
A positive correlation was found between the plasma bilirubin concentration and
the yellow colour of the skin in the forehead, Y,, the abdomen at the level of umbili-
cus, Y2, the knee, Y, and the foot, &, (Table I).
The corresponding measurements of the yellow colour of the skin at the four
body sites chosen are illustrated in Fig. 1. The values obtained from the forehead
were significantly higher than the values from the abdomen (P < O.OOOl),knee (P <
O.OOOOl),and foot (P < O.OOOOl),(all Wilcoxon’s tests).
The cephalocaudal colour difference between the skin in the forehead and the
foot correlated positively with the plasma bilirubin concentration, (Fig.2, Table I).
The gestational age showed a slight but significant negative correlation to the
cephalocaudal colour difference (Table I). In accordance with previous studies, the
present study demonstates a close relationship between the plasma bilirubin
concentration and the yellow colour of the skin at different body sites [6,8,16] and
documents the cepholocaudal progression of jaundice in newborns and that the
cephalocaudal colour difference is positively correlated with the plasma bilirubin
concentration.

TABLE I

Correlations between the yellow colour of the skin, the cephalocaudal colour gradients and observed par-
ameters. For explanation of 1, to _Y,see text. _Bis the total serum bilirubin concentration. Rho is calcu-
lated according to Spearman’s test and is corrected for ties. In brackets are given the Pearson’s r value for
comparison.

Correlation Rho Level of significance

y, vs. B 0.83 (0.86) P< O.OOOoOl

y, vs. _B 0.89 (0.92) P< O.OOOOOl
yI vs.1 0.82 (0.85) P< 0400001
y,vs._B 0.65 (0.65) P< O.OOoOl
x,--x, vs. B 0.28 (0.27) P< 0.0001
Y,-x, vs. B 0.38 (0.39) P< 0.001
X,-X, vs. gest. length - 0.28 (- 0.27) P< 0.01
y,-_X, vs. gest. length - 0.28 (- 0.30) P< 0.01
 21

20 ::.
.,..
. ...
.....
.......
16 .........
................
......
.............
................ .....
,..... ....... ....
12
................. ........

............ .......
..................
.....

....
..... ............
... .............
..........
... .............
..............
a ........
........
....

4 i

-y1 y3 Y4

Fig. 1. The yellow colour of the skin in the forehead, y,, abdomen at the level of umbilicus (y,), the knee
(I’,) and the foot (x,) in 136 newborns.

These findings support the hypothesis presented, and the cephalocaudal progres-
sion of jaundice in icteric newborns can be explained by the presence of young bili-
rubin albumin complexes in the blood undergoing conformational changes. The
theory does not exclude other mechanisms, such as local factors. From a theoretical
point of view, it might be noted that to the extent the cephalocaudal colour differ-
ence represents deposition of bilirubin acid in the skin, a high gradient would indi-
cate a greater risk of bilirubin-dependent brain damage than would a low gradient.

I
I ’ I ’ ’ ’ I
4- a 12 16 Y,. Ir,

Fig. 2. The difference of yellow colour of the skin between the forehead and foot (x-axis, arbitrary units)
pictured against the serum bilirubin concentration (v-axis, M). Rho = 0.58 (0.62), Spearman’s test cor-
rected for ties with Pearson’s r value in bracket calculated by the method of least squares.
28

Acknowledgements

Professor R. Brodersen, Institute of Medical Biochemistry, University of Aar-

hus, Denmark, is thanked for help and guidance during the study, and for critical
review of the manuscript. The study was supported by Niels Jensens Forsknings-
fond, County Hospital of Hjdrring, Denmark, Grant No. 5-9-1986.

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