Jaundice in Newborns (Hyperbilirubinemia)

             
 Treatment Overview

What is jaundice in newborns?

Jaundice is a condition that makes a newborn’s skin and the white part of the eyes look yellow. It happens because there is too much bilirubin in the baby’s blood (hyperbilirubinemia). Bilirubin is a substance that is made when the body breaks down old red blood cells.

Jaundice usually is not a problem. But in rare cases, too much bilirubin in the blood can cause brain damage (kernicterus). This can lead to hearing loss, mental retardation, and behavior problems.

In healthy babies, some jaundice almost always appears by 2 to 4 days of age. It usually gets better or goes away on its own within a week or two without causing problems.

In breast-fed babies, mild jaundice sometimes lasts until 10 to 14 days after birth. In some breast-fed babies, it goes away and then comes back. Jaundice may last throughout breast-feeding. This isn't usually a problem as long as the baby gets enough milk by being fed at regular times.

Your doctor probably will ask you to keep checking your baby at home to make sure the jaundice is going away. Your baby will need a follow-up exam within the first 5 days after birth. Call your doctor if the yellow color gets brighter after your baby is 3 days old.

What causes jaundice in newborns?

Jaundice occurs because your baby’s body has more bilirubin than it can get rid of. Bilirubin is made when the body breaks down old red blood cells. It leaves the body through urine and stool. During pregnancy, your body removes bilirubin from your baby through the placenta. After birth, your baby’s body must get rid of the bilirubin on its own.

Breast-fed newborns can become dehydrated easily if feedings are spaced too far apart. This lack of enough milk in the body makes it harder for your baby to get rid of wastes such as bilirubin. Also, some of the things that make up breast milk can change the way the body removes bilirubin.

In rare cases, too much bilirubin may be caused by infections, a problem with the baby’s digestive system, or a problem with the mom’s and baby’s blood types (Rh incompatibility). Your baby may have one of these problems if jaundice appears less than a day after birth.

What are the symptoms?

Jaundice can make your baby’s skin and the white part of the baby’s eyes look yellow. You may see the yellow color between 1 and 4 days after birth. It shows up first in the baby’s face and chest. Babies who have bilirubin levels that are too high may have a high-pitched cry. They also may be sluggish and cranky.

How is jaundice in newborns diagnosed?

Your baby’s doctor will do a physical exam and ask you questions. The doctor may ask about:

Your general health, especially during your pregnancy.

Whether your baby was born early (prematurely) or at full term.

Whether there were any problems with the birth.

Your baby's birth weight and whether the baby has lost or gained weight since birth.

Your baby's feeding and elimination habits.

Your blood type and whether you and the baby have a problem with Rh incompatibility.

Any family history of health problems that could cause jaundice.

A blood test for bilirubin may be done to find out if your baby needs treatment.

More tests may be done if the doctor thinks that a health problem is causing too much bilirubin in the blood.

How is it treated?

Most of the time no treatment is needed for jaundice, because it usually goes away on its own. If you are breast-feeding, you may be able to help reduce the jaundice by feeding your baby about 8 to 12 times a day.

Sometimes babies with jaundice are put under a type of fluorescent light. This is called phototherapy. The skin absorbs the light. This changes the bilirubin so that the body can more easily get rid of it in the stool and urine. The treatment is usually done in a hospital. But babies sometimes are treated at home.

If a health problem caused the jaundice, your baby may need other treatment.

Question and Answers:

To make sure your baby’s first week is safe and healthy, it is important that:
1. Your baby is checked for jaundice in the hospital.
2. If you are breastfeeding, you get the help you need to make sure it is going well.
3. If your baby is discharged before age 72 hours, your baby should be seen by a doctor or nurse within 2 days of discharge from the hospital.

Q: What is jaundice?
A: Jaundice is the yellow color seen in the skin of many newborns. It happens when a chemical called bilirubin builds up in the baby’s blood. Jaundice can occur in babies of any race or color.

Q: Why is jaundice common in newborns?
A: Everyone’s blood contains bilirubin, which is removed by the liver. Before birth, the mother’s liver does this for the baby. Most babies develop jaundice in the first few days after birth because it takes a few days for the baby’s liver to get better at removing bilirubin.

Q: How can I tell if my baby is jaundiced?
A: The skin of a baby with jaundice usually appears yellow.
The best way to see jaundice is in good light, such as daylight or under fluorescent lights. Jaundice usually appears first in the face and then moves to the chest, abdomen, arms, and legs as the bilirubin level increases. The whites of the eyes may also be yellow. Jaundice may be harder to see in babies with darker skin color.

Q: Can jaundice hurt my baby?
A: Most babies have mild jaundice that is harmless, but in unusual situations the bilirubin level can get very high and might cause brain damage. This is why newborns should be checked carefully for jaundice and treated to prevent a high bilirubin level.

Q: How should my baby be checked for jaundice?
A: If your baby looks jaundiced in the first few days after birth, your baby’s doctor or nurse may use a skin or blood test to check your baby’s bilirubin level. A bilirubin level is always needed if jaundice develops before the baby is 24 hours old. Whether a test is needed after that depends on the baby’s age, the amount of jaundice, and whether the baby has other factors that make jaundice more likely or harder to see.

Q: Does breastfeeding affect jaundice?
A: Jaundice is more common in babies who are breastfed than babies who are formula-fed, but this occurs mainly in newborns who are not nursing well. If you are breastfeeding, you should nurse your baby at least 8 to 12 times a day for the first few days. This will help you produce enough milk and will help to keep the baby’s bilirubin level down. If you are having trouble breastfeeding, ask your baby’s doctor or nurse or a lactation specialist for help. Breast milk is the ideal food for your baby.

Q: When should my newborn get checked after leaving the hospital?
A: It is important for your baby to be seen by a nurse or doctor when the baby is between 3 and 5 days old, because this is usually when a baby’s bilirubin level is highest. This is why, if your baby is discharged before age 72 hours, your baby should be seen within 2 days of discharge. The timing of this visit may vary depending on your baby’s age when released from the hospital and other factors.

Q: Which babies require more attention for jaundice?
A: Some babies have a greater risk for high levels of bilirubin and may need to be seen sooner after discharge from the hospital. Ask your doctor about an early follow-up visit if your baby has any of the following:
• A high bilirubin level before leaving the hospital
• Early birth (more than 2 weeks before the due date)
• Jaundice in the first 24 hours after birth
• Breastfeeding that is not going well
• A lot of bruising or bleeding under the scalp related to labor and delivery
• A parent, brother, or sister who had high bilirubin and received light therapy

Q: When should I call my baby’s doctor?
A: Call your baby’s doctor if
• Your baby’s skin turns more yellow.
• Your baby’s abdomen, arms, or legs are yellow.
• The whites of your baby’s eyes are yellow.
• Your baby is jaundiced and is hard to wake, fussy, or not nursing or taking formula well.

Q: How is harmful jaundice prevented?
A: Most jaundice requires no treatment. When treatment is necessary, placing your baby under special lights while he or she is undressed will lower the bilirubin level. Depending on your baby’s bilirubin level, this can be done in the hospital or at home. Jaundice is treated at levels that are much lower than those at which brain damage is a concern. Treatment can prevent the harmful effects of jaundice.

Putting your baby in sunlight is not recommended as a safe way of treating jaundice. Exposing your baby to sunlight might help lower the bilirubin level, but this will only work if the baby is completely undressed. This cannot be done safely inside your home because your baby will get cold, and newborns should never be put in direct sunlight outside because they might get sunburned.

Q: When does jaundice go away?
A: In breastfed babies, jaundice often lasts for more than 2 to 3 weeks. In formula-fed babies, most jaundice goes away by 2 weeks. If your baby is jaundiced for more than 3 weeks, see your baby’s doctor.

Definition

Newborn jaundice is a condition marked by high levels of bilirubin in the blood. The increased bilirubin cause the infant's skin and whites of the eyes (sclera) to look yellow.

Alternative Names

Jaundice of the newborn; Neonatal hyperbilirubinemia

Causes, incidence, and risk factors

Bilirubin is a yellow pigment that's created in the body during the normal recycling of old red blood cells. The liver processes bilirubin in the blood so that it can be removed from the body in the stool.

Before birth, the placenta -- the organ that nourishes the developing baby -- removes the bilirubin from the infant so that it can be processed by the mother's liver. Immediately after birth, the baby's own liver begins to take over the job, but this can take time. Therefore, bilirubin levels in an infant are normally a little higher after birth.

High levels of bilirubin in the body can cause the skin to look yellow. This is called jaundice. Jaundice is present to some degree in most newborns. Such "physiological jaundice" usually appears between day 2 and 3, peaks between days 2 and 4, and clears by 2 weeks. Physiological jaundice usually causes no problems.

Breast milk jaundice is another common, usually non-harmful form of newborn jaundice. Breast milk may contain a substance that increases reuse of bilirubin in the intestines. Such jaundice appears in some healthy, breastfed babies after day 7 of life, and usually peaks during weeks 2 and 3. It may last at low levels for a month or more.

Breastfeeding jaundice is a type of exaggerated physiological jaundice seen in breastfed babies in the first week, especially in those that are not nursing often enough. It is different than breast milk jaundice in that it occurs later and is caused by the milk itself.

Sometimes jaundice can be a sign of a serious underlying problem. Higher levels of bilirubin can be due to:

An event or condition that increases the number of red blood cells that needs to be processed

Anything that interferes with the body’s ability to process and remove bilirubin

The following increase the number of red blood cells that need to be processed:

·       Abnormal blood cell shapes

·       Congenital spherocytic anemia

·       Elliptocytosis

·       Blood type incompatibilities

·       ABO incompatibility (Mother has type O blood, baby does not)

·       Rh incompatibility (Mother is Rh negative, baby is not)

·       Cephalohematoma or other birth injury

·       Glucose-6-phosphate dehydrogenase deficiency

·       High levels of red blood cells (polycythemia)

·       More common in small for gestational age babies

·       More common in some twins

·       Infection

·       Prematurity

·       Pyruvate kinase deficiency

·       Transfusions

·       The following interfere with the body's ability to process and remove bilirubin:

·       Alpha-1 antitrypsin deficiency

·       Biliary atresia

·       Certain medications

·       Congenital cytomegalovirus (CMV) infection

·       Congenital herpes

·       Congenital hypothyroidism

·       Congenital rubella

·       Congenital syphilis

·       Congenital toxoplasmosis

·       Crigler-Najjar syndrome

·       Cystic fibrosis

·       Gaucher's disease

·       Gilbert syndrome

·       Hypoxia

·       Infections (such as sepsis)

·       Lucey-Driscol syndrome

·       Neonatal hepatitis

·       Niemann-Pick disease

·       Prematurity

In otherwise healthy babies born at 35 weeks gestation or greater, those most likely to eventually develop signs of newborn jaundice are those who have:

A brother or sister who needed phototherapy for jaundice

A high bilirubin level for their age, even if they are not yet jaundiced

Been exclusively breastfeed, especially if weight is excessive

Blood group incompatibility or other known red blood cell disease

Cephalohematoma or significant bruising

East Asian ancestry

Jaundice in the first 24 hours of life

Symptoms

The main symptom is a yellow color of the skin. The yellow color is best seen right after gently pressing a finger onto the skin. The color sometimes begins on the face and then moves down to the chest, belly area, legs, and soles of the feet.

Sometimes, infants with significant jaundice have extreme tiredness and poor feeding.

Signs and tests

All newborns should be examined for jaundice at least every 8 to 12 hours for the first day of life.

Any infant who appears jaundiced in the first 24 hours should have bilirubin levels measured immediately. This can be done with a skin or blood test.

Babies should be assigned a risk for later developing jaundice before they leave the hospital. Babies are classified as low risk, low intermediate risk, high intermediate risk, or high risk. Many hospitals do this by routinely checking total bilirubin levels on all babies at about 24 hours of age.

Further testing varies on the infant's specific situation and test results. For example, the possible cause of the jaundice should be sought for babies who require treatment or whose total bilirubin levels are rising more rapidly than expected.

Tests that will likely be done include:

Complete blood count

Coomb's test

Measurement of levels of specific types of bilirubin

Reticulocyte count

The level of albumin in the baby's blood may also be checked. Low albumin levels may increase the risk of damage from excessive jaundice.

Treatment

Treatment is usually not necessary. Keep the baby well-hydrated with breast milk or formula. Frequent feedings encourage frequent bowel movements, which helps remove bilirubin through the stools. (Bilirubin is what gives stool a brown color).

Sometimes special blue lights are used on infants whose levels are very high. This is called phototherapy. These lights work by helping to break down bilirubin in the skin. The infant is placed naked under artificial light in a protected isolette to maintain constant temperature. The eyes are protected from the light. The American Academy of Pediatrics recommends that breastfeeding be continued through phototherapy, if possible.

In the most severe cases of jaundice, an exchange transfusion is required. In this procedure, the baby's blood is replaced with fresh blood. Treating severely jaundiced babies with intravenous immunoglobulin may also be very effective at reducing bilirubin levels.

Expectations (prognosis)

Usually newborn jaundice is not harmful. For most babies, jaundice usually resolves without treatment within 1 to 2 weeks. However, if significant jaundice is untreated, very high levels of bilirubin can damage the brain. For babies who require treatment, the treatment is usually quite effective.

Complications

Rare, but serious, complications from high bilirubin levels include:

Cerebral palsy

Deafness

Kernicterus -- brain damage from very high bilirubin levels

Calling your health care provider

All babies should be seen by a health care provider in the first 5 days of life to check for jaundice.

Those who spend less than 24 hours in a hospital should be seen by age 72 hours.

Infants sent home between 24 and 48 hours should be seen again by age 96 hours.

Infants sent home between 48 and 72 hours should be seen again by age 120 hours.

Jaundice is an emergency if the baby has a fever, has become listless, or is not feeding well. Jaundice may be dangerous in high-risk newborns.

Jaundice is generally NOT dangerous in term, otherwise healthy newborns. Call the infant's health care provider if jaundice is severe (the skin is bright yellow), if jaundice continues to increase after the newborn visit, lasts longer than 2 weeks, or if other symptoms develop. Also call the doctor if the feet, particularly the soles, are yellow.

Prevention

In newborns, some degree of jaundice is normal and probably not preventable. The risk of significant jaundice can often be reduced by feeding babies at least 8 to 12 times a day for the first several days and by carefully identifying infants at highest risk.

All pregnant women should be tested for blood type and unusual antibodies. If the mother is Rh negative, follow-up testing on the infant's cord is recommended. This may also be done if the mother blood type is O+, but it not necessarily required if careful monitoring takes place.

Careful monitoring of all babies during the first 5 days of life can prevent most complications of jaundice. Ideally, this includes:

Considering a baby's risk for jaundice

Checking bilirubin level in the first day or so

Scheduling at least one follow-up visit the first week of life for babies sent home from the hospital in 72 hours