September 15th, 2011 by Hasham

Newborn Jaundice Overview

Jaundice is a yellow discoloration of the skin and the white part (the sclera) of the eyes. It results from having too much of a substance called bilirubin in the blood.

Bilirubin is formed when the body breaks down old red blood cells. The liver usually processes and removes the bilirubin from the blood.

Jaundice in babies usually occurs because their immature livers are not efficient at removing bilirubin from the bloodstream.

Causes

Bilirubin is a yellow pigment that is created in the body during the normal recycling of old red blood cells. The liver helps break down bilirubin 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, and is called “physiological jaundice.” It usually appears between day 2 and 3, peaks between days 2 and 4, and clears by 2 weeks. Physiological jaundice usually causes no problems.

Other types of jaundice that usually cause no harm include:

* Breast milk jaundice is probably caused by factors in the breast milk that slow the rate at which the liver breaks down bilirubin. 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 seen in breastfed babies in the first week of life, especially in babies who are not nursing often enough. Breastfeeding jaundice is different than breast milk jaundice.

Babies who are born too early (premature) are more likely to develop jaundice than full-term babies.

Conditions that increase the number of red blood cells that need to be broken down, and can cause more severe newborn jaundice:

* Abnormal blood cell shapes
* Blood type mismatch between the mother and the baby
* Bleeding underneath the scalp (cephalohematoma) caused by a difficult delivery
* Higher levels of red blood cells, which is more common in small-for-gestational-age babies and some twins
* Infection
* Lack (deficiency) of certain important enzymes

Conditions that make it harder for the baby’s body to remove bilirubin may also lead to more severe jaundice:

* Certain medications
* Congenital infections, such as rubella, syphilis, and others
* Diseases that affect the liver or biliary tract, such as cystic fibrosis or hepatitis
* Hypoxia
* Infections (such as sepsis)
* Many different genetic or inherited disorders

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.
Exams and Tests

Doctors, nurses, and family members will watch for signs of jaundice at the hospital, and after the newborn goes home.

Any infant who appears jaundiced should have bilirubin levels measured right away. This can be done with a blood test.

Many hospitals check total bilirubin levels on all babies at about 24 hours of age. Hospitals use probes that can estimate the bilirubin level just by touching the skin. High readings need to be confirmed with blood tests.

Tests that will likely be done include:

* Complete blood count
* Coomb’s test
* Reticulocyte count

Further testing may be needed for babies who need treatment or whose total bilirubin levels are rising more quickly than expected.
Treatment

Treatment is usually not needed.

When determining treatment, the doctor must consider:

* The baby’s bilirubin level
* How fast the level has been rising
* Whether the baby was born early (babies born early are more likely to be treated at lower bilirubin levels)
* How old the baby is now

Your child will need treatment if the bilirubin level is too high or is rising too quickly.

Keep the baby well hydrated with breast milk or formula. Frequent feedings (up to 12 times a day) encourage frequent bowel movements, which help remove bilirubin through the stools. Ask your doctor before giving your newborn extra formula.

Some newborns need to be treated before they leave the hospital. Others may need to go back to the hospital when they are a few days old. Treatment in the hospital usually lasts 1 to 2 days.

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 under artificial light in a warm, enclosed bed to maintain constant temperature. The baby will wear only a diaper and special eye shades to protect the eyes. The American Academy of Pediatrics recommends that breastfeeding be continued through phototherapy, if possible. Rarely, the baby may have an intravenous (IV) line to deliver fluids.

If the bilirubin level is not too high or is not rising quickly, you can do phototherapy at home with a fiberoptic blanket, which has tiny bright lights in it. You may also use a bed that shines light up from the mattress.

* You must keep the light therapy on your child’s skin and feed your child every 2 to 3 hours (10 to 12 times a day).
* A nurse will come to your home to teach you how to use the blanket or bed, and to check on your child.
* The nurse will return daily to check your child’s weight, feedings, skin, and bilirubin levels.
* You will be asked to count the number of wet and dirty diapers.

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.

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’s blood type is O+, but it is not needed 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

How are babies checked for jaundice?
A health care provider examines the baby for signs of jaundice before being discharged from the hospital. If the baby’s skin looks yellow or if the baby has certain risk factors that make jaundice more likely (see below), the provider may measure the level of bilirubin with a skin sensor or a blood test. The blood test is the most accurate way to determine the level of bilirubin. Providers may recommend one of these tests for some babies with darker skin because it may be difficult to tell if a baby has jaundice by examining the skin.

What causes jaundice in newborns?
Jaundice occurs when bilirubin builds up in the blood. Each day some red blood cells in the body die. As they break down, an oxygen-carrying substance called hemoglobin is changed to bilirubin.

Normally, the liver removes bilirubin from the blood and changes it into a form that can be passed from the body in bowel movements. In the newborn period, more red blood cells can break down than at most other times, creating more bilirubin to handle.

The liver of a newborn may be too immature to keep up with bilirubin removal, causing bilirubin to build up in the blood. This build-up turns skin and, sometimes, the white part of eyes yellow. Premature babies have especially immature livers, making jaundice more likely.

Jaundice caused by a maturing liver is called physiologic jaundice. This is the most common type of jaundice in newborns, occurring in both breastfed and formula-fed infants. Physiologic jaundice usually clears up within two weeks in formula-fed babies, though it may last for more than two to three weeks in breastfed infants (3).

Certain health problems in the baby can contribute to jaundice. In these cases, jaundice may begin in the first 24 hours of life and become more serious. A small number of babies have different blood types from their mothers (such as ABO or Rh incompatibility that can lead to an especially rapid breakdown of red blood cells and jaundice.

Certain newborn digestive system disorders, infections and genetic disorders also can contribute to jaundice, as can severe bruising at birth. Babies with these conditions are more likely than babies with physiologic jaundice to require treatment to reduce the levels of bilirubin in their blood.

When bilirubin levels get too high, bilirubin can enter the brain and cause brain damage.

Are breastfed babies more likely to develop jaundice?
Breastfed babies are more likely than formula-fed infants to develop jaundice (3). However, jaundice occurs mainly in babies who are not nursing well (3, 4). These babies may not get enough calories and may become dehydrated, both of which may contribute to jaundice. Breastfeeding mothers should nurse their babies at least 8 to 12 times a day for the first several days of life to help keep their baby’s bilirubin level down (4).

The AAP recommends that all healthy full-term and near-term babies be breastfed (4). Breastmilk is the ideal food for babies and provides many health benefits, including reducing the risk of infections.

What are the signs of jaundice?
Yellow discoloration usually first appears on the face and in the whites of the eyes. A parent often can tell if a baby has jaundice by looking at the baby under natural daylight or in a room that has fluorescent lights. If a parent thinks there is a yellowish color, he should contact the baby’s health care provider.

Most babies with jaundice are alert and eat and sleep normally. However, a parent should call the baby’s health care provider immediately or seek emergency medical care if a baby with jaundice (1, 4):

* Appears very yellow
* Is hard to wake
* Sucks or nurses poorly
* Appears floppy or stiff (or alternates between both)
* Arches the neck or back backwards
* Develops a high-pitched cry or fever
* Has unusual eye movements

These may be warning signs of dangerously high levels of bilirubin that require prompt treatment to prevent a rare form of brain damage called kernicterus.

Jaundice in Newborns and its Treatment

About 60% of newborn infants in the United States are jaundiced, that is they look yellow. Excessive jaundice in newborn infants may cause brain damage. Jaundice is caused by a high level of bilirubin in the blood (hyperbilirubinemia) and tissues. When bilirubin gets too high, it can be treated. Norms exist for bilirubin in term and nearly term babies based on the age in hours after birth. Other factors, such as prematurity, blood group incompatibilities between infant and mother including Rh and ABO blood types, and bruising, especially cephalohematomas and caputs (bleeding under the skin of the scalp), can increase bilirubin production and lead to excessive jaundice.

Babies with high bilirubin levels can be effectively treated. Phototherapy (treatment with light) is usually very effective. It is the blue color in visible light that alters the bilirubin from a toxic form to a water soluble, non-toxic form that can be eliminated. At higher, more dangerous levels of bilirubin, or in certain situations where the bilirubin is expected to rise very rapidly, such as Rh or other hemolytic diseases of the newborn, a more extreme treatment may be used, exchange transfusion, to rapidly remove toxic bilirubin from the blood.