jaundice in newborns

What is jaundice in newborn baby

Newborn jaundice is the yellowing of your baby’s skin and the white parts of his/her eyes. Jaundice in newborn is caused by the build-up of a substance in the blood called bilirubin. Bilirubin is a yellow substance made from the breakdown of red blood cells. Newborn jaundice is very common—about 3 in 5 babies (60 percent) have jaundice, including 8 out of 10 babies born prematurely (babies born before the 37th week of pregnancy). The medical term for jaundice in babies is neonatal jaundice.

The American Academy of Pediatrics recommends that every newborn be checked for jaundice before leaving the hospital and three to five days after birth. This is the time when bilirubin levels are the highest. If your baby leaves the hospital before 72 hours (3 days) of age, she should be checked within the next 2 days.

Physiological jaundice in newborn

Jaundice is caused by the build-up of bilirubin in the blood. Bilirubin is a yellow substance produced when red blood cells are broken down.

Jaundice is common in newborn babies because babies have a high level of red blood cells in their blood, which are broken down and replaced frequently. During pregnancy, your liver removes bilirubin for your baby. After birth, your baby’s liver is not fully developed, so it’s less effective at removing the bilirubin from the blood. It can take a few days for your baby’s liver to be able to do this. When a baby’s liver causes jaundice in the first days of life, it’s called physiologic jaundice. This is the most common kind of jaundice in newborns.

For reasons that are unclear, breastfeeding a baby also increases the risk of them developing jaundice, which can often persist for a month or longer. In most cases, the benefits of breastfeeding far outweigh any risks associated with jaundice.

By the time a baby is about two weeks old, babies liver is more effective at processing bilirubin, so jaundice often corrects itself by this age without causing any harm. However, only around 1 in 20 babies has a blood bilirubin level high enough to need treatment.

In a small number of cases, jaundice can be the sign of an underlying health condition. This is often the case if jaundice develops shortly after birth (within the first 24 hours). Babies with these health conditions are more likely to need treatment to help lower their bilirubin levels than babies with physiologic jaundice.

Figure 1. Newborn jaundice eyes

Other symptoms of newborn jaundice can include:

  • yellowing of the palms of the hands or soles of the feet
  • dark, yellow urine – a newborn baby’s urine should be colorless
  • pale-colored poo – it should be yellow or orange

The symptoms of newborn jaundice usually develop two to three days after the birth and tend to get better without treatment by the time the baby is about two weeks old.

Jaundice usually happens a few days after birth. Most of the time, jaundice in newborns is usually mild, doesn’t hurt your baby and goes away without treatment. Most cases of jaundice in babies don’t need treatment as the symptoms normally pass within 10 to 14 days, although symptoms can last longer in a minority of cases. However, if a baby has severe jaundice and doesn’t get quick treatment, it can lead to brain damage.

Treatment is usually only recommended if tests show a baby has very high levels of bilirubin in their blood because there’s a small risk the bilirubin could pass into the brain and cause brain damage.

If a baby with very high levels of bilirubin isn’t treated, there’s a risk they could develop permanent brain damage. This is known as kernicterus.

Kernicterus is very rare in the US, affecting less than 1 in every 100,000 babies born.

There are two main treatments that can be carried out in hospital to quickly reduce your baby’s bilirubin levels. These are:

  • Phototherapy – a special type of light shines on the skin, which alters the bilirubin into a form that can be more easily broken down by the liver
  • An exchange transfusion – a type of blood transfusion where small amounts of your baby’s blood are removed and replaced with blood from a matching donor

Most babies respond well to treatment and can leave hospital after a few days.

When to see your doctor

Your baby will usually be examined for signs of jaundice within 72 hours of being born, during the newborn physical examination.

If your baby develops signs of jaundice after this time, see to your doctor as soon as possible for advice.

While jaundice isn’t usually a cause for concern, it’s important to determine whether your baby needs treatment.

How do you know if your baby has jaundice?

When a baby has jaundice, a yellowish color usually first appears on his face. It then may spread to his chest, belly, arms, legs and white parts of his eyes. The best way to see jaundice is in good light, like in daylight or under fluorescent lights. Jaundice can be harder to see in babies with darker skin.

See your baby’s health care provider right away if your baby:

  • Looks very yellow, orange or greenish-yellow
  • Is hard to wake up or won’t sleep at all
  • Has trouble breastfeeding or sucking from a bottle
  • Is very fussy
  • Has too few wet or dirty diapers

Call your local emergency number for an ambulance or take your baby to the hospital if he/she:

  • Won’t stop crying or has a high-pitched cry
  • Arches backward
  • Has a stiff, limp or floppy body
  • Has strange eye movements

These may be warning signs of dangerously high levels of bilirubin that need quick treatment to prevent kernicterus. This is a kind of brain damage caused by high bilirubin levels. Kernicterus isn’t common because babies usually are treated before jaundice becomes severe. If untreated, kernicterus can cause:

  • Athetoid cerebral palsy. Babies with this condition have uncontrollable movements in the arms, legs, face and other body parts.
  • Hearing loss
  • Vision problems
  • Dental problems
  • Intellectual disabilities

What causes jaundice in newborn babies

Jaundice is caused by too much bilirubin in the blood. This is known as hyperbilirubinaemia. Jaundice usually occurs in newborns because theirs livers are not fully developed.

Jaundice is common in newborn babies because babies have a high level of red blood cells in their blood, which are broken down and replaced frequently.

The liver in newborn babies is also not yet fully developed, so it’s less effective at processing the bilirubin and removing it from the blood.

This means the level of bilirubin in babies can be about twice as high as in adults.

Bilirubin is a yellow substance produced when red blood cells, which carry oxygen around the body, are broken down.

The bilirubin travels in the bloodstream to the liver. The liver changes the form of the bilirubin so it can be passed out of the body in poo.

However, if there’s too much bilirubin in the blood or the liver can’t get rid of it, excess bilirubin causes jaundice.

By the time a baby is around two weeks old, they’re producing less bilirubin and their liver is more effective at removing it from the body. This means the jaundice often corrects itself by this point without causing any harm.

Breastfeeding

Breastfeeding your baby can increase their chances of developing jaundice. However, there’s no need to stop breastfeeding your baby if they have jaundice as the symptoms normally pass in a few weeks.

The benefits of breastfeeding outweigh any potential risks associated with the condition.

If your baby needs to be treated for jaundice, he or she may need extra fluids and more frequent feeds during treatment.

The reason why breastfed babies are more likely to develop jaundice is unclear, although a number of theories have been suggested. For example, it may be that breast milk contains certain substances that reduce the ability of the liver to process bilirubin.

Newborn jaundice thought to be linked to breastfeeding is sometimes called breast milk jaundice.

Underlying health conditions

In some cases, jaundice may be the result of another health problem. This is sometimes called pathological jaundice.

Some other medical conditions that make newborn jaundice worse are:

  • Blood group incompatibility – baby’s blood type does not match with his or her mother’s blood type
  • Rhesus factor disease – a condition that can occur if the mother has rhesus-negative blood and the baby has rhesus-positive blood
  • Baby is born with too many red blood cells (polycythemia). Some babies have too many red blood cells. This is more common in some twins and babies who are small for gestational age. This means a baby who is smaller than normal based on the number of weeks he’s been in the womb.
  • Baby has an infection in his or her blood (sepsis)
  • Baby has an infection e.g. a urinary tract infection
  • Baby has bruises from birth. A bruise happens when blood leaks out of a blood vessel. Sometimes babies get bruises during labor and birth. When large bruises heal, bilirubin levels may rise.
  • Internal bleeding. This is bleeding inside the body.
  • Baby swallowed blood during birth
  • Baby’s mother has diabetes
  • Baby has an underactive thyroid gland (hypothyroidism) – where the thyroid gland doesn’t produce enough hormones
  • Baby has a blockage or problem in his/her bile ducts and gallbladder – these create and transport bile, a fluid used to help digest fatty foods
  • A problem with your baby’s liver. Your baby’s liver may not work well if he has an infection, like hepatitis, or a disease, like cystic fibrosis, that affects the liver.
  • Crigler-Najjar syndrome – an inherited condition that affects the enzyme responsible for processing bilirubin
  • Baby has an inherited enzyme deficiency known as glucose 6 phosphate dehydrogenase (G6PD) could also lead to jaundice or kernicterus. This condition is when your body doesn’t have enough G6PD, an enzyme that helps your red blood cells work the right way. If you have a family history of G6PD, it’s important to let your doctor or pediatrician know and your baby’s jaundice symptoms are closely monitored.

Some babies are more likely than others to have jaundice. These include:

  • Premature babies. A premature baby is one who is born too early, before 37 weeks of pregnancy. A premature baby is more likely than others to have jaundice because his liver may not be fully developed.
  • Breastfed babies, especially babies who aren’t breastfeeding well. If you’re breastfeeding, feed your baby when he’s hungry. For most newborns, this is once every 2 to 3 hours (about eight to 12 times each day). Feeding this often helps keep your baby’s bilirubin level down. If you’re having trouble breastfeeding, ask your baby’s provider, a nurse or a lactation consultant for help. A lactation consultant is a person with special training in helping women breastfeed.
  • Babies with East Asian or Mediterranean ethnic backgrounds. Ethnic background means the part of the world or the ethnic group your ancestors come from. An ethnic group is a group of people, often from the same country, who share language or culture. Ancestors are family members who lived long ago, even before your grandparents.

Jaundice in newborns complications

Kernicterus is a rare but serious complication of untreated jaundice in babies. It’s caused by excess bilirubin damaging the brain or central nervous system.

In newborn babies with very high levels of bilirubin in the blood (hyperbilirubinemia), the bilirubin can cross the thin layer of tissue that separates the brain and blood (the blood-brain barrier).

The bilirubin can damage the brain and spinal cord, which can be life threatening. Brain damage caused by high levels of bilirubin is also called bilirubin encephalopathy.

Your baby may be at risk of developing kernicterus if:

  • they have a very high level of bilirubin in their blood
  • the level of bilirubin in their blood is rising rapidly
  • they don’t receive any treatment

Kernicterus is now extremely rare in the US, affecting less than 1 in every 100,000 babies.

Initial symptoms of kernicterus in babies include:

  • decreased awareness of the world around them – for example, they may not react when you clap your hands in front of their face
  • their muscles become unusually floppy, like a rag doll
  • poor feeding

As kernicterus progresses, additional symptoms can include seizures (fits) and arching of the neck or spine.

Treatment for kernicterus involves using an exchange transfusion as used in the treatment of newborn jaundice.

If significant brain damage occurs before treatment, a child can develop serious and permanent problems, such as:

  • cerebral palsy – a condition that affects a child’s movement and co-ordination
  • hearing loss – which can range from mild to severe
  • learning difficulties
  • involuntary twitching of different parts of their body
  • problems maintaining normal eye movements – people affected by kernicterus have a tendency to gaze upwards or from side to side rather than straight ahead
  • poor development of the teeth.

Newborn jaundice signs and symptoms

Jaundice usually appears about three days after birth and disappears by the time the baby is two weeks old.

In premature babies, who are more prone to jaundice, it can take five to seven days to appear and usually lasts about three weeks. It also tends to last longer in babies who are breastfed, affecting some babies for a few months.

If your baby has jaundice, their skin will look slightly yellow. The yellowing of the skin usually starts on the head and face, before spreading to the chest and stomach.

In some babies, the yellowing reaches their legs and arms. The yellowing may also increase if you press an area of skin down with your finger.

Signs of jaundice in newborn

Jaundice often appears in newborns on the second or third day after birth. Newborn jaundice progresses in the following pattern of severity. Stage 1 is the least severe.

  • Stage 1: jaundice in baby’s face, especially the eyes
  • Stage 2: jaundice in baby’s arms and chest
  • Stage 3: jaundice in baby’s thighs
  • Stage 4: jaundice in baby’s legs and palms of hands

Changes in skin color can be more difficult to spot if your baby has a darker skin tone. In these cases, yellowing may be more obvious elsewhere, such as:

  • in the whites of their eyes
  • inside their mouth
  • on the soles of their feet
  • on the palms of their hand

A newborn baby with jaundice may also:

  • be poor at sucking or feeding
  • be sleepy
  • have a high-pitched cry
  • be limp and floppy
  • have dark, yellow urine – it should be colorless
  • have pale poo – it should be yellow or orange.

Jaundice in newborns diagnosis

Your baby will be checked for jaundice within 72 hours of being born during the newborn physical examination.

However, you should keep an eye out for signs of the condition after you return home as it can sometimes take up to a week to appear.

When you’re at home with your baby, you should look out for yellowing of their skin or the whites of their eyes. Gently pressing your fingers on the tip of their nose or on their forehead can make it easier for you to spot any yellowing.

You should also check your baby’s urine and poo. Your baby may have jaundice if their urine is yellow (a newborn baby’s urine should be colorless) or their poo is pale.

You should speak to your midwife or healthcare provider as soon as possible if you think your baby may have jaundice. Tests will need to be carried out to determine whether any treatment is necessary.

Visual examination

A visual examination of your baby will be carried out to look for signs of jaundice. Your baby needs to be undressed during this so their skin can be looked at under good – preferably natural – light.

Other things that may also be checked include:

  • the whites of your baby’s eyes
  • your baby’s gums
  • the color of your baby’s urine or poo

Bilirubin test

If it’s thought your baby has jaundice, the level of bilirubin in their blood will need to be tested. This can be done using:

  • a small device called a bilirubinometer, which beams light on to your baby’s skin – it calculates the level of bilirubin by analyzing how the light reflects off or is absorbed by the skin
  • a blood test of a sample of blood taken by pricking your baby’s heel with a needle – the level of bilirubin in the liquid part of the blood (the serum) is then measured

In most cases, a bilirubinometer is used to check for jaundice in babies. Blood tests are usually only necessary if your baby developed jaundice within 24 hours of birth or the reading is particularly high.

The level of bilirubin detected in your baby’s blood is used to decide whether any treatment is necessary.

Further blood tests

Further blood tests may need to be carried out if your baby’s jaundice lasts longer than two weeks or treatment is needed. The blood is analyzed to determine:

  • the baby’s blood group – this is to see if it’s incompatible with the mother’s
  • whether any antibodies (infection-fighting proteins) are attached to the baby’s red blood cells
  • the number of cells in the baby’s blood
  • whether there’s any infection
  • whether there’s an enzyme deficiency

These tests help determine whether there’s another underlying cause for the raised levels of bilirubin.

Jaundice newborn treatment

You should speak to your midwife or doctor if your baby develops jaundice. They’ll be able to assess whether treatment is needed.

Treatment is usually only necessary if your baby has high levels of a substance called bilirubin in their blood, so tests need to be carried out to check this.

Most babies with jaundice don’t need treatment because the level of bilirubin in their blood is found to be low. In these cases, the condition usually gets better within 10 to 14 days and won’t cause any harm to your baby.

If treatment is felt to be unnecessary, you should continue to breastfeed or bottle feed your baby regularly, waking them up for feeds if necessary. Breastfeeding your baby more often so that she/he has more bowel movements. This helps to get rid of bilirubin. If your baby’s condition gets worse or doesn’t disappear after two weeks, contact your doctor.

Prolonged newborn jaundice (lasting longer than two weeks) can occur if your baby was born prematurely or if he or she is solely breastfed. It usually improves without treatment. However, further tests may be recommended if the condition lasts this long to check for any underlying health problems.

If your baby’s jaundice doesn’t improve over time or tests show high levels of bilirubin in their blood, they may be admitted to hospital and treated with phototherapy or an exchange transfusion.

These treatments are recommended to reduce the risk of a rare but serious complication of jaundice called kernicterus, which can cause brain damage.

Phototherapy

Phototherapy is treatment with light. It is used in some cases of newborn jaundice to lower the bilirubin levels in your baby’s blood through a process called photo-oxidation.

Photo-oxidation adds oxygen to the bilirubin so it dissolves easily in water. This makes it easier for your baby’s liver to break down and remove the bilirubin from their blood.

There are two main types of phototherapy.

  • Conventional phototherapy – where your baby is laid under a halogen or fluorescent lamp with their eyes covered
  • Fibreoptic phototherapy – where your baby lies on a blanket that incorporates fibreoptic cables; light travels through the fibreoptic cables and shines on to your baby’s back

In both methods of phototherapy, the aim is to expose your baby’s skin to as much light as possible.

Conventional phototherapy is the treatment tried first in most cases, although fibreoptic phototherapy may be used first if your baby was born prematurely.

These types of phototherapy will usually be stopped for 30 minutes every three to four hours so you can feed your baby, change their nappy and give them a hug.

If your baby’s jaundice doesn’t improve after conventional or fibreoptic phototherapy, continuous multiple phototherapy may be offered. This involves using more than one light and often a fibreoptic blanket at the same time.

Treatment won’t be stopped during continuous multiple phototherapy. Instead, milk that has been squeezed out of your breasts in advance may be given through a tube into your baby’s stomach, or fluids may be given into one of their veins (intravenously).

During phototherapy, you baby’s temperature will be monitored to ensure they’re not getting too hot and they’ll be checked for signs of dehydration. Your baby may need intravenous fluids if they’re becoming dehydrated and aren’t able to drink a sufficient amount.

The bilirubin levels will be tested every four to six hours after phototherapy has started. Once levels start to fall, they’ll be checked every six to 12 hours.

Phototherapy will be stopped when the bilirubin level falls to a safe level, which usually takes a day or two.

Phototherapy is generally very effective for newborn jaundice and has very few side effects, although your baby may develop a temporary rash or tan as a result of the treatment.

Intravenous immunoglobulin

If jaundice is caused by an underlying health problem, such as an infection, this usually needs to be treated.

If the jaundice is caused by rhesus disease (when the mother has rhesus-negative blood and the baby has rhesus-positive blood), intravenous immunoglobulin (IVIG) may be used.

Intravenous immunoglobulin (IVIG) is usually only used if phototherapy alone hasn’t worked and the level of bilirubin in the blood is continuing to rise.

Exchange transfusion

A blood transfusion, known as an exchange transfusion, may be recommended if your baby has particularly high levels of bilirubin in their blood or if phototherapy hasn’t been effective.

During an exchange transfusion, small amounts of your baby’s blood are removed through a thin plastic tube placed into blood vessels in their umbilical cord, arms or legs. The blood is then replaced with blood from a suitable matching donor (someone with the same blood group).

As the new blood won’t contain bilirubin, the overall level of bilirubin in your baby’s blood will fall quickly.

Your baby will be monitored throughout the transfusion process, which can take several hours to complete. Any problems that may arise, such as bleeding, will be treated.

Your baby’s blood will be tested within two hours of treatment to check if it’s been successful. If the level of bilirubin in your baby’s blood remains high, the procedure may need to be repeated.

Only certain hospitals can perform exchange transfusions.