Patient education: Jaundice in newborn infants (Beyond the Basics)
- Ronald J Wong, BA
Ronald J Wong, BA
- Senior Research Scientist
- Stanford University School of Medicine
- Vinod K Bhutani, MD, FAAP
Vinod K Bhutani, MD, FAAP
- Professor of Pediatrics
- Stanford University School of Medicine
Jaundice is a yellow discoloration of the skin and/or whites of the eyes that is often seen in newborn infants. The discoloration is caused by a yellow substance called bilirubin. Infants with high blood levels of bilirubin, called hyperbilirubinemia, develop the yellow color when bilirubin accumulates in the skin. Infants with darker skin color can have high blood bilirubin levels, and the jaundice may not be identified. Jaundice during the first 24 hours after birth or the presence of yellowing of palms and soles is a medical emergency. An urgent blood test must be considered in these situations.
Jaundice is not a disease, but is a symptom of an elevated blood bilirubin level. Jaundice is not painful, but in some infants, serious complications can occur if elevated bilirubin levels are not treated in a timely manner. Jaundice is a marker that identifies those infants who may be at risk for developing severe hyperbilirubinemia. Severe hyperbilirubinemia can be toxic to the nervous system of infants, potentially causing brain damage.
Jaundice initially causes the skin to become yellowed. Later, the whites of the eyes (conjunctiva) may have a yellowish tinge. These changes may be hard to recognize in children with a dark skin color or if a baby is unable to open eyelids. The color change:
●Is noticeable in the face first, and may progress down to the chest, abdomen, arms, and then finally to the legs. However, in some infants, the head-to- toe progression of jaundice can be masked, and the jaundice may appear over the entire body like a tan.
●Can be checked by pressing one finger on your baby's forehead or nose. If the skin is jaundiced, it will appear yellow when you release pressure from the skin.
●Can be tracked in some babies by pressing over the bony prominences of the chest, hips, and knees to check if the jaundice is progressing.
●Should be checked before your baby leaves the hospital. If your baby goes home sooner than 72 hours after birth, you will need to monitor the baby's skin color at home every day. In addition, your infant should see a doctor or nurse within one to three days after going home.
Signs of worsening jaundice — Call your infant's healthcare provider if you notice any of the following:
●If the yellow coloring is at the knee or lower, if the yellow color is more intense (lemon yellow to orange yellow), or if the "whites" of the eyes appear yellow
●If the baby has any difficulty in feeding
●If it is hard to wake up your infant
●If your infant is irritable and is difficult to console
●If your infant arches his/her neck or body backwards
Jaundice is caused by the accumulation of bilirubin in the blood. Bilirubin is formed when red blood cells are broken down. Bilirubin (a yellow pigment) is naturally removed by the liver, and then excreted in stool and urine. Bilirubin levels become elevated when bilirubin is produced faster than it can be removed.
Jaundice is common in newborns, since two to three times more bilirubin is produced during this period as compared with during adulthood. Benign newborn jaundice, which affects nearly all newborns, is caused by a mild to moderate elevation of bilirubin and is not usually harmful to infants. It develops between 72 and 96 hours after birth, and usually goes away by one to two weeks after birth. In infants who are born at 35 to 37 weeks of gestation and those who are severely jaundiced, the jaundice may require more time to resolve as normal elimination mechanisms mature.
Newborns with higher levels of bilirubin in the blood have "severe hyperbilirubinemia", a more serious condition than physiologic jaundice. Infants may develop severe hyperbilirubinemia within the first 24 hours after birth. If this happens, you must consult your doctor immediately.
One reason that bilirubin levels are higher in infants is that more red blood cells are broken down (and as a result, more bilirubin is produced). This can be related to:
●Bruising and mild injuries during delivery.
●If the mother and infant's blood groups and types are incompatible; the mother's immune system may attack the infant's red blood cells.
●Inherited causes of red blood cell breakdown (such as deficiency of an enzyme called glucose-6-phosphate dehydrogenase [G6PD], which may occur more frequently among African-American, Mediterranean, and Asian races).
●Asian race or ancestry (in these infants, the ability to remove bilirubin takes longer to mature).
Bilirubin is also more slowly removed in the newborn compared with in adults because a newborn's liver and intestines are not fully mature.
Breastfeeding — Jaundice is sometimes observed in infants who are breastfed because of two different reasons:
●Breastfeeding failure occurs in infants with inadequate intake of breast milk because of difficulty in feeding, or if the mother does not have an adequate milk supply. These infants lose a large amount of weight, thereby increasing bilirubin concentrations. Increasing the mother's milk supply, frequent feeding, and ensuring good sucking (latch) are the best treatments for inadequate intake jaundice. (See "Patient education: Common breastfeeding problems (Beyond the Basics)".)
●Breast milk jaundice is thought to be due to the infant's immature liver and intestines, which results in a slower removal process. Jaundice begins the first week after birth, peaks within two weeks after birth, and declines over the next few weeks. Jaundice in breastfed infants is not a reason to stop breastfeeding as long as the baby is feeding well, gaining weight, and otherwise thriving. Breastfed infants with jaundice rarely need treatment unless severe hyperbilirubinemia develops. All infants with jaundice should be monitored by a doctor or nurse. (See "Patient education: Common breastfeeding problems (Beyond the Basics)".)
In either setting, the mother should be encouraged to continue breastfeeding because of the overall benefits of human milk.
Newborn jaundice can be diagnosed by examining the infant and testing bilirubin levels in the blood. The blood test involves collecting a small amount (less than one-half teaspoon or 2.5 mL) of blood. Results of blood testing are available in most hospitals within a few hours. Jaundice beyond one week of age should be investigated as this may rarely be due to a serious conditions (obstruction of the bilirubin removal due to biliary atresia). In some centers, screening for high bilirubin is at first performed by a device that measures bilirubin through the skin (referred to as transcutaneous screening). When the skin measurement exceeds a normal value, blood testing is performed to confirm that level of bilirubin in the blood.
In babies whose blood bilirubin levels reach harmful levels, bilirubin may get into the brain and cause reversible damage (called acute bilirubin encephalopathy) or permanent damage (called kernicterus or chronic bilirubin encephalopathy). Frequent monitoring and urgent, early treatment of infants at high risk for jaundice may help to prevent severe hyperbilirubinemia.
The goal of jaundice treatment is to quickly and safely reduce the level of bilirubin. Infants with mild jaundice may need no treatment. Infants with higher bilirubin levels or hyperbilirubinemia will require treatment, which is described below. (See "Treatment of unconjugated hyperbilirubinemia in term and late preterm infants".)
Jaundice is common in premature infants (those born before 38 weeks of gestation). Premature infants are more vulnerable to hyperbilirubinemia because brain toxicity occurs at lower levels of bilirubin than in term infants. As a result, premature infants are treated at lower levels of bilirubin, but with the same treatments discussed here.
Encourage feeding — Providing adequate breast milk or formula is an important part of preventing and treating jaundice because it promotes elimination of the yellow pigment in stools and urine. You will know that your infant is getting enough milk or formula if s/he has at least six wet diapers per day, the color of the bowel movements changes from dark green to yellow, and s/he seems satisfied after feeding.
Phototherapy — Phototherapy ("light" therapy) is the most common medical treatment for jaundice in newborns. In most cases, phototherapy is the only treatment required. It consists of exposing an infant's skin to blue light, which breaks bilirubin down into parts that are easier to eliminate in the stool and urine. Treatment with phototherapy involves using special blue lights, such as blue light-emitting diodes (LEDs), and is successful for almost all infants.
Phototherapy is usually done in the hospital, but in certain cases, it can be done at home if the baby is healthy and at low risk for complications.
Infants undergoing phototherapy should have as much skin exposed to the light as possible. Infants are usually naked (or wearing only a diaper) in an open bassinet or warmer, but wear eye patches to protect the eyes (picture 1). It is important to ensure that the lamps do not generate excessive heat, which could burn an infant's skin. In some institutions, phototherapy blankets are used (picture 2). Phototherapy should be continuous, with breaks only for feeding.
Exposure to sunlight was previously thought to be helpful, but is not currently recommended due to the risk of sunburn. Sunburn does not occur with the lights used in phototherapy when used properly.
Phototherapy is stopped when bilirubin levels decline to a safe level. It is not unusual for infants to still appear jaundiced after phototherapy is completed. Bilirubin levels may rebound 18 to 24 hours after stopping phototherapy, although this rarely requires further treatment.
●Side effects – Phototherapy is very safe, but it can have temporary side effects, including skin rashes and loose stools. Overheating and dehydration can occur if the infant does not get enough breast milk or formula. Therefore, the infant's skin color, body temperature, and number of wet diapers are closely monitored.
●Rarely, some infants will develop "bronze baby" syndrome, a dark, grayish-brown discoloration of the skin and urine. Bronze baby syndrome is not harmful and gradually resolves without treatment after several weeks.
●Hydration – It is important for infants receiving phototherapy to drink adequate fluids (breast milk or a supplement) since bilirubin is excreted in urine and stool. Breast- or bottle-feeding should continue during phototherapy. Use of oral glucose water is not necessary. In some babies with severe dehydration, intravenous fluids may be necessary.
●Breastfeeding – Infants who are not able to consume enough breast milk, whose weight loss is excessive, or who are dehydrated may need extra expressed breast milk or other milk supplements. Mothers who supplement should continue to breastfeed and/or pump to maintain their milk supply.
There is some controversy about the practice of giving supplemental formula to exclusively breastfed infants. Parents should discuss these issues with your infant's doctor. (See "Patient education: Breastfeeding guide (Beyond the Basics)".)
Exchange transfusion — Exchange transfusion is an emergency, life-saving procedure that is done to rapidly decrease bilirubin levels. The transfusion replaces an infant's blood with donated blood in an attempt to quickly lower bilirubin levels. Exchange transfusion may be performed in infants who have not responded to other treatments and who have signs of or are at significant neurologic risk of bilirubin toxicity.
PREVENTION OF SEVERE HYPERBILIRUBINEMIA
Prevention of severe hyperbilirubinemia is important in avoiding serious complications. Infants who are at risk for hyperbilirubinemia need close surveillance and follow-up. The following information applies to infants who are healthy and late preterm or older (greater than or equal to 35 weeks of gestation).
Screen — Leading experts recommend that all infants have their bilirubin levels tested before going home. This is especially true for infants who are jaundiced before 24 hours of age.
Monitor — Parents and healthcare providers should monitor the infant closely if jaundice develops. Hyperbilirubinemia is usually easy to prevent and treat initially, but the complications can be serious and irreversible if treatment is delayed. You should contact your infant's healthcare provider immediately if you are concerned about worsening jaundice.
Treat promptly — Infants with elevated bilirubin levels should be treated by a qualified doctor or nurse to safely reduce bilirubin levels and prevent the risk of brain damage. Parents and healthcare providers should not delay treatment for any reason.
WHERE TO GET MORE INFORMATION
Your child's healthcare provider is the best source of information for questions and concerns related to your infant's medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Jaundice in babies (The Basics)
Patient education: What to expect in the NICU (The Basics)
Patient education: Gilbert syndrome (The Basics)
Patient education: Screening for hearing loss in newborns (The Basics)
Patient education: Glucose-6-phosphate dehydrogenase deficiency (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Classification and causes of jaundice or asymptomatic hyperbilirubinemia
Clinical manifestations of unconjugated hyperbilirubinemia in term and late preterm infants
Diagnostic approach to the adult with jaundice or asymptomatic hyperbilirubinemia
Evaluation of unconjugated hyperbilirubinemia in term and late preterm infants
Gilbert syndrome and unconjugated hyperbilirubinemia due to bilirubin overproduction
Pathogenesis and etiology of unconjugated hyperbilirubinemia in the newborn
Postnatal diagnosis and management of hemolytic disease of the fetus and newborn
Treatment of unconjugated hyperbilirubinemia in term and late preterm infants
The following organizations also provide reliable health information.
●National Library of Medicine
●American Academy of Pediatrics
●Parents of Infants and Children with Kernicterus
●Center for Disease Control and Prevention
●The Academy of Breastfeeding Medicine
- American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:297.
- Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia. N Engl J Med 2001; 344:581.
- Maisels MJ, Bhutani VK, Bogen D, et al. Hyperbilirubinemia in the newborn infant > or =35 weeks' gestation: an update with clarifications. Pediatrics 2009; 124:1193.
- Ip S, Chung M, Kulig J, et al. An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics 2004; 114:e130.
- Maisels MJ, McDonagh AF. Phototherapy for neonatal jaundice. N Engl J Med 2008; 358:920.
- Sheridan SE. Parents of Infants and Children with Kernicterus. J Perinatol 2005; 25:227.
- Bhutani VK. Public policy to prevent severe neonatal hyperbilirubinemia. In: Care of the Jaundiced Neonate, Stevenson DK, Maisels MJ, Watchko JF (Eds), McGraw-Hill, New York 2012. p.243.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.