Patient information: Jaundice in newborn infants

JAUNDICE OVERVIEW

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.

Jaundice is not a disease but is a symptom of an elevated blood bilirubin level. Jaundice is not painful, but serious complications can occur if elevated bilirubin levels are not treated in a timely manner. Jaundice is a marker used to identify 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 SYMPTOMS

Jaundice initially causes the skin and whites of the eyes to become yellowed. This change may be hard to recognize in children with a dark skin color. The color change:

• Is noticeable in the face first, then may progress down the chest, abdomen, arms, and finally the legs.
• 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.
• 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 severe jaundice — Call your child's healthcare provider if you notice any of the following:

• Jaundice is worsening (especially if the yellow coloring is at the knee or lower, or if the yellow color is more intense, lemon yellow to orange yellow)
• It is hard to wake up your infant
• If your infant has a shrill cry
• If your infant is irritable and is difficult to console
• If your infant arches his/her neck or body backwards

JAUNDICE CAUSES

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 cleared through the liver, and then excreted in stool and urine. Bilirubin levels become elevated when bilirubin is produced faster than it can be eliminated.

Jaundice is common in newborns, since two to three times more bilirubin is produced during this period as compared to during adulthood. "Physiologic jaundice", which affects nearly all newborns, is caused by a mild 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.

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 of life.

Increased production — 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 from the birth process
• If the mother and infant's blood 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])

Breastfeeding — Breastfeeding is encouraged in infants who are jaundiced. A breastfeeding nurse or other expert can be especially helpful. Contact phone numbers (both day and night) should be available for parents who have questions or problems. (See "Patient information: Common breastfeeding problems".)

Infants who do not consume enough breastmilk are at risk for jaundice, especially if the infant loses an excessive amount of weight because of difficulty feeding or if the mother does not have an adequate milk supply. There are two types of jaundice associated with breastfeeding: breast milk jaundice and breastfeeding failure jaundice.

Breast milk jaundice — Breast milk jaundice typically begins the first week after birth, peaks within two weeks after birth, and declines over the next few weeks. This type of jaundice may be related to the infant's immature liver and intestines.

Breast milk jaundice is not a reason to stop breastfeeding as long as the baby is feeding well, gaining weight, and otherwise thriving. Infants with breast milk jaundice rarely need treatment unless severe hyperbilirubinemia develops. All infants with jaundice should be monitored by a doctor or nurse. (See "Patient information: Common breastfeeding problems".)

Inadequate intake jaundice — Inadequate intake jaundice is distinct from breast milk jaundice occurs if a newborn is not getting enough breast milk. This is more likely to occur in babies who have difficulty with breastfeeding due to physical problems (prematurity, cleft lip or palate, tongue-tie) or a mother's insufficient milk supply.

Increasing the mother's milk supply, frequent feeding, and ensuring good sucking (latch) are the optimal treatments for inadequate intake jaundice. (See "Patient information: Common breastfeeding problems".)

JAUNDICE DIAGNOSIS

Newborn jaundice can be diagnosed by examining the infant and testing blood levels of bilirubin. A blood test involves collecting a small amount (one-half teaspoon) of blood. Results of blood testing are available in most hospitals within a few hours.

JAUNDICE COMPLICATIONS

In babies whose bilirubin blood levels reach hazardous levels, bilirubin may cross to the brain and cause reversible damage (called early acute bilirubin encephalopathy) or permanent damage (called kernicterus). Frequent monitoring and early treatment of infants at high risk for jaundice can help to prevent severe hyperbilirubinemia.

JAUNDICE TREATMENT

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 37 weeks of gestation). Premature infants are at greater risk for 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 breastmilk or formula is an important part of preventing and treating jaundice. You will know that your child 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 yellow to dark green, 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 a special blue light, which breaks bilirubin down into parts that are easier to eliminate in the stool and urine. Treatment with phototherapy is successful for most infants.

Phototherapy is usually done in the hospital, but in select cases, it can be done in the home if the baby is healthy and at low risk of 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 lamps do not generate excessive heat, which could scald 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 the treatment is 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 a skin rash and loose bowel movements. 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 formula) since bilirubin is excreted in urine and bowel movements. Breast- or bottle-feeding should continue during phototherapy, and in some cases, intravenous fluids may be necessary.
• Breastfeeding — Breastfed 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 formula. Mothers who supplement with formula should continue to breastfeed 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 the child's doctor. (See "Patient information: Breastfeeding basics".)

Treatment of blood type incompatibility — Infants with hyperbilirubinemia due to incompatibility with their mother's blood may be given intravenous immunoglobulin (IVIG). Intensive phototherapy is used as a first line treatment.

Exchange transfusion — Exchange transfusion is an emergency procedure that is done to prevent or minimize bilirubin-related brain damage. 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 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 — Experts recommend that all infants have bilirubin blood testing before going home. This is especially true for infants who are jaundiced before 24 hours of age or are jaundiced below the level of the umbilicus (navel).

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 child'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 child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Common breastfeeding problems
Patient information: Breastfeeding basics

Professional Level Information:
Classification and causes of jaundice or asymptomatic hyperbilirubinemia
Clinical manifestations of unconjugated hyperbilirubinemia in term and late preterm infants
Crigler-Najjar syndrome
Diagnostic approach to the patient with jaundice or asymptomatic hyperbilirubinemia
Evaluation of unconjugated hyperbilirubinemia in term and late preterm infants
Gilbert's syndrome and unconjugated hyperbilirubinemia due to bilirubin overproduction
Pathogenesis and etiology of unconjugated hyperbilirubinemia in the newborn
Postnatal diagnosis and management of alloimmune hemolytic disease of the newborn
Treatment of unconjugated hyperbilirubinemia in term and late preterm infants

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Pediatrics

     www.aap.org/family/jaundicefaq.htm

• Parents of Infants and Children with Kernicterus

     www.pickonline.org

• Center for Disease Control and Prevention

      (www.cdc.gov/ncbddd/dd/kernicterus/ker_parent.htm)

• The Academy of Breastfeeding Medicine

      www.bfmed.org

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