Newborn Jaundice

Jaundice causes a yellowish discoloration of the skin.

• 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 of a normal increase in red blood cell breakdown and the fact that their immature livers are not efficient at removing bilirubin from the bloodstream.

• As a baby's bilirubin levels rise, jaundice moves from the head to involve the arms, trunk, and finally the legs. If the bilirubin levels are very high, a baby will appear jaundiced below the knees and over the palms of his or her hands. One easy way to check for jaundice is to press a finger against your baby's skin, temporarily pushing the blood out of it. Normal skin will turn white when you do this, but jaundiced skin will stay yellow.
• Older children and adults will appear jaundiced when the amount of bilirubin in their blood is above 2 milligrams per deciliter (mg/dL). Newborn babies will begin to appear jaundiced when they have more than 5 mg/dL of bilirubin in their blood. It is important to recognize and treat neonatal jaundice because high levels of bilirubin can cause permanent damage to a baby's brain. This brain damage is called kernicterus. Today, because of increased awareness and effective treatment of neonatal jaundice, kernicterus is extremely rare.
• Jaundice itself does not produce any clinical symptoms, but the underlying cause may produce the following symptoms:
  • Ill appearance
  • Fever
  • Poor feeding

Jaundice in newborns most commonly occurs because their livers are not mature enough to remove bilirubin from the blood. Jaundice may also be caused by a number of other medical conditions.

• Physiologic jaundice is the most common form of newborn jaundice. The baby's liver plays the most important part in bilirubin breakdown. The type of bilirubin that causes the yellow discoloration of jaundice is called unconjugated or indirect bilirubin. This form of bilirubin is not easily removed from the baby's body. The baby's liver changes this unconjugated bilirubin into conjugated or direct bilirubin, which is easier to excrete. The liver of a newborn baby is immature, so the job of conjugating and removing bilirubin is not done completely well. This causes an elevation of bilirubin, which results in the yellow discoloration of the baby's eyes skin. As the breakdown of red blood cells slows down, and the baby's liver matures, the jaundice rapidly disappears. When jaundice is due to these factors alone, it is called physiologic jaundice.
• Neonatal jaundice can be seen in cases of maternal-fetal blood type incompatibility. The mother's body will actually produce antibodies that attack the fetus's blood cells. This causes a breakdown of the red blood cells and thus an increased release of bilirubin from the red cells.
• Healthy red blood cells can be destroyed in a condition called hemolysis.
• Polycythemia is a condition in which a child is born with an excess of red blood cells.
• A large scalp bruise called a cephalohematoma can occur during the birthing process. Such a bruise is really a collection of clotted blood just beneath the skin surface. As the body naturally breaks down this clotted blood, a large amount of bilirubin is released at once. This sudden excess in serum bilirubin may be too much for the baby's liver to handle, and jaundice will develop.
• Sometimes a baby swallows blood during birth. This swallowed blood is broken down in the baby's intestines and absorbed into the bloodstream. Just as the excess blood from a blood clot will cause a rise in serum bilirubin, so will this.
• A mother who has diabetes may cause a baby to develop neonatal jaundice.
• Crigler-Najjar syndrome and Lucey-Driscoll syndrome are also conditions that can cause jaundice.

When to call a doctor

Call your doctor if your newborn baby becomes jaundiced.

• If your doctor is aware of the jaundice and you are observing your child at home, call your doctor if the jaundice spreads to the arms or legs or if it lasts beyond 1 week.
• Call your doctor if you don't feel comfortable watching your child at home or if you have any other questions or concerns.

When to go to the hospital

• If your child appears ill to you (if he or she is refusing to eat, seems excessively sleepy, or has floppy arms and legs) or has a temperature of 100.4 F (38 C) or higher, you should seek medical attention immediately.
• Go to the hospital if your child seems to be having difficulty breathing.
• If your child stops breathing or begins turning blue, administer rescue breaths if you are trained in CPR. Send someone to call 911 immediately.

Before a baby can be treated, the exact cause of an infant's jaundice must be determined. In some cases, a careful examination by a pediatrician is all that is needed. In other cases, blood tests may be required.

• The serum bilirubin level may be checked. Based on this test, the doctor may request that more tests be ordered. Some health care practitioners use a device that measures transcutaneous bilirubin such as the BiliCheck, so there is no need to draw blood. This screening tool is now widely used in newborn nurseries and outpatient clinics, offices, and emergency departments to obtain a rapid and non-invasive estimate of the degree of hyperbilirubinemia.
  • Coombs test checks for antibodies that destroy an infant's red blood cells.
  • Complete blood count may be ordered.
  • Reticulocyte count is performed to be sure your baby is making enough new red blood cells.
• Certain red blood cell diseases are found in people of Mediterranean descent. In such cases, it may be necessary to check blood samples for a condition known as G6PD deficiency.

• Sunlight helps to break down indicrect bilirubin so that a baby's liver can process it more easily.
  • Place the child in a well-lit window for 10 minutes twice a day is often all that is needed to help cure mild jaundice.
  • Never place an infant in direct sunlight.
• If the bilirubin level is too high, the child may need to be placed under a special type of light. This treatment is called phototherapy.
  • Sometimes, such lights can be set up at your home with careful monitoring.
  • The doctor (with the parent's help) will decide whether to begin a child on phototherapy.
• If an infant's bilirubin levels are very high or if the child appears ill, the baby will most likely be admitted to the hospital for treatment.

• Significant jaundice is often treated with phototherapy. This involves placing the baby on a warmer beneath special lights.
  • These lights are able to penetrate a baby's skin and affect the bilirubin within the child. The light changes bilirubin into lumirubin, which is easily handled by the baby's body.
  • This treatment may seem much like a visit to a local tanning booth. Special goggles or a shade is placed over the baby's eyes to shield them from the lights.
• Two factors help decide whether or not to start phototherapy: the age of the child and the level of bilirubin.
  • Younger children with higher bilirubin levels will more often require treatment.
  • The decision to begin phototherapy depends on the opinion of your pediatrician and on your comfort level.
• If standard phototherapy doesn't work to reduce a baby's bilirubin level, the doctor may try other treatments. For example, the baby may be placed on a fiber optic blanket and an additional bank of lights may be added.
• If these treatments don't work, babies most often have a serious condition that is causing their jaundice. Physiologic jaundice (the most common form) almost never requires treatment beyond phototherapy.
• When all other treatments have failed to reduce the bilirubin level enough, the last resort is an exchange transfusion. In this treatment, the baby's blood is exchanged with donated blood. This is a very specialized procedure and is done only in facilities capable of caring for critically ill children.

In most cases, jaundice is not preventable.

• The best way to avoid jaundice is to make sure your baby is getting enough fluids.
• If you are breastfeeding your child and have any questions or concerns, speak to a lactation consultant. Many hospitals provide this service.
• If you have not received formal training in infant or child CPR and you have children at home, contact your local American Heart Association chapter to enroll in a class as soon as possible.

The majority of children with jaundice will recover fully and without permanent adverse effects.

• Sometimes, a baby will need light treatment in a hospital to lower bilirubin levels
• Only a very few infants will require exchange transfusion.