Infant jaundice

Overview

Infant jaundice is the yellow coloring of a newborn baby's skin and eyes. It's caused by a buildup of pigment called bilirubin in the baby's blood.

Infant jaundice is a common condition, especially in babies born before 37 weeks' gestation (preterm babies) and some breastfed babies. It usually happens because a baby's liver isn't mature enough to get rid of bilirubin (bil-ih-ROO-bin) in the bloodstream. In some babies, an underlying disease may cause infant jaundice.

Most infants born between 35 weeks' gestation and full term need no treatment for jaundice. Rarely, an unusually high blood level of bilirubin can place a newborn at risk of brain damage, particularly in the presence of certain risk factors for serious jaundice.

Symptoms

Yellowing of the skin and the whites of the eyes — the main sign of infant jaundice — usually appears within a few days after birth.

To check for infant jaundice, press gently on your baby's forehead or nose. If the skin looks yellow where you pressed, it's likely your baby has mild jaundice. If your baby doesn't have jaundice, the skin color should simply look slightly lighter than its usual color for a moment.

Examine your baby in good lighting conditions, preferably in natural daylight.

When to see a doctor

Most hospitals have a policy of examining babies for jaundice before discharge. The American Academy of Pediatrics recommends that:

• Newborns be examined for jaundice during routine medical checks and at least every 12 hours while in the hospital.
• A newborn's bilirubin levels should be checked between 24 and 48 hours after birth.

The following symptoms may suggest complications from too much bilirubin. Call a healthcare professional if:

• Your baby's skin becomes more yellow.
• The skin on your baby's belly, arms or legs looks yellow.
• The whites of your baby's eyes look yellow.
• Your baby seems listless or sick or is hard to wake up.
• Your baby isn't gaining weight or is feeding poorly.
• Your baby makes high-pitched cries.
• Your baby develops any other symptoms that concern you.

Causes

Excess bilirubin, called hyperbilirubinemia, is the main cause of jaundice. Bilirubin is a yellow-pigmented substance released into the bloodstream when red blood cells break down.

Newborns produce more bilirubin than adults do. This is due to greater production and faster breakdown of red blood cells in the first few days of life. Typically, the liver filters bilirubin from the bloodstream and releases it into the intestinal tract. A newborn's immature liver often can't remove bilirubin quickly enough. This causes a buildup of bilirubin. Jaundice caused by these typical newborn conditions is called physiologic jaundice, and it typically appears on the second or third day of life.

Other causes

An underlying condition may cause infant jaundice. In these cases, jaundice often appears much earlier or much later than does the more common form of infant jaundice. Conditions that can cause jaundice include:

• Internal bleeding, called hemorrhage.
• An infection in your baby's blood, called sepsis.
• Other viral or bacterial infections.
• An incompatibility between the mother's blood and the baby's blood.
• A liver malfunction.
• Biliary atresia, a condition in which the baby's tubes that connect to the liver, called bile ducts, are blocked or scarred.
• An enzyme deficiency.
• An issue with your baby's red blood cells that causes them to break down rapidly.

Risk factors

Major risk factors for jaundice, particularly severe jaundice that can cause complications, include:

• Premature birth. A baby born before 37 weeks of gestation may not be able to process bilirubin as quickly as full-term babies do. Premature babies also may feed less and have fewer bowel movements, resulting in less bilirubin removed through stool.
• Significant bruising during birth. Newborns who become bruised during delivery may have higher levels of bilirubin from the breakdown of more red blood cells.
• Blood type. If the mother's blood type is different from her baby's, the baby may have received antibodies through the placenta that cause rapid breakdown of red blood cells.
• Breastfeeding. Babies who are breastfed, particularly those who have difficulty nursing or getting enough nutrition from breastfeeding, are at higher risk of jaundice. Dehydration or a low caloric intake may contribute to the onset of jaundice. However, because of the benefits of breastfeeding, experts still recommend it. It's important to make sure your baby gets enough to eat and is adequately hydrated.
• A family history of certain blood disorders. Having a family member with certain blood conditions, such as glucose-6-phosphate dehydrogenase [G6PD] deficiency, increases a baby's risk of having jaundice.
• A parent or sibling who was treated for jaundice. If a family member had jaundice, your baby's risk of jaundice is higher.
• Down syndrome. Newborns with Down syndrome have a higher risk of developing serious jaundice.
• Being a larger-than-average baby with a mother who has diabetes. Larger babies are commonly associated with diabetic pregnancies. Jaundice happens in 10% to 30% of babies of mothers with diabetes. The risk is even higher in babies born before 37 weeks' gestation.

Complications

High levels of bilirubin that cause severe jaundice can cause serious complications if not treated.

Acute bilirubin encephalopathy

Bilirubin is toxic to cells of the brain. If a baby has severe jaundice, there's a risk of bilirubin passing into the brain, a condition called acute bilirubin encephalopathy. Prompt treatment may prevent significant lasting damage.

Signs of acute bilirubin encephalopathy in a baby with jaundice include:

• Listlessness.
• Difficulty waking.
• High-pitched crying.
• Poor sucking or feeding.
• Backward arching of the neck and body.
• Fever.

Kernicterus

Kernicterus is the syndrome that happens if acute bilirubin encephalopathy causes permanent damage to the brain. Kernicterus may result in:

• Movements that are not controlled or intended,, known as athetoid cerebral palsy.
• Permanent upward gaze.
• Hearing loss.
• Improper development of tooth enamel.

Diagnosis

A healthcare professional will likely diagnose infant jaundice by checking a baby's appearance. However, it's still necessary to measure the level of bilirubin in a baby's blood. The level of bilirubin can show how serious the jaundice is and help decide the course of treatment. Tests to diagnose jaundice and measure bilirubin include:

• A physical exam.
• A laboratory test of a sample of your baby's blood.
• A skin test with a device called a transcutaneous bilirubinometer, which measures the reflection of a special light shone through the skin.

A healthcare professional may order additional tests if there's evidence that your baby's jaundice is caused by an underlying disorder.

Treatment

Mild infant jaundice often disappears on its own within two or three weeks. For moderate or severe jaundice, a baby may need to stay longer in the newborn nursery or be readmitted to the hospital.

Treatments to lower the level of bilirubin in baby's blood may include:

• Light therapy, also called phototherapy. Your baby may be placed under a special lamp that emits light in the blue-green spectrum. The light changes the shape and structure of bilirubin molecules in such a way that they can be excreted in both the urine and stool. During treatment, your baby will wear only a diaper and protective eye patches. Light therapy may be supplemented with the use of a light-emitting pad or mattress.
• Enhanced nutrition. To prevent weight loss, a healthcare professional may recommend more-frequent feeding or supplementation to ensure that your baby receives enough nutrition.
• Intravenous immunoglobulin (IVIg). Jaundice may be related to blood type differences between mother and baby. This condition results in the baby carrying antibodies from the mother that contribute to the rapid breakdown of the baby's red blood cells. Intravenous transfusion of an immunoglobulin — a blood protein that can reduce levels of antibodies — may decrease jaundice and lessen the need for an exchange transfusion, although results are not conclusive.
• Exchange transfusion. Rarely, when severe jaundice doesn't respond to other treatments, a baby may need an exchange transfusion of blood. This involves repeatedly withdrawing small amounts of blood and replacing it with donor blood. The procedure dilutes the bilirubin and maternal antibodies and is done in a newborn intensive care unit.

Self care

When infant jaundice isn't severe, a healthcare professional may recommend changes in feeding habits that can lower levels of bilirubin. Talk to your baby's healthcare professional if you have any questions or concerns about how much or how often your baby is feeding or if you're having trouble breastfeeding. The following steps may lessen jaundice:

• More-frequent feedings. Feeding more frequently will provide your baby with more milk and cause more bowel movements, increasing the amount of bilirubin eliminated in your baby's stool. Infants who are breastfed should have 8 to 12 feedings a day for the first several days of life. Formula-fed infants usually should have 1 to 2 ounces (about 30 to 60 milliliters) of formula every 2 to 3 hours for the first week.
• Supplemental feedings. If your baby is having trouble breastfeeding, is losing weight or is dehydrated, your baby's healthcare professional may suggest giving your baby formula or expressed milk to supplement breastfeeding. Depending on the situation, your baby's health professional may recommend using formula alone for a couple of days and then resuming breastfeeding. Ask your baby's health professional what feeding options are right for your baby.

Prevention

The best preventive of infant jaundice is adequate feeding. Breastfed infants should have 8 to 12 feedings a day for the first several days of life.

Preparing for your appointment

Bilirubin levels in the blood tend to peak when a baby is between 2 and 5 days old. So it's important for your baby's healthcare professional to examine your baby for jaundice during that time.

When your baby is discharged from the hospital, your baby will be checked for jaundice. If your baby has jaundice, your baby's healthcare professional will assess the likelihood of severe jaundice based on several factors:

• How much bilirubin is in the blood.
• Whether your baby was born prematurely.
• How well your baby is feeding.
• How old your baby is.
• Whether your baby has bruising from delivery.
• Whether an older sibling also had severe jaundice.

Follow-up visit

If risk factors for severe jaundice are present, your doctor may recommend a follow-up visit a day or two after the baby leaves the hospital.

When you arrive for your follow-up appointment, be prepared to answer the following questions.

• How well is your baby feeding?
• Is your baby breastfed or formula-fed?
• How often does your baby feed?
• How often does your baby have a wet diaper?
• How often is there stool in the diaper?
• Does your baby wake up easily for feeding?
• Does your baby seem sick or weak?
• Have you noticed any changes in the color of your baby's skin or eyes?
• If your baby has jaundice, has the yellow color spread to parts of the body other than the face?
• Has your baby's temperature been stable?

You also may prepare questions to ask your baby's care team at a follow-up appointment, including:

• Is the jaundice severe?
• What is the cause of the jaundice?
• What tests does my baby need?
• Does my baby need to begin treatment for jaundice?
• Will my baby need to go back into the hospital?
• When should my baby have a follow-up visit?
• Should I keep feeding my baby the way I am now?
• Can you recommend websites with information about jaundice? Do you have any brochures about jaundice and proper feeding?