Jaundice in Newborns (Hyperbilirubinemia)

What is jaundice in newborns?

Jaundice is a condition that makes a newborn’s skin and the white part of the eyes look yellow. It happens because there is too much bilirubin in the baby’s blood (hyperbilirubinemia). Bilirubin is a substance that is made when the body breaks down old red blood cells.

Jaundice usually is not a problem. But in rare cases, too much bilirubin in the blood can cause brain damage (kernicterus). This can lead to hearing loss, mental retardation, and behavior problems.

In healthy babies, some jaundice almost always appears by 2 to 4 days of age. It usually gets better or goes away on its own within a week or two without causing problems.

In breast-fed babies, mild jaundice sometimes lasts until 10 to 14 days after birth. In some breast-fed babies, it goes away and then comes back. Jaundice may last throughout breast-feeding. This isn't usually a problem as long as the baby gets enough milk by being fed at regular times.

Your doctor probably will ask you to keep checking your baby at home to make sure the jaundice is going away. You may be asked to take your baby for a follow-up exam within the first 5 days after birth. Call your doctor if the yellow color gets brighter after your baby is 3 days old.

What causes jaundice in newborns?

Jaundice occurs because your baby’s body has more bilirubin than it can get rid of. Bilirubin is made when the body breaks down old red blood cells. It leaves the body through urine and stool. During pregnancy, your body removes bilirubin from your baby through the placenta. After birth, your baby’s body must get rid of the bilirubin on its own.

Breast-fed newborns can become dehydrated easily if feedings are spaced too far apart. This lack of enough milk in the body makes it harder for your baby to get rid of wastes such as bilirubin. Also, some of the things that make up breast milk can change the way the body removes bilirubin.

In rare cases, too much bilirubin may be caused by infections, a problem with the baby’s digestive system, or a problem with the mom’s and baby’s blood types (Rh incompatibility). Your baby may have one of these problems if jaundice appears less than a day after birth.

What are the symptoms?

Jaundice can make your baby’s skin and the white part of the baby’s eyes look yellow. You may see the yellow color between 1 and 4 days after birth. It shows up first in the baby’s face and chest. Babies who have bilirubin levels that are too high may have a high-pitched cry. They also may be sluggish and cranky.

How is jaundice in newborns diagnosed?

Your baby’s doctor will do a physical exam and ask you questions. The doctor may ask about:

• Your general health, especially during your pregnancy.
• Whether your baby was born early (prematurely) or at full term.
• Whether there were any problems with the birth.
• Your baby's birth weight and whether the baby has lost or gained weight since birth.
• Your baby's feeding and elimination habits.
• Whether you and the baby have a problem with Rh incompatibility.
• Any family history of health problems that could cause jaundice.

A blood test for bilirubin may be done to find out if your baby needs treatment.

More tests may be done if the doctor thinks that a health problem is causing too much bilirubin in the blood.

How is it treated?

Most of the time no treatment is needed for jaundice, because it usually goes away on its own. If you are breast-feeding, you may be able to help reduce the jaundice by feeding your baby 8 to 10 times a day.

Sometimes babies with jaundice are put under a type of fluorescent light. This is called phototherapy. The skin absorbs the light. This changes the bilirubin so that the body can more easily get rid of it in the stool and urine. The treatment is usually done in a hospital. But babies sometimes are treated at home.

If a health problem caused the jaundice, your baby may need other treatment.

Frequently Asked Questions

The most common symptom of jaundice in newborns is a yellowish tinge to the skin, the white part of the eyes, or the inside of the mouth. This yellow tint usually appears first in the infant's face and chest between 1 and 5 days after birth, although the exact timing may vary by child and by the type of jaundice.

• Physiologic jaundice develops in all babies (although it may be very slight and not noticeable) sometime after the first day of life because their organs are not yet able to eliminate excess bilirubin effectively. If noticeable, the yellowing of the skin and eyes usually appears about 24 hours after birth and increases until about the third or fourth day. Most often, the blood bilirubin level then gradually lowers, and the yellowing fades or disappears in about a week without causing problems.
• Breast-feeding jaundice is caused by mild dehydration, which prolongs and intensifies physiologic jaundice. Dehydration contributes to jaundice because it makes removing bilirubin from the body even harder for babies' immature systems. Breast-feeding jaundice can occur when a baby does not get enough fluids, most often because feedings are spaced too far apart. Typically, if feedings become more frequent, this type of jaundice decreases or resolves sometime between 5 and 7 days after birth.
• Breast milk jaundice is a rise in bilirubin levels that occurs about 10 to 14 days after birth. It is likely related to how certain components of breast milk affect bilirubin elimination in the infant. Breast milk jaundice usually begins to fade by the second month, although a slight yellow tint may be visible throughout the duration of breast-feeding.

In rare cases, jaundice in a newborn may be caused by an underlying condition. Symptoms that begin to appear less than 24 hours after birth are unlikely to be jaundice and need to be evaluated carefully for other possible causes.¹

In general, call your health professional if the yellowing appears to increase after your baby's third day of life or has not decreased by the fifth day. Remember, however, that if you are breast-feeding, increasing the frequency of feedings may help to lower your baby's bilirubin levels and decrease jaundice.

Brain damage (kernicterus) can develop if a baby with a high bilirubin blood level is not treated. See your health professional right away if your baby develops signs of a high bilirubin level, which include:

• Sluggishness and poor sucking ability.
• Irritability, jitteriness, and crying.
• Arching of the baby's back.
• A shrill, high-pitched cry.

Signs of a very high level of bilirubin may include:

• Periods of not breathing (apnea) or difficulty breathing (dyspnea).
• Seizures.

Your health professional will diagnose jaundice in your newborn by doing a physical exam and taking a medical history. As part of the medical history, your baby's health professional may ask questions about:

• The mother's general health, particularly during the pregnancy.
• Whether your baby was born prematurely or at full term.
• Whether your baby had any difficulties during delivery.
• Your baby's birth weight and whether there has been any weight gain or loss since birth.
• Your baby's feeding and elimination habits since birth.
• Whether the baby and mother have incompatible blood types (ABO or Rh incompatibility).
• Your family history of health conditions that could cause jaundice.

The health professional will examine your baby and evaluate his or her skin color. This may include pressing a finger lightly on your baby's skin. The health professional will note whether yellowing related to jaundice is visible only in the eyes, face, and head or if it is also noticed on the chest and lower body. He or she may also look for signs of underlying conditions that can cause jaundice.

A transcutaneous jaundice meter may be used to measure your baby's bilirubin level. If the results are concerning, a bilirubin test may be done to more precisely measure the bilirubin level in your baby's blood. The results will help your health professional determine whether treatment is needed.

If the health professional thinks that another condition is causing the hyperbilirubinemia, more tests may be done. For example, if the health professional thinks that a difference in the baby's blood type and the mother's blood type (ABO or Rh incompatibility) is causing the hyperbilirubinemia, blood type tests may be done on the mother's and baby's blood.

Many mothers and their newborns leave the hospital within 48 hours of the baby's birth, often before signs of jaundice develop. Your baby should have a follow-up exam with your health professional within the first 5 days after birth. Also, call your health professional if at any time you notice a yellow tinge to your baby's skin and eyes.

Most of the time no medical treatment is needed for jaundice in a newborn (hyperbilirubinemia). However, watch for increasing intensity of the yellow tint in the skin and eyes or any change in your baby's behavior.

Babies who have bilirubin in their blood at a level that could be harmful need treatment. Whatever the cause, if the condition is not treated, excessive amounts of bilirubin in the blood may lead to brain damage (kernicterus), which could result in hearing loss, mental retardation, and behavior problems.

The most common treatment for hyperbilirubinemia is phototherapy, which uses fluorescent light to help transform bilirubin into a form the body can more quickly eliminate. Standard phototherapy is usually done in a hospital. However, babies with jaundice who are otherwise healthy may be treated at home with a type of phototherapy that uses a fiber-optic wrap, usually a blanket or a band. These wraps usually reduce blood bilirubin levels more slowly than standard phototherapy, so generally they are used only for mild jaundice. Sometimes standard therapy and fiber-optic wrap therapy are used together.²

If your newborn is receiving phototherapy for jaundice in the hospital, you can help by:

• Asking whether you can stay in the hospital overnight so you can continue to care for your baby. If you are not able to stay, visit frequently.
• Touching your baby often during phototherapy sessions in the enclosed plastic crib (incubator). You can reach into the incubator through specially made armholes on both sides of the incubator.
• Talking or singing to your baby, because babies can hear through the incubator.
• Holding your baby during the short periods when he or she is taken out from under the light.

The fluorescent lights used in phototherapy for babies with jaundice are not harmful if precautions are taken. Eye shields are placed over the baby's eyes to protect them while under the light. The shields are removed during feedings. Babies are accustomed to being in the dark after months in the womb, so the shields should not bother your baby.

If your baby is being treated at home for jaundice, it is important that you understand how to use all the equipment. Ask your health professional for help if you have questions or concerns. A home health nurse may visit to make sure all is going well. The amount of bilirubin in your baby's blood may need to be measured every day.

If the baby's jaundice is being caused by an underlying condition, other treatments may be needed. For example, if severe jaundice is caused by the baby's body destroying red blood cells (blood type incompatibility), the baby may need to be admitted to a hospital and given a blood transfusion.

Parents are often asked to watch their newborns for signs of jaundice, which produces a yellow tint to the skin and eyes. Many mothers and their newborns leave the hospital within 48 hours of the baby's birth, often before signs of jaundice develop. It is recommended that your infant have a follow-up exam with your health professional within the first 5 days after birth.

If a baby develops jaundice but at this point does not need phototherapy, your doctor will ask you to watch for and report any signs of increasing jaundice or changes in behavior. To check for signs of increasing jaundice:

• Undress your baby and look at his or her skin closely twice a day. For dark-skinned babies, look at the white part of the eyes to check for jaundice. Remember that your baby will get cold quickly when undressed. Cover your baby after about 1 minute.
• Check your baby at the same time of day, in the same room, under the same lighting conditions each time. If you think that your baby's skin is getting more yellow, call your health professional.

The best home treatment for jaundice is frequent feedings, whether breast-feeding or bottle-feeding. Feeding your baby frequently (8 to 10 or more times a day) will provide him or her with the fluids needed to get rid of the extra bilirubin.

Babies with jaundice who are otherwise healthy may be treated at home with a type of phototherapy that uses a fiber-optic wrap, usually a blanket or a band. These wraps usually reduce blood bilirubin levels more slowly than standard phototherapy, so generally they are used only for mild jaundice. Sometimes standard therapy and fiber-optic wrap therapy are used together.²

If your baby is being treated at home for jaundice, it is important that you understand how to use all the equipment. Ask your health professional for help if you have questions or concerns. A home health nurse may visit to make sure all is going well. The amount of bilirubin in your baby's blood may need to be measured every day.

If your baby has been treated with phototherapy, the yellow tint to the baby's skin and eyes may not disappear immediately. However, if the yellow tint intensifies, report it to your health professional.

Sometimes parents try to treat their jaundiced babies on their own without the proper equipment. Placing a baby under lights at home, near a windowsill in the sunlight, or outside in the sun will not lower the amount of bilirubin in his or her blood. Your baby's skin may get burned by the lights or the sun. In addition, your baby may get too cold. Special lights and controlled surroundings are always needed to treat jaundice safely.

Some mothers who breast-feed their babies are concerned that they will need to stop breast-feeding if their babies develop jaundice. The American Academy of Pediatrics encourages women to continue breast-feeding newborns with jaundice who are otherwise healthy and to focus on increasing the frequency of feedings (8 to 10 or more times every 24 hours).¹ If your baby is hospitalized, you may need to pump your breasts to maintain your milk production. You can then take the milk to the hospital for your baby's feedings.

• Bilirubin

Citations

1. American Academy of Pediatrics (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1): 297–316.

2. Mills JF, Tudehope D (2005). Fibreoptic phototherapy for neonatal jaundice. Cochrane Database of Systematic Reviews (2). Oxford: Update Software.

Other Works Consulted

• Stoll BJ, Kliegman RM (2004). Digestive system disorders. In RE Behrman et al., eds., Nelson Textbook of Pediatrics, 17th ed., pp. 588-599. Philadelphia: Saunders.

• Akobeng AK (2005). Neonatal jaundice. Clinical Evidence (13): 396–401.

• Bhutani VK, Johnson LH (2002). Neonatal hyperbilirubinemia: An evidence-based approach. In FD Burg et al., eds., Gellis and Kagan's Current Pediatric Therapy, 17th ed., pp. 298–306. Philadelphia: W.B. Saunders.

• Dennery PA, et al. (2001). Neonatal hyperbilirubinemia. New England Journal of Medicine, 344(8): 581–590.

• Stevenson DK, Madan A (2003). Jaundice in the newborn section of Newborn infant. In CD Rudolph, AM Rudolph, eds., Rudolph's Pediatrics, 21st ed., pp. 164–169. New York: McGraw-Hill.

• Thilo EH, Rosenberg AA (2005). Neonatal jaundice section of Common problems in the term newborn infant. In Current Pediatric Diagnosis and Treatment, 17th ed., pp. 11–17. New York: Lange Medical Books/McGraw-Hill.