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Patient education: Jaundice in newborn infants (Beyond the Basics)

Patient education: Jaundice in newborn infants (Beyond the Basics)
Authors:
Ronald J Wong, BA
Vinod K Bhutani, MD, FAAP
Section Editor:
Steven A Abrams, MD
Deputy Editor:
Laurie Wilkie, MD, MS
Literature review current through: Feb 2022. | This topic last updated: Feb 01, 2021.

JAUNDICE OVERVIEW — Jaundice is the medical term for a yellowish tinge of the skin. The yellow color is caused by a substance called bilirubin, which is made normally in the body. Babies with higher than normal blood levels of bilirubin, a condition called "hyperbilirubinemia," get this yellow color when bilirubin builds up in the skin. In babies with darker skin, jaundice may not be visible even if they have high blood bilirubin levels. Jaundice during the first 24 hours after birth, or yellowing of the palms of the hands and soles of the feet, is a medical emergency. If this happens, doctors will perform blood tests in order to identify and treat the problem.

Jaundice is not a disease, but rather a sign of an elevated blood bilirubin level. Jaundice is not painful, but in some babies, serious medical conditions can occur if hyperbilirubinemia is not treated. The presence of jaundice allows doctors to identify babies who are at risk of developing severe hyperbilirubinemia. If this happens, it can be toxic to the nervous system, potentially causing brain damage. Fortunately, safe and effective treatments are available.

JAUNDICE SYMPTOMS — Jaundice initially causes the skin to become yellow. Later, the gums, palms of the hands, and soles of the feet, as well as the whites of the eyes, may also develop a yellow color. These changes may be hard to see in children with darker skin or if a baby is unable to open their eyelids. The color change:

Is noticeable first in the face, and then the chest, stomach area, arms, and then finally the legs. However, in some babies, the head-to-toe progression of jaundice may not be seen, and the jaundice may appear over the entire body like a tan.

Can be checked by pressing one finger on a baby's forehead or nose (called "blanching" the skin). If the skin is jaundiced, it will appear yellow when the finger is removed.

Can be followed in some babies by pressing over their bony prominences of their chest, hips, and knees to check if the jaundice is worsening.

Should be checked more than once before a baby leaves the hospital after birth. If you bring your baby home sooner than three days after birth, you should check their skin color every day until the next scheduled appointment. The baby should be taken to see a doctor or nurse for a checkup within one to three days after going home.

Signs of worsening jaundice — Call your baby's doctor if any of the following occurs:

The yellow color is visible at the knee or lower, is more dark in appearance (changing from a lemon yellow to an orange yellow color), or if the "whites" of the eyes appear yellow

Your baby has a fever

Your baby has any difficulty eating

Your baby is more sleepy than usual

It is hard to wake up your baby

Your baby is irritable and is difficult to console

Your baby arches their neck or body backwards

JAUNDICE CAUSES — Jaundice is caused by the build-up of bilirubin in the blood. Bilirubin is formed and produced when red blood cells are broken down. Bilirubin (a yellow substance) is naturally removed by the liver and then excreted in stool and urine. Bilirubin levels become high when bilirubin is made faster than it can be removed.

Jaundice is common in newborns since two to three times more bilirubin is made than in adults. Newborn jaundice affects nearly all babies and is caused by a mild to moderate increase in bilirubin levels and is usually not harmful. It often reaches highest levels three to four days after birth and usually goes away by one to two weeks after birth. In babies who are born at 38 weeks or less and those who are significantly jaundiced, the jaundice may require more time to go away, as normal elimination processes develop with age.

Newborns with higher levels of bilirubin in the blood have what is called "severe hyperbilirubinemia," a more serious condition. Babies could develop severe hyperbilirubinemia within the first day after birth. If your baby becomes very yellow, it's very important to call or see your doctor immediately.

One reason that bilirubin levels are higher in babies 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 tissue injuries during delivery.

If a mother and baby's blood group and type are different (or "incompatible"); the mother's immune system may damage the baby'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 in Black, Mediterranean, or Asian populations).

Overall, bilirubin is also more slowly removed in a baby compared with adults because a baby's liver and intestines are not fully developed. In Eastern Asian babies, the ability to remove bilirubin takes even longer to develop.

Breastfeeding — Jaundice can be seen in breastfed babies for two key reasons:

Some babies do not get enough breast milk because they have difficulty feeding or the mother is not producing enough breast milk. If this happens, the baby may lose a large amount of weight, which increases bilirubin levels. Increasing the mother's milk supply, breastfeeding frequently, and making sure that the baby has a good "latch" are the best treatments for jaundice caused by not enough milk intake. (See "Patient education: Common breastfeeding problems (Beyond the Basics)".)

Breast milk jaundice is thought to be due to a baby's immature liver and intestines, which results in a slower removal of bilirubin. Jaundice begins the first week after birth, peaks within two weeks after birth, and declines over the next few weeks. Jaundice in breastfed babies is not a reason to stop breastfeeding as long as a baby is feeding well, gaining weight, and otherwise growing. Breastfeeding has many known benefits for both mother and baby. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)

Aside from increasing breast milk intake if necessary, babies with jaundice rarely need treatment unless severe hyperbilirubinemia develops. If your baby's jaundice, does not go away, you should see a doctor or nurse for evaluation.

JAUNDICE DIAGNOSIS — Newborn jaundice can be detected by examining the baby and testing bilirubin levels in the blood. The blood test involves collecting a small amount (less than one-half teaspoon) of blood. Results of blood testing are available in most hospitals within a few hours. Jaundice after one week of age should be checked to see if it is from a serious condition (eg, a blockage of bilirubin removal in the liver). In some hospitals, screening for high bilirubin is at first performed by a device that measures bilirubin in the skin (referred to as "transcutaneous" screening). When the skin measurement exceeds a normal value, blood testing is done to make sure that level of bilirubin is accurate.

JAUNDICE COMPLICATIONS — 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 babies at high risk for jaundice helps to prevent severe hyperbilirubinemia.

JAUNDICE TREATMENT — The goal of treating jaundice is to efficiently and safely reduce the level of bilirubin. Babies with mild hyperbilirubinemia may need no treatment at all. Babies with higher bilirubin levels will need brief treatment, which is described below.

Jaundice is common in premature babies (those born before 38 weeks). Premature babies are more vulnerable to hyperbilirubinemia because brain toxicity occurs at lower levels of bilirubin than in term babies. As a result, premature babies are treated at lower levels of bilirubin but with the same treatments discussed below.

Frequent feeding — Providing adequate breast milk is an important part of preventing and treating jaundice because it helps in the removal of bilirubin in stools and urine. If your baby is not getting enough milk through breastfeeding, your doctor can talk to you about options such as supplementing with formula or donor breast milk. You will know that your baby is getting enough milk if they have at least six wet diapers per day, the color of their stools changes from dark green to yellow, and they seems satisfied after feeding.

Phototherapy — Phototherapy ("light" therapy) is the most common medical treatment for hyperbilirubinemia in babies. In most cases, phototherapy is the only treatment required. The baby's skin surface is exposed to special blue light, which breaks bilirubin into compounds that are easier to eliminate in stool and urine. Treatment with phototherapy is successful for almost all babies.

Phototherapy is usually given in the hospital, but in certain cases, it can be done at home if the baby is healthy and at low risk for complications.

Babies should have as much skin as possible exposed to the light. Babies are usually naked (or wearing only a diaper) in an open bassinet or warmer, but need to wear patches or a special mask to protect the eyes (image 1). Phototherapy should be continuous and stopped only for feeding and skin-to-skin care of the baby. Some hospitals have special phototherapy blankets that allow treatment to continue while you hold or feed your baby.

Exposure to sunlight was previously thought to be helpful but is no longer recommended due to the risk of sunburn unless ultraviolet rays are filtered out. Sunburn does not occur with the lights used in phototherapy.

Phototherapy is stopped when bilirubin levels drop to a safe level. It is not unusual for babies to still appear jaundiced for a period of time after phototherapy is completed. Bilirubin levels may rise again 18 to 24 hours after stopping phototherapy. Although rare, this requires follow-up for those who may need more 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 a baby does not get enough breast milk or formula. Therefore, a baby's skin color, temperature, and number of wet diapers should be closely monitored.

Unusually, some babies can develop a dark, grayish-brown discoloration of the skin and urine or "bronze baby" syndrome. It is not harmful and gradually goes away without treatment after several weeks.

Breastfeeding during phototherapy — It is important for babies receiving phototherapy to drink adequate fluids (ideally breast milk) since bilirubin is excreted in urine and stool. Breastfeeding should continue during phototherapy. Use of oral glucose water is not necessary. In babies with serious dehydration, intravenous (IV) fluids may be necessary to correct the loss of fluid.

Babies who are not able to eat enough breast milk, lose a lot of weight, or are dehydrated may need extra expressed breast milk or medically recommended formula for a short time. Mothers who supplement with formula should continue to breastfeed and/or pump regularly to maintain their milk supply.

There is some controversy about the practice of giving supplemental formula to exclusively breastfed babies. If you are considering doing this, it's a good idea to talk to your baby's doctor or nurse first. (See "Patient education: Breastfeeding guide (Beyond the Basics)".)

Exchange transfusion — Exchange transfusion is an emergency, life-saving procedure that is sometimes necessary to rapidly decrease bilirubin levels. The transfusion replaces a baby's blood with donated blood to quickly lower bilirubin levels (2 to 3 hours). Exchange transfusion is performed only for babies who have not responded to other treatments and who have signs of or are at significant risk for brain damage.

PREVENTION OF SEVERE HYPERBILIRUBINEMIA — Prevention of severe hyperbilirubinemia is important in avoiding serious complications. Babies who are at risk for hyperbilirubinemia need to have regular follow-up visits with their doctor; these should be scheduled at the time of hospital discharge. The following information only applies to babies who are healthy and born at term or late preterm (within a month of their due date).

Screening — Leading experts recommend that all newborns have their bilirubin levels tested before going home from the hospital, regardless of age. This is especially true for babies who are jaundiced before one day of age, in which case repeated testing is needed.

Monitoring — Parents, other caregivers, and health care providers should watch babies closely if jaundice develops. Hyperbilirubinemia is usually easy to prevent and treat initially. However, complications can be serious and irreversible if treatment is delayed. You should contact your baby's health care provider immediately if you are concerned about worsening jaundice.

Prompt treatment — Babies with high bilirubin levels should be treated by a qualified health care provider to safely reduce bilirubin levels and prevent the risk of brain damage. Parents and health care providers should not delay treatment for any reason.

WHERE TO GET MORE INFORMATION — Your baby's health care provider is the best source of information for questions and concerns related to your baby's medical problem.

This article will be updated as needed on our website (https://www.uptodate.com/home/uptodate-subscription-options-patients). Related topics for patients, as well as selected articles written for health care 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.

Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Breastfeeding guide (Beyond the Basics)

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
Unconjugated hyperbilirubinemia in term and late preterm infants: Epidemiology and clinical manifestations
Crigler-Najjar syndrome
Diagnostic approach to the adult with jaundice or asymptomatic hyperbilirubinemia
Unconjugated hyperbilirubinemia in term and late preterm infants: Screening
Gilbert syndrome and unconjugated hyperbilirubinemia due to bilirubin overproduction
Unconjugated hyperbilirubinemia in the newborn: Pathogenesis and etiology
Postnatal diagnosis and management of hemolytic disease of the fetus and newborn
Unconjugated hyperbilirubinemia in term and late preterm infants: Management

The following organizations also provide reliable health information.

National Library of Medicine

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

American Academy of Pediatrics

(www.healthychildren.org/English/ages-stages/baby/pages/Jaundice.aspx)

Parents of Infants and Children with Kernicterus

Center for Disease Control and Prevention

(www.cdc.gov/ncbddd/jaundice/index.html)

Academy of Breastfeeding Medicine

(www.bfmed.org)

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This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
Topic 1203 Version 26.0

References

1 : Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

2 : Neonatal hyperbilirubinemia.

3 : Hyperbilirubinemia in the newborn infant>or =35 weeks' gestation: an update with clarifications.

4 : An evidence-based review of important issues concerning neonatal hyperbilirubinemia.

5 : Phototherapy for neonatal jaundice.

6 : Parents of Infants and Children with Kernicterus.