Neonatal Jaundice

Neonatal jaundice – otherwise known as neonatal hyperbilirubinemia – is a common and usually harmless condition that turns the skin and other parts of a newborn baby’s body yellow in color. 1 Jaundice is often found among newborn babies. In fact, it is the most common disorder for which newborns receive medical attention and/or are (re)admitted to hospital. The condition is caused by excessive levels of the chemical compound bilirubin in the tissues of the body.

Although neonatal jaundice is normally a non-serious condition, babies experiencing the disorder should always be seen by a doctor or midwife, who will be able to advise on a method of treatment where necessary. In very rare cases, when the levels of bilirubin are very high, serious complications are possible. 1

The main symptom of neonatal jaundice is a yellowing of the skin and other parts of the body. As the condition progresses, the whites of the eyes may take on a yellow tinge.

Symptoms will typically begin in the region of the face and gradually progress down the body to the legs. This progression may be unidentifiable in some cases, with the discoloration appearing to occur across the whole body all at once. If there is any doubt about skin discoloration, possible in babies with dark skin, this can be checked by pressing a finger down on the skin. In cases of jaundice, the skin should appear yellow when the finger is released. 2

Signs that neonatal jaundice is worsening include:

• Yellow skin below the knee
• Yellow skin becoming more intense in colour
• Difficulty feeding the baby
• Difficulty waking the baby
• Irritability
• The baby arching his/her neck or body backwards.

If any of these signs occur, immediate medical attention should be sought. If you are concerned that a child you care for has neonatal jaundice, you can do a free symptom assessment with the Ada app at any time.

Neonatal jaundice is caused by a buildup of the chemical compound bilirubin in the blood. Normally, the liver breaks down bilirubin and disposes of it through urine and stool. If bilirubin is produced faster than it can be broken down, jaundice occurs.

Newborns process bilirubin more slowly than adults, because their liver and intestines are not yet completely mature. The breakdown of red blood cells in infants can be related to: 1 2

• Bruising or mild injury to the newborn during delivery.
• An incompatibility between the mother’s blood type and that of the baby, which may cause the mother’s immune system to attack the baby’s red blood cells.
• Hereditary causes of red blood cell breakdown, such as a deficiency of the enzyme glucose-6-phosphate-dehydrogenase (G6PD). This is more common among people of an African-American, Asian or Mediterranean ancestry.
• Asian ancestry. In Asians, the ability to remove bilirubin takes longer to develop.

A slight increase in the breakdown of red blood cells, combined with a liver that is not functioning very well, can therefore lead to jaundice. 1 Generally, bilirubin production slows down significantly a few weeks after birth, once the liver and intestines are fully developed. ref1 2

Physiological jaundice is the most common form of the condition and is largely harmless. It usually begins two days after birth, reaches its peak at four days and disappears after seven to ten days. This type of neonatal jaundice is caused by a mild accumulation of bilirubin.

Jaundice in infants is classified as prolonged jaundice if symptoms persist for 14 days or longer after birth; this can be 21 days in premature babies. 3 The condition is usually caused by breastfeeding (see FAQs below), but may indicate a more serious problem. A doctor will be able to identify the cause behind prolonged jaundice and recommend treatment.

Neonatal jaundice will usually disappear after the liver has had time to fully develop and red blood cell breakdown has naturally slowed. If this does not happen, it may be that the condition is being caused by other factors. Additional signs that this is the case may include:

• The baby is unwell, e.g. not feeding well or unusually irritable or appears a lot quieter than usual
• Symptoms of jaundice are present in the first 24 hours after birth
• Symptoms of jaundice are still present two weeks after birth
• The baby has pale, chalky stools
• The baby has urine that causes dark stains on the nappy.

These symptoms may indicate that the baby has more severe hyperbilirubinemia, and in these cases it will be especially important to seek medical attention without delay.

Factors that may cause a more serious form of neonatal jaundice include blood or liver conditions, as well as blood type incompatibility with the mother. When a baby and mother have incompatible blood types, the mother’s blood can destroy red blood cells in the baby and cause jaundice.

Babies are checked for neonatal jaundice as part of the routine medical examination which typically takes place within 72 hours of birth. As the condition can take up to one week to appear, the baby should also be checked frequently after being taken home. Parents should monitor for yellowing of the skin and eyes, as well as for bright yellow urine and abnormally pale stool. If jaundice is suspected, parents should contact a doctor or midwife who will then usually recommend a bilirubin test. 4

If jaundice is suspected, a test to measure the levels of bilirubin in the blood will usually be carried out. This will either be done using an instrument known as a bilirubinometer, which uses light to test for bilirubin, or through a blood test. A blood test is generally only used if symptoms appear within 24 hours of birth or if the results from the bilirubinometer show particularly high levels.

The results of a bilirubin test will be used to decide on an appropriate treatment route for the condition.

Treatment for neonatal jaundice is aimed at reducing the levels of bilirubin in the blood. In mild cases, no treatment at all may be required other than monitoring the child, making sure that the jaundice improves.

In other cases, treatment may be necessary and options include:

Phototherapy is the most common treatment option for babies with jaundice and is in the majority of cases the only treatment method that is necessary for recovery.

Phototherapy involves exposing the baby’s skin to special blue light, which is able to break down bilirubin into a harmless substance. For the best results, the baby should be exposed to the light for as long as possible. This will usually take place at the hospital, but in some cases may be possible to do it at home.

Generally, phototherapy is very safe, though the infant’s eyes will need to be protected from the light, and temporary side-effects such as dehydration, a skin rash and loose stool may result. These are all treatable.

Intravenous immunoglobulin (IVIG) treatment is used for the treatment of blood group, Rhesus (Rh), ABO and other blood group incompatibilities. It is believed to reduce the need for exchange transfusions.

Intravenous immunoglobulin therapy may not be very helpful for babies that are already immunized, but it has been shown to be beneficial to babies that would otherwise need an exchange transfusion. The reasons behind this are not completely understood. In some cases, it may be necessary to try IVIG preparations from various manufacturers if the initial treatment does not work.

Generally, IVIG preparations are infused intravenously over a period of a few hours. The process can be repeated, and combined with phototherapy.

In emergency situations, when very high levels of bilirubin need to be reduced quickly, an exchange transfusion may be required. This is a procedure in which some of the baby’s blood is replaced with donor blood. This can be effective in bringing down bilirubin levels quickly.

In the majority of cases, neonatal jaundice is a harmless condition that leads to no serious complications. However, serious complications which can lead to both temporary and permanent disability can occur, albeit rarely.

A possible, but overall rare complication of neonatal jaundice is (acute) bilirubin encephalopathy, which may sometimes be termed kernicterus; this more likely affects premature babies or – in a minority of cases – babies with very high bilirubin levels. Signs of bilirubin encephalopathy may include: 5 6

• Severe jaundice within the first few days of birth
• Difficulty feeding
• High-pitched cry
• Arched neck or back.

Treating kernicterus usually involves phototherapy or, in emergency situations, an exchange transfusion. If kernicterus is not detected and treated early, it can cause long-term damage, including a certain form of cerebral palsy (athetoid cerebral palsy), sensory disability and, in rare cases, mortality.

Q: Can breastfeeding cause neonatal jaundice?
A: Neonatal jaundice is most common in infants who are breastfed. There are two main mechanisms behind breastfeeding-related jaundice.

In breastfeeding jaundice, which occurs within one week of birth, the problem is that the baby is not getting sufficient breast milk. This leads to low calorie intake and to inadequate numbers of bowel movements, which means that bilirubin is not removed from the body. It therefore recirculates in the intestines, where more bilirubin is absorbed.

Treatment for breastfeeding jaundice is with rehydration, i.e. making sure the baby receives adequate fluids, and increased breastfeeding sessions.

In breast milk jaundice, which occurs within two weeks of birth and can last for between four and 13 weeks, the cause is an interplay between a substance in breast milk and the baby’s digestive tract. Increased level of beta-glucuronidase in the mother’s breast milk, combined with a low population of gut bacteria in the baby’s digestive tract, causes the bilirubin in the infant’s body to be re-absorbed and thus stay in the body. This causes jaundice to persist.

Treatment is by continued breastfeeding, supplemented with formula feeding. Phototherapy can be used in addition if necessary.

Jaundice should not be considered a reason to cease breastfeeding a baby, however, as long as the baby is feeding adequately and gaining weight.

Q: How can neonatal jaundice be prevented?
A: Although neonatal jaundice is a very common problem among newborn babies, there are ways to reduce the chance of it developing. The key mechanism is to prevent bilirubin from remaining in the body, and this is done by: 7

• Frequent breastfeeding with adequate amounts of breast milk increases the infant’s gut motility (how often the gut moves) and frequency of bowel movements, which result in greater removal of bilirubin from the body and consequently less risk of jaundice.
• Protein-rich feeds, whether through special formula or breast milk. These inhibit jaundice by preventing bilirubin being reabsorbed and recirculated by the body.
• In dehydrated babies, rehydrating with a protein-rich feeding solution rather than with glucose or water.