Jaundice in newborns

Jaundice is a common and usually harmless condition in newborn babies that causes yellowing of the skin and the whites of their eyes.

Introduction

Jaundice is a common and usually harmless condition in newborn babies that causes yellowing of the skin and the whites of their eyes. (The medical term for this condition is neonatal jaundice.)

Other possible symptoms include:

  • dark urine
  • pale coloured stools (faeces) instead of bright yellow or orange coloured stools

Symptoms usually develop 2-3 days after birth.

Read more about the symptoms of jaundice in babies.

Most cases of jaundice in babies get better without the need for treatment.

When to see your midwife or doctor

Your baby will usually be checked for jaundice by a midwife within 72 hours of birth.

However, if your baby develops jaundice after this time contact your midwife or doctor for advice.

While jaundice is not usually a cause for concern it is important to get it checked to see if it needs treating.

Why does my baby have jaundice?

Jaundice is caused by the build-up of bilirubin in the blood. Bilirubin is a yellow substance produced when red blood cells are broken down.

The liver should filter the bilirubin from the blood, and change it into a form that allows it to be passed out from the body in stools. In newborn babies, the bilirubin builds up too fast for the liver to filter it all out, causing jaundice. This can occur because:

  • newborn babies have more red blood cells than adults, and the red blood cells have a shorter lifespan
  • the breakdown and removal of bilirubin is slower in newborn babies than in adults as the liver is still developing

Although in a small number of causes jaundice can be the sign of an underlying health condition. This is often the case if jaundice develops quickly after birth (within the first 24 hours).

Read more about the causes of jaundice in babies.

Treating jaundice

Most cases of jaundice in babies do not require treatment as the symptoms normally pass within 10-14 days (although in a minority of cases symptoms can last longer).

Treatment is usually only recommended if tests show a baby has very high levels of bilirubin in their blood (this is known as significant hyperbilirubinaemia). This is because there is a small risk that the bilirubin could pass into the brain and cause brain damage.

There are a number of very effective treatments used to quickly reduce bilirubin levels, including:

  • phototherapy –a special type of light shines on the skin which breaks down bilirubin
  • a type of blood transfusion known as an exchange transfusion

Most babies respond well to treatment and can leave hospital after a few days.

Read more about treating jaundice in babies.

Complications

Excessively high levels of bilirubin cause permanent brain damage. This is known as kernicterus and is rare, affecting less than 1 in every 100,000 births.

Kernicterus tends only to be a significant problem in countries with limited access to medical care.

Read more about the complications of jaundice in babies.

Who is affected?

Jaundice is one of the most common conditions that can affect newborn babies. It is estimated that 6 out of every 10 babies will develop jaundice (this rises to 8 out of 10 babies born prematurely.).

Although only around 1 in 20 babies has levels of bilirubin in their blood that are high enough to need treatment.

For reasons that are unclear breastfeeding a baby increases the risk of them developing jaundice which can often persist for a month or longer. It is estimated that 1 out of 10 breastfed babies will still have jaundice when they are one month old.

(Though in most cases the benefits of breastfeeding far outweigh any risks associated with jaundice).

Symptoms

Jaundice usually appears about three days after birth and disappears by the time the baby is two weeks old. In premature babies, who are more prone to jaundice, it can take five to seven days to appear and usually lasts slightly longer. It also lasts longer in babies who are breastfed.

If your baby has jaundice, their skin will look slightly yellow. It often looks like a suntan. The yellowing of the skin usually starts on the head and face, before spreading to the chest and stomach. In some babies, the yellowing reaches their legs and arms.

Yellowing may appear more pronounced if you press an area of skin down with your finger.

Changes in skin colour can be more difficult to spot if your baby has a darker skin tone, so other signs of yellowing to watch out for include:

  • in the whites of their eyes
  • inside their mouth
  • on the soles of their feet
  • on the palms of their hand

Other associated symptoms can include:

  • poor sucking or feeding
  • sleepiness
  • a high-pitched cry
  • limpness (floppiness)
  • dark urine instead of colourless urine
  • pale stools (faeces or 'poo') instead of bright yellow or orange coloured stools

When to seek medical advice

You will usually be referred to a follow-up appointment 72 hours after birth with a midwife or similar to check for signs of jaundice.

But if your baby develops jaundice after this time contact your doctor for advice.

While jaundice is not usually a cause for concern it is important their bilirubin levels are measured to determine if they require treatment.

Read more about the diagnosis of jaundice in babies.

Causes

Jaundice is caused by too much bilirubin in the blood. This is known as hyperbilirubinaemia

Bilirubin is a yellow substance produced when red blood cells, which carry oxygen around the body, are broken down.

The bilirubin travels in the bloodstream to the liver. The liver changes the form of the bilirubin so that it can be passed out of the body in stools (faeces).

However, if there is too much bilirubin in the blood, or if the liver cannot get rid of it, excess bilirubin will cause jaundice.

Jaundice in babies

There are three main reasons why jaundice is common in new born babies:

  • newborn babies have a greater number of red blood cells than adults
  • the red blood cells in babies have a shorter lifespan than those found in adults, so they need to be broken down and replaced at a faster rate
  • the process to break down and excrete the bilirubin is slower than it is in adults

By the time a baby is two weeks old, they are producing less bilirubin and their liver is more effective at removing it from the body which means the jaundice usually corrects itself without causing harm.

Breastfeeding

Breastfeeding your baby makes it more likely they will develop jaundice; which tends to last longer than in bottle-fed babies.

The reasons for this are unclear. A number of theories have been suggested, such as:

  • when you first start breastfeeding it can be hard to provide all the nutrients your baby requires so they are not getting nutrients and fluids necessary to help their body break down and excrete bilirubin; this tends to only be a short-term issue
  • breastfeeding may somehow cause the bilirubin in the intestines (part of the digestive system) to be re-absorbed back into the blood, instead of being passed out
  • it is also possible that breast milk contains an unidentified, but harmless, substance that causes jaundice in newborn babies

If you are breastfeeding your baby, continue to do so even if your baby has symptoms of jaundice as they will pass in time. Benefits of breastfeeding outweigh any potential risks associated with jaundice.

You may wish to discuss this further with your doctor or midwife.

Who’s at risk?

Your baby is more likely to need treatment for high levels of bilirubin in their blood if:

  • they were born before the 38th week of your pregnancy
  • you have another child that needed treatment for jaundice
  • you intend to only breastfeed your baby (not bottle-feed as well)
  • they develop jaundice within 24 hours of being born

There is also some evidence that babies with a low birth weight (less than 2 and a half kilos or 5.5 pounds) are more likely to need treatment for jaundice.

Alternative causes

In some cases, jaundice may have an alternative cause. Some of these are described below.

  • An underactive thyroid gland (hypothyroidism).
  • Blood group incompatibility, when the mother and baby have different blood types, and these are mixed during the pregnancy or the birth.
  • Rhesus factor disease, a condition that can occur if the mother has rhesus-negative blood, and the baby has rhesus-positive blood.
  • An inherited enzyme deficiency (enzymes are proteins that speed up and control chemical reactions in the body), such as a deficiency of glucose-6-phosphate-dehydrogenase (G-6-PD), an enzyme that helps red blood cells function.
  • The baby experiences bleeding in and around the skull (cephalohaematoma) due to a difficult delivery – this condition is not usually serious.
  • The mother of the baby has diabetes.
  • The baby has a urinary tract infection (an infection, usually bacterial, that develops inside any part of the body used to pass urine, such as the bladder)
  • Crigler-Najjar syndrome, an inherited condition that adversely affects the enzyme responsible for processing bilirubin, leading to an excess build up of bilirubin.
  • An obstruction or defect in the biliary system. The biliary system is made up of the bile ducts and gall bladder, and it creates and transports bile (a fluid used to help digest fatty foods).

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

The intestines are the part of the digestive system between the stomach and the anus that digests and absorbs food and liquid.

The liver is the largest organ in the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Oxygen is an odourless, colourless gas that makes up about 20% of the air we breathe.

Diagnosis

When your baby is born they will be checked for jaundice, although it does not usually appear for a few days. If your baby has jaundice, they may be kept in hospital for a few days for observation.

When you are at home with your baby, you should keep an eye on them. Check their skin and the whites of their eyes in a well-lit room. Your midwife or health visitor will also check for jaundice.

To test for jaundice, gently press your fingers on the tip of your child's nose or forehead. If the pressed skin goes white, your child does not have jaundice. If it‘s yellow,they may have jaundice.

You should see your doctor or midwife if:

  • your baby is jaundiced
  • your baby’s jaundice is getting worse
  • your baby’s faeces (stools) are chalky white
  • your baby has been jaundiced for over two weeks

Visual examination

A visual examination of your baby will be carried out to look for signs of jaundice. Your baby will need to be undressed during this so their skin can be looked at under good light. Other things that may also be checked include:

  • the whites of your baby’s eyes
  • your baby’s gums
  • the colour of your baby’s stools (faeces or 'poo')

Bilirubin test

If it's thought that your baby may have jaundice, the level of bilirubin (the yellow substance produced when red blood cells are broken down) in your baby’s blood will need to be tested. This can be done in two ways:

  • A transcutaneous bilirubinometer is a small device that beams light onto your baby’s skin. By analysing how the beams of light are reflected off the skin, or absorbed by the skin, the device calculates the level of bilirubin in the blood.
  • A serum bilirubin measurement can be obtained from a sample of blood, usually taken by pricking the heel of your baby’s foot with a needle. The level of bilirubin in the liquid part of the blood (the serum) is then measured.

Further tests

Some further tests may need to be carried out if your baby's jaundice lasts longer than two weeks, or if the jaundice requires treatment. The tests will help to determine whether there is another underlying cause for the raised levels of bilirubin.

Possible tests include:

  • finding out the baby’s blood group by testing a sample of their blood to see if their blood group is incompatible with their mother’s
  • a Coombs test, testing a sample of blood to detect antibodies (infection fighting chemicals) that may be attached to the surface of your baby’s red blood cells
  • finding out the packed cell volume of your baby’s blood – this tests the amount of cells that are in the blood
  • testing a sample of your baby’s blood, urine, or cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) for infections
  • testing for the enzyme glucose-6-phosphate dehydrogenase (G-6-PD) in a sample of your baby’s blood to see whether they have a G-6-PD deficiency
  • carrying out a full blood count on a sample of your baby’s blood – this involves a number of tests to check different parts of the blood

Antibodies are your body's natural defence against any foreign antigens that enter your blood. An antibody is a protein produced by the body to neutralise or destroy disease-carrying organisms and toxins.

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Enzymes are proteins that speed-up and control chemical reactions, such as digestion, in the body.

The liver is the largest organ in the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Treatment

You should see your doctor or midwife if your baby develops jaundice. They will be able to assess whether it needs to be treated.

If your baby develops jaundice within the first week of life, treatment is not usually necessary as long as your baby is healthy. Your doctor or midwife may monitor your baby by measuring the level of bilirubin in their blood.

If you are breastfeeding, you should continue to breastfeed your baby regularly, waking them up for feeds if necessary.

Jaundice usually disappears after 10 to 14 days, but it may last up to three weeks in premature babies (babies born before the 37th week of the pregnancy). In babies who are breastfed, 1 in 10 will still have jaundice when they are one month old.

Contact your midwife or doctor if:

  • your baby’s jaundice does not disappear after two weeks
  • the jaundice does not start until seven days after they are born
  • your baby’s faeces (stools) are chalky white

If your baby’s jaundice does not improve, or it is severe, they may be admitted to hospital and treated with:

  • phototherapy
  • an exchange transfusion

Phototherapy

Phototherapy is treatment with light. Phototherapy lowers the bilirubin levels in your baby’s blood by photo-oxidation. Oxidation is the process of adding oxygen to change a substance (in this case, the bilirubin).

The photo-oxidation converts the bilirubin into a substance that dissolves easily in water. This makes it easier for your baby’s liver to break down and remove the bilirubin from their blood.

There are two types of phototherapy.

  • Conventional phototherapy, where your baby is placed under a halogen or fluorescent lamp with their eyes covered to prevent damage to eyes.
  • Fibreoptic phototherapy, where your baby lies on a blanket that incorporates fibreoptic cables. Light travels through the fibreoptic cables and shines onto your baby’s back.

In both methods of phototherapy, the aim is to expose your baby’s skin to as much light as possible.

In most cases, conventional phototherapy is the first choice for treatment. However, if your baby was born prematurely, fibreoptic phototherapy may be used first.

If possible, the phototherapy will be stopped for 30 minutes every three to four hours so that you can feed your baby, change their nappy and give them a hug.

In more severe cases, phototherapy will not be stopped. Instead, your baby will be fed with a tube intravenously (through a vein) or orally (through their mouth).

The bilirubin levels will be tested every four to six hours after phototherapy has started. Once levels start to fall, they will be checked every 6-12 hours.

Phototherapy will be stopped when the bilirubin level is at a safe level. Most courses of phototherapy take around 1-2 days to complete.

Side effects of phototherapy

It is possible for your baby to become dehydrated (when the normal water content of their body is reduced) during phototherapy.

As your baby’s body expels the bilirubin, more water is lost through their skin, and more urine is produced.

Your baby may need to have intravenous hydration (where water is given into a vein) if they are not able to drink a sufficient amount.

Exchange transfusion

A blood transfusion, known as an exchange transfusion, will be considered if:

  • your baby has, or is at risk of, high levels of bilirubin in the blood (hyperbilirubinaemia)
  • your baby has hyperbilirubinaemia and phototherapy has not worked

Exchange transfusions have been used since the 1950s and are very effective. The transfusion normally takes place through a(a tube that is inserted into a vein.

During an exchange transfusion, some of your baby’s blood will be removed and replaced with blood from a suitable, matching donor (someone with the same blood group). As the new blood will not contain bilirubin, the overall level of bilirubin in your baby’s blood will fall.

Throughout the process, your baby will be monitored and any complications that arise will be treated.

Other treatments

If jaundice is caused by something else, such as an infection, this will usually be treated with medication or surgery.

If the jaundice is caused by Rhesus disease (when the mother has rhesus-negative blood and the baby has rhesus-positive blood), intravenous immunoglobulin (IVIG) may be used.

The immunoglobulin is a solution of antibodies (proteins produced by the body to destroy disease-carrying organisms) from healthy donors. It is injected into a vein (intravenous).

IVIG will only be used if phototherapy alone has not worked, and the level of bilirubin in the blood is continuing to rise.

Antibodies are your body's natural defence against any foreign antigens that enter your blood. An antibody is a protein that is produced by the body to neutralise or destroy disease-carrying organisms and toxins.

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

The liver is the largest organ in the body. Its main jobs are to secrete bile (to help digestion), detoxify the blood and change food into energy.

Oxygen is an odourless, colourless gas that makes up about 20% of the air we breathe.

The retina is the nerve tissue lining the back of the eye, which senses light and colour, and sends it to the brain as electrical impulses.

Complications

Kernicterus is a rare but serious complication of untreated jaundice in babies caused by excess bilirubin damaging the brain or central nervous system.

In newborn babies with very high levels of bilirubin in the blood (hyperbilirubinaemia), the bilirubin can cross the thin layer of tissue that separates the brain and the blood (the blood-brain barrier).

The bilirubin can damage the brain and spinal cord which can be life threatening.

Brain damage caused by high levels of bilirubin is also called bilirubin encephalopathy.

Your baby may be at risk of developing kernicterus if:

  • they have a very high level of bilirubin in their blood
  • the level of bilirubin in their blood is rising rapidly
  • they do not receive any treatment

Initial symptoms of kernicterus in babies include:

  • decreased awareness in the world around them – for example they may not make any reaction when you clap your hands in front of their face
  • their muscles become unusually floppy like a rag doll – this is known as hypotonia
  • poor feeding

As kernicterus progresses additional symptoms can include:

  • seizures (fits)
  • they begin arching their neck or their spine back, or in some cases, both

Treatment for kernicterus involves using an exchange transfusion as used in the treatment of newborn jaundice.

Although if significant brain damage has occurred a child can often develop long-term symptoms that will persist throughout their lifetime, such as:

  • cerebral palsy (a condition that affects the brain and nervous system) that causes both increased and decreased muscle tone, and affects your baby’s movement and coordination
  • hearing loss – which can range from mild to severe
  • learning difficulties – though this tends to be only mild to moderate
  • involuntary twitching of different parts of their body
  • problems maintaining normal eye movements; people affected by kernicterus have a tendency to gaze upwards or from side to side rather than straight ahead
  • the normal development of the teeth can be disrupted resulting in teeth that are misshapen, discoloured and vulnerable to tooth decay

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.

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