Jaundice is a yellow discoloration of the skin and whites of the eyes. Yellow discoloration of the whites of the eyes is also called scleral icterus.
Jaundice is caused by a buildup of bilirubin in the blood. The buildup of bilirubin in the blood is called hyperbilirubinemia.
Bilirubin is a yellow substance formed when hemoglobin (the part of red blood cells that carries oxygen) is broken down as part of the normal process of recycling old or damaged red blood cells.
Bilirubin is carried in the bloodstream to the liver and processed so that it can be excreted out of the liver as part of bile (the digestive fluid produced by the liver). Bilirubin processing in the liver involves attaching it to another chemical substance in a process called conjugation. Processed bilirubin in the bile is called conjugated bilirubin. Unprocessed bilirubin is called unconjugated bilirubin.
Bile is transported through the bile ducts into the beginning of the small intestine (duodenum). If bilirubin cannot be processed and excreted by the liver and bile ducts quickly enough, it builds up in the blood and causes hyperbilirubinemia. As bilirubin levels in the blood increase, the whites of the eyes often turn yellow first, followed by the skin. Slightly more than half of all newborns have jaundice that can be seen in the first week of life. However, jaundice may be hard to see, especially in newborns with dark skin.
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During the first week of life, most newborns develop some unconjugated (unprocessed) hyperbilirubinemia, which often causes jaundice that normally resolves within a week or two. Other causes can contribute to jaundice in newborns as well. Jaundice is even more common among premature infants because their liver, feeding patterns, and stooling patterns and way their body processes red blood cells are not fully mature.
(See also Jaundice in Adults.)
Complications of jaundice
Whether jaundice is dangerous depends on several factors:
What causes the jaundice
How high the bilirubin level is
Whether the bilirubin is conjugated or unconjugated
Some disorders that cause jaundice, such as infections and biliary atresia, are dangerous no matter what the bilirubin level is. In the most common causes of jaundice in the newborn, however, it is the level of unconjugated bilirubin in the blood that determines the level of danger.
Extremely high levels of unconjugated bilirubin are dangerous regardless of the cause. The most serious consequence of high unconjugated bilirubin levels is bilirubin encephalopathy.
Bilirubin encephalopathy refers to the toxic effects of bilirubin on the brain. It may lead to developmental delay, cerebral palsy, hearing loss, and seizures and may be fatal.
Acute bilirubin encephalopathy is when bilirubin accumulates and starts to have toxic effects on the brain. It causes sluggishness or irritability, abnormal muscle tone or muscle contractions, poor feeding, a high-pitched cry, and sometimes seizures. Acute bilirubin encephalopathy is potentially reversible if it is treated rapidly; If untreated, acute bilirubin encephalopathy leads to chronic bilirubin encephalopathy (also called kernicterus), which is brain injury and permanent brain damage due to accumulation of bilirubin in the brain. The risk of this disorder is higher for newborns who are premature, who are seriously ill, or who are given certain medications. Although now rare, chronic bilirubin encephalopathy still occurs, but it can nearly always be prevented by early diagnosis and treatment of hyperbilirubinemia. Once brain injury has occurred, there is no treatment to reverse it.
Causes of Jaundice in Newborns
Common causes of jaundice
Some of the most common causes of jaundice in the newborn include the following:
Physiologic hyperbilirubinemia
Breastfeeding (chestfeeding) jaundice
Breast milk (human milk) jaundice
Excessive breakdown of red blood cells (hemolysis)
Physiologic hyperbilirubinemia occurs for 2 reasons. First, the red blood cells in newborns break down faster than in older infants, resulting in increased bilirubin production. Second, the newborn's liver is immature and cannot process bilirubin and get it out of the body as well as in older infants.
Almost all newborns have physiologic hyperbilirubinemia. It typically appears 2 to 3 days after birth (jaundice that appears in the first 24 hours after birth may be due to a serious disorder). Physiologic hyperbilirubinemia usually does not cause other symptoms and resolves within 1 week. If the infant still has jaundice at 2 weeks of age, doctors evaluate the infant for other causes.
Breastfeeding jaundice develops in some breastfed newborns in the first few days of life and typically resolves in the first week. It occurs in newborns who do not consume enough human milk, for example, when their mother's milk has not yet come in well. Such newborns have fewer bowel movements and thus eliminate less bilirubin. As newborns continue to breastfeed and consume more milk, the jaundice goes away on its own.
Human milk jaundice differs from breastfeeding jaundice in that it occurs towards the end of the first week of life and may resolve by 2 weeks of age or persist for several months. Human milk jaundice is caused by substances in the milk that interfere with a newborn's ability to process and excrete bilirubin out of the liver.
Excessive breakdown of red blood cells (hemolysis) can overwhelm the newborn's liver with more bilirubin than it can process. (A reduced red blood cell count due to hemolysis is called hemolytic anemia.) There are several causes of hemolysis, which are categorized by whether they are caused by an:
Immune disorder
Nonimmune disorder
Immune disorders cause hemolysis when there is an antibody in the infant's blood that attacks and destroys the infant's red blood cells. This destruction can occur when the fetus's blood type is not a match (incompatible) with the mother's (see also Rh incompatibility).
Nonimmune disorders that cause hemolysis include hereditary deficiency of the red blood cell enzyme glucose-6-phosphate dehydrogenase (G6PD deficiency) and hereditary red blood cell disorders such as alpha-thalassemia and sickle cell disease.
Newborns who were injured during birth sometimes have a collection of blood (hematoma) under their skin. When the blood in the hematoma breaks down, it may cause jaundice. Infants born to a mother with diabetes may get excess blood from the placenta. The breakdown of this blood can also cause jaundice. Breakdown of transfused blood cells can cause increased bilirubin.
Other causes of jaundice in newborns
Other causes of jaundice include the following:
Severe infections, including sepsis
An underactive pituitary gland (hypopituitarism)
An underactive thyroid gland (hypothyroidism)
Certain hereditary disorders
Obstruction of bile flow from the liver
Some of these causes involve cholestasis, which is a reduction in bile flow that causes conjugated hyperbilirubinemia. Hypothyroidism interferes with the processing (conjugation) of bilirubin. Sepsis may cause both cholestasis and hemolysis.
A urinary tract infection (UTI) without sepsis acquired during or shortly after birth can cause jaundice. Infections acquired by the fetus in the womb are sometimes the cause. Such infections include toxoplasmosis and infections with cytomegalovirus or the herpes simplex or rubella viruses.
Some hereditary disorders that can cause jaundice include cystic fibrosis, Dubin-Johnson syndrome, Rotor syndrome, Crigler-Najjar syndrome, and Gilbert syndrome.
Bile flow may be reduced or blocked because of a birth defect of the bile ducts such as biliary atresia or because a disorder such as cystic fibrosis damages the liver.
Evaluation of Jaundice in Newborns
While newborns are in the hospital, doctors periodically check them for jaundice. Jaundice is sometimes obvious by the color of the whites of the newborn's eyes or skin. But most doctors also measure the newborn's bilirubin level before discharge from the hospital. If the newborn has jaundice, doctors focus on determining whether it is physiologic and, if not, focus on identifying the cause so that any dangerous causes can be treated. Newborns who have jaundice that lasts more than 2 weeks need to be evaluated by doctors because they may have a serious disorder.
Warning signs
In newborns, the following symptoms are cause for concern:
Jaundice that appears on the first day of life
Jaundice that appears for the first time in newborns over 2 weeks old
Sluggishness, poor feeding, irritability, and difficulty breathing
A fever
Doctors are also concerned when bilirubin levels are very high or are increasing rapidly or when blood tests suggest that the flow of bile is reduced or blocked.
When to see a doctor
Newborns with warning signs should be evaluated by a doctor right away. If the newborn is discharged from the hospital on the first day after birth, a follow-up visit to measure the bilirubin level should done within 2 days of discharge.
Once at home, if parents notice that their newborn’s skin or eyes look yellow, they should contact their doctor immediately. The doctor can decide how urgently to evaluate the newborn based on whether the newborn has any symptoms or risk factors such as prematurity.
What the doctor does
Doctors first ask questions about the newborn’s symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done.
Doctors ask when the jaundice started, how long has it been present, and whether the newborn has other symptoms such as sluggishness and poor feeding. Doctors ask what, how much, and how often the newborn is being fed. They ask how well the newborn is latching onto the breast or taking the nipple of the bottle, whether the mother feels that her milk has come in, and whether the newborn is swallowing during feedings and seems satisfied after feedings.
Doctors also ask about stool color. Information about how much urine and stool the newborn produces can help doctors evaluate whether the newborn is being fed enough. Stool that is pale and not the normal yellow-gold color suggests the newborn may have cholestasis.
Doctors ask the mother whether she had infections or disorders during pregnancy (such as diabetes) that can cause jaundice in the newborn, what her blood type is, and what medications she has been taking. They also ask whether family members have had any of the hereditary disorders that can cause jaundice.
During the physical examination, doctors check the newborn's skin to see how far jaundice has progressed down the body (the lower down on the body that jaundice is visible, the higher the bilirubin level). They also look for other clues suggesting a cause, particularly signs of infection, injury, thyroid disease, or problems with the pituitary gland.
Testing
Bilirubin levels are measured to confirm the diagnosis of jaundice, and tests are done to determine whether elevated bilirubin, if present, is conjugated or unconjugated. Levels may be measured in a sample of blood or by using a sensor placed on the skin (bilirubinometer).
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If the bilirubin level is high, other blood tests are done. They typically include the following:
Hematocrit or blood count (the percentage or amount of red blood cells in blood)
Examination of a blood sample under a microscope to look for signs of red blood cell breakdown
Reticulocyte count (the number of newly formed red blood cells)
Direct Coombs test (which checks for certain antibodies attached to red blood cells)
Measurement of different types of bilirubin
Blood type and Rh status (positive or negative) of the newborn and mother
Other tests may be done depending on results of the history and physical examination and on the newborn's bilirubin level. They may include culturing samples of blood, urine, or cerebrospinal fluid to check for infection, measuring levels of red blood cell enzymes to check for unusual causes of red blood cell breakdown, doing blood tests of thyroid and pituitary function, and doing tests for liver disease.
Treatment of Jaundice in Newborns
When a disorder is identified, it is treated if possible. In general, dehydrated infants need more fluid, which is usually supplied through increased feedings but sometimes through a vein (intravenously). A high bilirubin level may also require specific treatments to reduce the bilirubin level.
Physiologic hyperbilirubinemia usually does not require treatment and resolves within 1 week. For newborns being fed formula or human milk, frequent feedings can help prevent jaundice or reduce its severity. Frequent feedings increase the frequency of bowel movements and thus eliminate more bilirubin in stool. The type of formula does not seem to matter.
Breastfeeding jaundice may also be prevented or reduced by increasing the frequency of feedings. If the bilirubin level continues to increase, infants may need to be temporarily switched to formula.
In breast milk jaundice, mothers may be advised to stop breastfeeding for only 1 or 2 days and give their newborn formula and to express milk regularly during this break from breastfeeding to keep their milk supply up. Then they can resume breastfeeding as soon as the newborn's bilirubin level starts to decrease. While breastfeeding, mothers are usually advised not to give the newborn water or water containing sugar because doing so may decrease how much milk the newborn drinks and may disrupt the mother's milk production. However, breastfed infants who are dehydrated despite efforts to increase breastfeeding may need additional fluids.
High unconjugated bilirubin levels may be treated with:
Exposure to a special light (phototherapy)
Exchange transfusion
Phototherapy or "bili lights"
Phototherapy uses bright light to change bilirubin that has not been processed by the liver into a form that can be eliminated rapidly from the body by excretion in the urine. White light is used most often, and most doctors use special commercial phototherapy units.
Newborns are placed under the lights and are undressed to expose as much skin as possible. They are turned frequently and left under the lights for variable periods of time (typically about 2 days to a week) depending on how much the bilirubin levels in the blood need to be lowered. Phototherapy can help prevent chronic bilirubin encephalopathy.
To determine how well the treatment is working, doctors periodically measure bilirubin levels in blood. The color of the newborn's skin (or whichever parts of the newborn have jaundice) is not a reliable enough guide.
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This treatment is not used for all types of hyperbilirubinemia. For example, phototherapy is not used for jaundice caused by cholestasis.
Exchange transfusion
This treatment is sometimes used when unconjugated bilirubin levels are very high and phototherapy is not sufficiently effective or if the newborn has any signs of bilirubin encephalopathy.
An exchange transfusion can rapidly remove bilirubin from the bloodstream. A small amount of the newborn's blood is gradually removed (1 syringe at a time) and replaced with (exchanged for) an equal volume of donor blood. The procedure usually takes about 2 to 4 hours. Exchange transfusion may also remove antibodies against red blood cells if the hyperbilirubinemia is due to blood type mismatch between mother and infant.
Exchange transfusions may need to be repeated if bilirubin levels remain high. Also, the procedure has risks and complications, such as heart and breathing problems, blood clots, and electrolyte imbalances in the blood.
The need for exchange transfusion has decreased since phototherapy has become so effective and since doctors have become better able to prevent problems resulting from incompatible blood types.
Key Points
In many newborns, jaundice develops 2 or 3 days after birth and disappears on its own within a week.
Whether jaundice is of concern depends on what is causing it and how high the bilirubin levels are.
Jaundice may result from serious disorders, such as incompatibility of the newborn’s and mother’s blood, excessive breakdown of red blood cells, or a severe infection.
If jaundice develops in a newborn at home, parents should call their doctor right away.
If jaundice is caused by a specific disorder, that disorder is treated.
If high bilirubin levels require treatment, infants are typically treated with phototherapy and rarely with exchange transfusions.
