Complications: Neonatal Hyperbilirubinemia (AKA, Newborn Jaundice)
Newborn jaundice is a common condition that causes a noticeable yellowing of the sclera (white part of eyes) and skin in 65% of babies in their first week of life. It is caused by the accumulation of bilirubin in the bloodstream.1 Jaundice is more common in babies born before the 38th week of pregnancy.
Jaundice is noticeable on the baby’s face first, followed by the chest, abdomen, arms, and legs. It is possible to check to see if the baby is jaundiced by gently pressing one finger or his/her nose or forehead. If the skin is jaundiced, the area will have a yellowish appearance when the finger is removed from the skin.
What is jaundice, anyway?
Bilirubin is produced by the normal breakdown (or hemolysis) of red blood cells in the newborn’s reticuloendothelial system and bone marrow. The bilirubin attaches to albumin and carried to the baby’s liver. Once it reaches the liver, it is absorbed by liver cells (hepatocytes).
Before birth, the removal of bilirubin from baby’s body is handled by the placenta. Newborns have a higher number of red blood cells. These blood cells have a shorter life span, so they are replaced more frequently. This results in more bilirubin being produced when these red blood cells are broken down. In addition, the newborn baby’s liver is not totally mature, therefore, it takes longer to be cleared from the body.1
In addition to the liver being immature, a newborn does not have the normal amount of what is called “gut flora.” Also, the process of moving substances through the intestines is slower in newborns, causing bilirubin to remain in the intestines longer (stasis). When the bilirubin remains in the intestines for a long period, it is reabsorbed by the intestinal cells and sent back to baby’s liver. The extra amount of bilirubin results in hyperbilirubinemia.
Different types of jaundice
There are four main categories of jaundice that your new baby may develop:
- Physiological jaundice, the most common type, appears between baby’s 2nd and 4th day of life and disappears by the time baby is two weeks old. It occurs in both breast-fed and bottle-fed babies.
- Jaundice associated with prematurity is relatively common in babies born before the 38th week of pregnancy. It occurs as a result of the liver and intestinal tract being less mature than a full-term baby’s, and therefore less prepared to handle the bilirubin.
- Jaundice associated with breastfeeding (known as early jaundice, and “lack of milk jaundice”) occurs when baby is not receiving enough breast milk. It may be due to difficulty breastfeeding, or the supply of breastmilk is not yet enough to keep baby hydrated (milk supply will increase when Mom’s milk “comes in”). It is also related to how often baby has a bowel movement.
- Breastmilk jaundice, also known as “late-onset” jaundice, occurs when baby’s bilirubin levels climb after his/her 3rd day of life until 2 weeks of age. It is caused by specific factors that are present in breast milk after Mom’s milk has “come in” that affect how bilirubin is processed and removed from baby’s body.
There is one other cause of jaundice that we need to address: ABO blood group incompatibility. Also called Antibody-mediated hemolysis, may occur when Mom has type O blood and the baby has either type A or B blood. The mother with type O blood has naturally-occurring antibodies (anti-A, or anti B IgG antibodies) that recognize the baby’s type A or B blood as being foreign, or different. These antibodies pass through the placenta to the baby and break down (hemolysis) some of the baby’s red blood cells, which increases the amount of bilirubin produced in the baby’s body.
After a baby is born, the umbilical cord is clamped and cut, a sample of blood from the cord is collected and sent to the lab for testing. This testing will determine baby’s blood type. A Coombs test will also be performed on the cord blood. A positive Coombs test means that baby is more likely to develop hyperbilirubinemia (jaundice).
Risk factors for your baby developing jaundice
There are certain factors that could put your baby at a higher risk for developing jaundice. We’ve grouped them into three categories, so you can check for yourself whether or not you should spend some extra time with your doctor discussing these risks, and what steps you should take if your baby exhibits the signs of jaundice.
Higher risk factors:
- Baby looks jaundiced before he/she is 24 hours old
- Transcutaneous bilirubin levels are high
- Has a positive Coombs test
- Born between the 35th and 36th week of pregnancy
- Has an older brother or sister that required phototherapy for jaundice
- Baby is receiving only breast milk and loses more weight that considered to be normal
- Baby suffered bruising, or a cephalohematoma during the delivery process
- Inherited cause of red blood cell breakdown
- Being of Asian descent
Lower risk factors:
- Babies born between the 37th and 38th week of pregnancy
- Older brother or sister with jaundice but did not require phototherapy
- Baby looks jaundiced before discharge from the hospital
- Baby is big (macrosomia) and mom is a diabetic
- Baby’s transcutaneous bilirubin levels are slightly higher than normal
Lowest risk factors:
- Transcutaneous bilirubin levels are low
- Born at or after the 41st week of pregnancy
- Bottle fed
- Discharged from the hospital after 72 hours of age
- Being of African-American descent
If your child is diagnosed with jaundice, there are treatments available to help him/her. The treatment that is recommended to you depends on how high baby’s bilirubin level is, how fast it is rising, the baby’s age as well as gestational age.
Treatment One: Phototherapy (Bilirubin Lights)
When baby’s bilirubin levels reach a certain level, or that are climbing rapidly, phototherapy is usually started.
The ultraviolet lights help to break down the bilirubin in baby’s body. Wearing only a diaper, baby will be placed in a warm, enclosed bed with eye patches to protect the eyes from damage from the lights. The unconjugated bilirubin in baby’s skin absorbs the light. After being absorbed by the light, the bilirubin becomes water-soluble, making it capable of being eliminated from baby’s body through his/her bowel movements.
While baby is under phototherapy, his/her bilirubin levels will be checked. How often this occurs depends on factors such as how high the levels are and age of baby. The bilirubin levels are checked by testing a small amount of blood taken by a heel stick.
Treatment Two: Bilirubin Blanket
In addition to phototherapy, a bilirubin blanket may also be used. If the bilirubin levels are elevated, but not high enough that baby requires phototherapy under the standard lights, a “bili blanket” may be used alone. The blanket is made of woven fiber optic pads. It is placed directly next to baby’s skin with blankets or clothing over it.
The light from a bili blanket is not as strong as standard phototherapy, therefore, your baby may need to wear the blanket for a longer period of time. When baby is taken out of the heated, enclosed crib for feedings, the bili blanket remains next to baby’s back, secured by a blanket.
Your baby may be discharged from the hospital with a bilirubin blanket. A nurse will deliver the blanket to your home and instruct you on how to use it. It is very important that the blanket remains in contact with baby.
Baby’s bilirubin levels will be checked at an outpatient lab. Baby’s pediatrician will instruct you when to have them checked.
Treatment Three: Exchange Transfusion
An exchange transfusion involves replacing the baby’s blood with donated blood to lower the amount of bilirubin quickly. This is done when a baby’s bilirubin levels have not decreased with phototherapy, or baby is at risk for bilirubin toxicity.
Risks associated with newborn jaundice
As with any condition, there are serious risks to your baby or she develops jaundice. They include:
Bilirubin toxicity is caused by what is called unconjugated bilirubin anion. This anion attaches to the surface of the cells, causing the surface to become weak, which allows the bilirubin anions to enter the cells.
The exact levels of unconjugated bilirubin capable of destroying the cells is unknown. The risk of bilirubin toxicity depends on the concentration (amount) of albumin in baby’s blood, how long the bilirubin levels have been elevated, and the overall health of the baby. Premature babies have a higher risk of bilirubin toxicity because they do not have as much albumin in their bloodstreams as full-term babies do.
Acute bilirubin encephalopathy
Acute bilirubin encephalopathy refers to the signs and symptoms that develop when bilirubin enters the cells in baby’s brain. If the baby is treated early, the damage is reversible. It is caused by the destruction of brain cells by the bilirubin ions. One early sign is that your baby is very sleepy and isn’t interested in nursing or taking formula from a bottle.
Additional signs or symptoms may include:
- Baby is very fussy and has a high-pitched cry
- Arching of the neck
- Baby has periods of apnea
The term kernicterus (chronic bilirubin encephalopathy) refers to permanent damage to the brain as a result of toxic bilirubin levels. In these cases, the bilirubin anions have disabled the cells ability to create energy needed for survival, causing the cells to die. Infants and children that suffer from kernicterus often have:
- Choreoathetoid cerebral palsy (Extrapyramidial movement disorders)
- An abnormal gaze
- Dysplasia (abnormal) enamel of the deciduous (baby) teeth
Most newborns are discharged from the hospital between 24 and 48 hours of age. This is before the peak time period for jaundice, and before mom’s milk supply has been established. For this reason, baby’s bilirubin levels should be measured by a transcutaneous bilirubin procedure. Also, risk factors that baby has should be reviewed. The more risk factors that are present, the greater the risk that jaundice will develop.
The American Academy of Pediatrics recommends that babies that are discharged from the hospital before they are 72 hours of age be seen by the pediatrician within 24 to 48 hours following discharge.
A final word about breastfeeding and jaundice
Hyperbilirubinemia in babies can be decreased or avoided by breastfeeding soon after baby is born. This will increase the activity in baby’s intestines, causing bilirubin to leave his/her body sooner in the stools. Breastfeeding baby frequently (every 2 to 3 hours) will help clear extra bilirubin in the stool. It also helps with mom’s milk production. The more breastmilk baby receives, the risk of high bilirubin levels decreases.
The American Academy of Pediatrics recommends that you continue to breastfeed your baby whenever possible. If baby isn’t getting enough breastmilk (if he or she shows signs of dehydration, or has lost more weight than normal), they suggest supplementing with either expressed breastmilk or formula.
Babies that nurse more than eight times in a 24-hour period during the first three days of life tend to have lower bilirubin levels. The researchers recommend frequent breastfeeding (every 2 to 3 hours) and baby be placed under intensive phototherapy. Frequent breastfeeding for short periods of time are better than less-frequent longer feedings.2
If your baby is jaundiced and being breastfed, the nursing staff will closely monitor his/her diapers. The amount of urine baby is voiding is calculated by weighing the diapers. They will ask you to keep a detailed record of how long, and how often baby nurses.
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- Smith, D., & Grover, T. (2016). The Newborn Infant. In Hay, W., Jr., Levin, M., Deterding, R., Abzug, M. (Eds.). CURRENT diagnosis & treatment Pediatrics. New York, NY: McGraw-Hill
- Lawrence, R. (2011). Breastfeeding. A guide for the medical professional (7th ed.). Philadelphia, PA: Saunders