What you need to know about newborn jaundice

When Kara de Man looked into the eyes of her day-old son, Nick, she could see he was jaundiced. The whites of his eyes were cloudy yellow, and the skin on his nose and chest looked lightly bruised. A nurse determined Nick’s jaundice was mild by using a light meter on his forehead, but both mom and baby were kept in hospital for monitoring for four days.

“It was an emotional journey for us,” says the Saint John, NB, mom, who worried Nick wasn’t getting enough milk, as he lost weight and his yellow skin tone initially deepened (both of which are normal in newborn jaundice). Frequent feedings flush out the jaundice, but jaundiced babies are often sleepy and slow to eat.

“Feeding Nick was a two-person job those first few days,” says de Man. Her husband kept Nick awake by tickling and rubbing him with cold cloths while she compressed her breast. Under their nurses’ advice, the couple also held Nick by a sunny window, as exposure to natural light can help clear jaundice. When de Man’s milk came in on day four, Nick started gaining weight. Two weeks later, his skin was a healthy pink.

What causes jaundice? 

Dr. Carmela Sosa, MD, a pediatrician at Valley Children's Medical Group in Madera, California, explains that the term "jaundice" originates from the French word "jaune," meaning yellow. She states that jaundice indicates an underlying condition causing high bilirubin levels in the blood, which results in the yellow skin color and also colors stool.

The most common type of jaundice in newborns is indirect or unconjugated hyperbilirubinemia, according to Dr. Sousa. Several factors can cause elevated indirect bilirubin levels:

• Increased enterohepatic circulation (e.g., breastfeeding)
• Increased bilirubin production (e.g., maternal-fetal blood incompatibility)
• Decreased bilirubin clearance (e.g., genetic conditions like Gilbert syndrome)
• Conjugated hyperbilirubinemia, a more serious form, may indicate an underlying liver disease.

What are the symptoms of jaundice?

“The first signs of newborn jaundice are yellowing of the whites of the eyes, face, and inside the mouth," explains Dr. Sosa. "As a rule of thumb, the yellowing usually spreads downward from the head as the bilirubin levels rise.”

However, as levels increase to dangerous levels, Dr. Sosa warns that symptoms will become more concerning. “Infants may show signs of poor feeding, low muscle tone, lethargy, jitteriness, or a high-pitched cry,” she adds “At even higher levels, infants may become stiff, have seizures, or stop breathing.”

Fortunately, most jaundice is not harmful to infants and will resolve as the baby’s body matures enough to handle the bilirubin. “Most of these severe cases are preventable through early testing and intervention (see treatment),” adds Dr. Sosa.

How is newborn jaundice diagnosed? 

Newborn jaundice can be diagnosed through transcutaneous testing, which measures bilirubin levels by analyzing the wavelength of light reflected from the skin, or through blood testing, explains Dr. Sosa.

“The baby's healthcare provider will plot the results on a graph to determine if further testing or intervention is necessary,” she says. “If transcutaneous testing indicates elevated bilirubin levels above a specific threshold, a blood test is always required to confirm the results.”

Dr. Sosa emphasizes that conjugated hyperbilirubinemia requires further medical evaluation. Therefore, she recommends that the initial blood test checks for both conjugated and unconjugated bilirubin. “These values may be reported as total and direct bilirubin, where the indirect (unconjugated) bilirubin is calculated by subtracting the direct bilirubin from the total bilirubin,” she adds.

Will your baby have jaundice?

Newborn jaundice affects about three-quarters of preterm and half of full-term babies. It’s mild in most newborns and typically sets in a day after birth, peaks at four or five days, and then usually goes away on its own within a few days to a month.

“Parents get really worried about jaundice, because jaundice in an adult indicates severe illness,” says Karen Buhler, head of family practice at BC Women’s Hospital in Vancouver. “But jaundice is a normal part of the process of going from a fetus to a newborn.” Babies are born with extra red blood cells, and as the cells break down, a substance called bilirubin is produced. Some babies’ livers are not mature enough to efficiently expel bilirubin, which builds up in the blood and body tissues and causes skin and eyes to yellow.

Treatment 

About five percent of all babies need to be treated with phototherapy, which turns bilirubin into a harmless substance that easily passes through the body, instead of depositing in the brain, where it can cause nerve damage.

There are different kinds of phototherapy used in the hospital and at home. Newborns can be treated with a hand-held, blue light paddle, or wrapped in a “biliblanket,” a blanket with fibre optic cables that shine light on the skin. (Picture a bundled-up glow worm.)

Most commonly, babies with newborn jaundice are kept in hospital and put in an incubator under blue lights for a few days while their bilirubin levels are monitored.

Annie-Rae Pennington’s daughter, Jordan, was 12 days old and traffic-cone orange when she was readmitted to hospital suffering from severe jaundice, dehydration and starvation. Jordan was given an IV and went under the lights for three days, in only her diaper and eyeshades.

“I was a wreck. I wasn’t sleeping,” recalls Pennington, who lives in White Rock, BC.

She pumped milk, measured how much Jordan was drinking and weighed her diapers. Pennington struggled with the limited cuddle time, and the mommy guilt. In hindsight, she advises other parents to remember that a jaundiced baby is not your fault. “And it’s something that so many people go through,” she adds.

For some parents, the hardest part is not being able to hold their new baby all the time, says Buhler. “But jaundiced babies are only in the incubator for a short time, and they usually sleep really well in there,” she says. If your baby gets fussy, Buhler says, it’s probably a good sign—it means she’s getting better.

Does breastfeeding increase your risk of jaundice? 

Breastfeeding can increase the chances of jaundice in newborns. Dr. Sosa explains that this is because of colostrum, the first form of milk, which is a thick, yellow, and concentrated liquid produced by the breasts.

"Colostrum is packed with protective antibodies and other nutrients, but it is produced in very small amounts—about a teaspoon per feeding," she says. "As a result, breastfed infants might become dehydrated or experience delayed stool passage, which allows more time for bilirubin to be reabsorbed."

Fortunately, this issue gradually resolves as the mother's milk supply increases after 2 to 4 days, and as breastfeeding and stooling patterns become more regular.

Can you prevent jaundice?  

Dr. Sosa explains that while it isn't always possible to prevent newborn jaundice, one effective method to lower the risk is by providing frequent feedings during the initial hours and days of life.

“This is particularly true for parents who are breastfeeding, " she explains to Today’s Parent. “Feeding frequently helps babies stool, which in turn increases excretion of bilirubin through the intestinal tract by lessening the enterohepatic circulation of bilirubin.”

When to call a doctor

Should your newborn display the following signs, Dr. Sosa suggests reaching out to your healthcare provider immediately:

• Poor feeding or refusal of feeding
• Sleepy and not waking or unable to wake for feeds
• Has lost more than 10% of birth weight (easiest to calculate using grams)
• Arms and legs are yellow (remember: jaundice is first noticed on the face, and movies downward as the levels increase — it will similarly recede as levels decrease)
• Fever of 100.4 F (38.0C) or greater
• Always talk to a healthcare provider if your newborn develops jaundice in the first 24 hours of life

A version of this article appeared in our December 2012 issue, with the headline "Coping with Jaundice", p. 66

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