Infantile Jaundice

1 What is Infantile Jaundice?

Infantile Jaundice, a common condition in newborns, refers to the yellow color of the skin and whites of the eyes that happens when there is too much bilirubin in the blood.

Bilirubin is produced by the normal breakdown of red blood cells. Normally, it passes through the liver, which releases it into the intestines as bile (a liquid that helps with digestion).

Jaundice happens when bilirubin builds up faster than a newborn's liver can break it down and pass it from the body. Some of the causes of excess bilirubin include:

  • Newborns make more bilirubin than adults do since they have more turnovers of red blood cells.
  • A newborn baby's still-developing liver might not be able to remove enough bilirubin from the blood.
  • A baby's intestines absorb bilirubin that would normally leave the body in the stool.

Severe jaundice (when levels of bilirubin are high, usually above 25 mg) that is not treated can cause deafness, cerebral palsy, or other forms of brain damage. In rare cases, jaundice may be a sign of of another condition, such as an infection or a thyroid problem.

Doctors recommend that all infants be checked for jaundice within a few days of birth.

Types of Jaundice

The most common types of jaundice are:

  • Physiological (normal) jaundice: Most newborns have this mild jaundice because their liver is still maturing. It often appears when a baby 2 to 4 days old and disappears by 1 to 2 weeks of age.
  • Jaundice of prematurity: This is common in premature babies since their bodies are even less ready to excrete bilirubin effectively. To avoid complications, they'll be treated even when their bilirubin levels are lower than those of full-term babies with normal jaundice.
  • Breastfeeding jaundice: Jaundice can happen when breastfeeding babies don't get enough breast milk due to difficulty with breastfeeding or because the mother's milk isn't in yet. This is not caused by a problem with the breast milk itself, but by the baby not getting enough of it. If a baby has this type of jaundice, it's important to involve a lactation (breastfeeding) consultant.
  • Breast milk jaundice: In 1% to 2% of breastfed babies, jaundice is caused by substances in breast milk that can make the bilirubin level rise. These can prevent the excretion of bilirubin through the intestines. It starts after the first 3 to 5 days and slowly improves over 3 to 12 weeks.
  • Blood group incompatibility (Rh or ABO problems): If a mother and baby have different blood types, the mother's body might produce antibodies that destroy the infant's red blood cells. This creates a sudden buildup of bilirubin in the baby's blood. Incompatibility jaundice can begin as early as the first day of life. Rh problems once caused the most severe form of jaundice, but now can be prevented by giving the mother Rh immune-globulin injections.

Severe newborn jaundice may occur if the baby has a condition that increases the number of red blood cells that need to be replaced in the body, such as:

  • Abnormal blood cell shapes
  • Blood type mismatch between the mother and baby
  • Bleeding underneath the scalp (cephalo hematoma) caused by a difficult delivery
  • Higher levels of red blood cells, which is more common in small-for-gestational-age babies and some twins
  • Infection
  • Lack (deficiency) of certain important proteins, called enzymes

Things that make it harder for the baby's body to remove bilirubin may also lead to more severe jaundice, including:

  • Certain medicines
  • Infections present at birth, such as rubella, syphilis, and others
  • Diseases that affect the liver or biliary tract, such as cystic fibrosis or hepatitis
  • Low oxygen level (hypoxia)
  • Infections (sepsis)
  • Many different genetic or inherited disorders

2 Symptoms

Yellowing first on the face, then the chest and stomach, and finally, the legs are the main symptoms of infantile jaundice. Jaundice usually appears around the second or third day of life. It can also make the whites of a baby's eyes look yellow.

Most newborns now go home from the hospital 1 or 2 days after birth, so it's important for their doctors to check them for jaundice 1 to 2 days later.

Parents also should watch their baby for jaundice. Jaundice can be hard to see, especially in babies with dark skin. If you're unsure, gently press the skin on your baby's nose or forehead — if jaundice is present, the skin will appear yellow when you lift your finger.

The baby's urine may be darker instead of colourless, and their poo may be paler than normal.

Sometimes, infants with significant jaundice have extreme tiredness and poor feeding.

Signs of worsening jaundice — call your child's healthcare provider if you notice any of the following:

  • If the yellow coloring is at the knee or lower, if the yellow color is more intense (lemon yellow to orange yellow), or if the "whites" of the eyes appear yellow
  • If the baby has any difficulty in feeding
  • If it is hard to wake up your infant
  • If your infant is irritable and is difficult to console
  • If your infant arches his/her neck or body backwards
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3 Causes

Jaundice is caused when your baby's body has more bilirubin than it can get rid of.

It is normal for a baby's bilirubin level to be a bit higher after birth.

When the baby is growing in the mother's womb, the placenta removes bilirubin from the baby's body. The placenta is the organ that grows during pregnancy to feed the baby. After birth, the baby's liver starts doing this job. This can take a while.

Most newborns have some yellowing of the skin, or jaundice. This is called “physiological jaundice." It is harmless, and usually is worst when the baby is 2 - 4 days old. It goes away within 2 weeks and doesn't usually cause a problem.

Two types of jaundice may occur in newborns that are breast fed. Both types are usually harmless.

  • Breastfeeding jaundice is seen in breastfed babies during the first week of life, especially in babies who do not nurse well or if the mother's milk is slow to come in.
  • Breast milk jaundice may appear in some healthy, breastfed babies after day 7 of life. It usually peaks during weeks 2 and 3. It may last at low levels for a month or more. It may be due to how substances in the breast milk affect how bilirubin breaks down in the liver. Breast milk jaundice is different than breastfeeding jaundice.

Severe newborn jaundice may occur if your baby has a condition that increases the number of red blood cells that need to be replaced in the body, such as:

  • Abnormal blood cell shapes
  • Blood type mismatch between the mother and the baby
  • Bleeding underneath the scalp (cephalo hematoma) caused by a difficult delivery
  • Higher levels of red blood cells, which is more common in small-for-gestational-age babies and some twins
  • Infection
  • Lack (deficiency) of certain important proteins, called enzymes

Things that make it harder for the baby's body to remove bilirubin may also lead to more severe jaundice, including:

  • Certain medications
  • Congenital infections, such as rubella, syphilis, and others
  • Diseases that affect the liver or biliary tract, such as cystic fibrosis or hepatitis
  • Low oxygen level (hypoxia)
  • Infections (such as sepsis)
  • Many different genetic or inherited disorders

Babies who are born too early (premature) are more likely to develop jaundice than full-term babies.

4 Making a Diagnosis

Doctors and nurses will be able to diagnose infantile jaundice at the hospital upon birth.

Doctors, nurses, and family members will watch for signs of jaundice at the hospital, and after the newborn go home.

Any infant who appears jaundiced should have bilirubin levels measured right away. This can be done with a blood test.

Many hospitals check total bilirubin levels on all babies at about 24 hours of age. Hospitals use probes that can estimate the bilirubin level just by touching the skin. High readings need to be confirmed with blood tests.

Tests that will likely be done include:

Further testing may be needed for babies who need treatment or whose total bilirubin levels are rising more quickly than expected.

5 Treatment

The goal of infantile jaundice treatment is to quickly and safely reduce the level of bilirubin. Infants with mild jaundice may need no treatment. Infants with higher bilirubin levels or hyperbilirubinemia will require treatment.

Jaundice is common in premature infants (those born before 38 weeks of gestation). Premature infants are at greater risk for hyperbilirubinemia because brain toxicity occurs at lower levels of bilirubin than in term infants. As a result, premature infants are treated at lower levels of bilirubin, but with the same treatments discussed here.

Encourage feeding

— Providing adequate breast milk or formula is an important part of preventing and treating jaundice because it promotes elimination of the yellow pigment in stools and urine. You will know that your child is getting enough milk or formula if s/he has at least six wet diapers per day, the color of the bowel movements changes from dark green to yellow, and she seems satisfied after feeding.

Phototherapy

— Phototherapy ("light" therapy) is the most common medical treatment for jaundice in newborns. In most cases, phototherapy is the only treatment required. It consists of exposing an infant's skin to blue light, which breaks bilirubin down into parts that are easier to eliminate in the stool and urine. Treatment with phototherapy using special blue lights, such as blue light-emitting diodes (LEDs), is successful for almost all infants.

Phototherapy is usually done in the hospital, but in select cases, it can be done in the home if the baby is healthy and at low risk for complications.

Infants undergoing phototherapy should have as much skin exposed to the light as possible. Infants are usually naked (or wearing only a diaper) in an open bassinet or warmer, but wear eye patches to protect the eyes. It is important to ensure that the lamps do not generate excessive heat, which could burn an infant's skin. In some institutions, phototherapy blankets are used. Phototherapy should be continuous, with breaks only for feeding.

Exposure to sunlight was previously thought to be helpful, but is not currently recommended due to the risk of sunburn. Sunburn does not occur with the lights used in phototherapy when used properly.

Phototherapy is stopped when bilirubin levels decline to a safe level. It is not unusual for infants to still appear jaundiced after phototherapy is completed. Bilirubin levels may rebound 18 to 24 hours after stopping phototherapy, although this rarely requires further treatment.

Side effects

– Phototherapy is very safe, but it can have temporary side effects, including a skin rash and loose bowel movements. Overheating and dehydration can occur if the infant does not get enough breast milk or formula. Therefore, the infant's skin color, body temperature, and number of wet diapers are closely monitored.

  • Rarely, some infants will develop ""bronze baby"" syndrome, a dark, grayish-brown discoloration of the skin and urine. Bronze baby syndrome is not harmful and gradually resolves without treatment after several weeks.
  • Hydration – It is important for infants receiving phototherapy to drink adequate fluids (breast milk or a supplement) since bilirubin is excreted in urine and bowel movements. Breast- or bottle-feeding should continue during phototherapy. Use of oral glucose water is not necessary. In some babies with severe dehydration, intravenous fluids may be necessary.
  • Breastfeeding – Breastfed infants who are not able to consume enough breast milk, whose weight loss is excessive, or who are dehydrated may need extra expressed breast milk or other milk supplements. Mothers who supplement should continue to breastfeed and/or pump to maintain their milk supply.

There is some controversy about the practice of using cow milk or soy formula to exclusively breastfed infants. Parents should discuss these issues with the child's doctor.

Exchange transfusion

— Exchange transfusion is a procedure that is done urgently to prevent or minimize bilirubin-related brain damage. The transfusion replaces an infant's blood with donated blood in an attempt to quickly lower bilirubin levels. Exchange transfusion may be performed in infants who have not responded to other treatments and who have signs of or are at significant neurologic risk of bilirubin toxicity.

6 Prevention

In newborns, some degree of jaundice is normal and probably not preventable. The risk of significant jaundice can often be reduced by feeding babies at least 8 to 12 times a day for the first several days and by carefully identifying infants at highest risk.

All pregnant women should be tested for blood type and unusual antibodies. If the mother is Rh negative, follow-up testing on the infant's cord is recommended. This may also be done if the mother's blood type is O+, but it is not needed if careful monitoring takes place.

Careful monitoring of all babies during the first 5 days of life can prevent most complications of jaundice. Ideally, this includes:

  • Considering a baby's risk for jaundice
  • Checking bilirubin level in the first day or so
  • Scheduling at least one follow-up visit the first week of life for babies sent home from the hospital in 72 hours

7 Risks and Complications

There are several risks and complications associated with infantile jaundice.

The effects of bilirubin toxicity are often devastating and irreversible. Early signs of kernicterus are subtle and nonspecific, typically appearing three to four days after birth. However, hyperbilirubinemia may lead to kernicterus at any time during the neonatal period.

After the first week of life, the affected newborn begins to demonstrate late effects of bilirubin toxicity. If the infant survives the initial severe neurologic insult, chronic bilirubin encephalopathy (evident by three years of age) leads to developmental and motor delays, sensorineural deafness, and mild mental retardation.

Early effects of bilirubin toxicity in newborn include:

  • Lethargy
  • Poor feeding
  • High pitched cry
  • Hypotonia

Late features include:

Chronic complications are:

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