Articles >> Postpartum >> Jaundice in Newborns

Jaundice in Newborns

During pregnancy, many expectant parents worry about the health of their unborn babies. The initial relief of finding that the baby has all its fingers and toes enables parents to relax and confirms the image of a healthy child. This image, however, is often disrupted by the diagnosis of jaundice, or hyperbilirubinemia, on about the third day of life. Few parents understand that jaundice is not an illness: it merely indicates the presence of relatively high amounts of bilirubin (a bile pigment) in the baby’s blood.

All newborn babies are breaking down red blood cells at relatively high rate. One of the by-products of this process is bilirubin. Bilirubin is eliminated by being “conjugated” (joined to glucuronic acid) by the liver and excreted by the bowels. In newborn babies, immature livers may not take up and conjugate the bilirubin expeditiously: in addition, infrequent bowel movements allow the bilirubin in the lower intestine to be reabsorbed into the blood.

Since all babies experience high levels of bilirubin, it can be considered to be normal and healthy. However, excessively high amounts of bilirubin can cross the blood-brain barrier, where it may cause neurological damage, hearing loss, and even seizures and death. The difficulty comes in differentiating between normal (physiologic) jaundice and abnormal or dangerous (pathologic) jaundice. Unfortunately, it is not simply the amount of bilirubin in the blood (total serum bilirubin, or TSB) which determines whether the baby is in danger. Other factors, imperfectly understood, cause a baby to be susceptible to brain damage from bilirubin. The pH of the baby blood, the amount of albumin available to bind to the bilirubin, and the integrity of the blood-brain barrier are all factors which affect the likelihood of neurological damage from hyperbilirubinemia. Therefore, the current recommendation of the American Academy of Pediatrics is to carefully screen all newborns, particularly those at higher risk of developing hyperbilirubinemia, and intervene when jaundice seems to be severe or caused by an underlying problem.

Risk Factors

It is important for parents to be aware of the risk factors for hyperbilirubinemia. Although most risk factors are not avoidable, parents will be better prepared and can consider discussing jaundice with their pediatricians before or soon after birth. Babies born prematurely are more likely to suffer from hyperbilirubinemia because of the exaggerated immaturity of their livers, as well as a decreased ability to transport bilirubin to the liver.

Blood incompatibilities such as an Rh negative mother and a Rh positive baby, or ABO incompatibility, may cause more blood cells to be broken down, creating higher levels of bilirubin than the baby’s body is capable of handling. Genetic enzyme deficiencies may also cause an unusually high level of red blood cells to be destroyed in the first days of life. The most common of these enzyme deficiencies is glucose-6-phosphate dehydrogenase (G6PD) deficiency. G6PD deficiency occurs mostly in babies of  non-European ancestry. 13% of African-American males have G6PD deficiency, and the percentage is even higher in some Asian and Mediterranean ethnic groups.

Breastfeeding infants have higher levels of bilirubin than formula-fed babies, although this should not be confused with “breast milk jaundice.” One theory which could explain it is the normally high levels of bilirubin are in some way beneficial; they may actually “turn on” some process in the liver. Be that as it may, the American Academy of Pediatrics discourages an interruption of breastfeeding, and recommends continued and frequent nursing (at least 8-10 feedings per 24 hours).

Prevention

If hyperbilirubinemia is caused by an underlying problem, there is little that can be done to prevent it. However, in term healthy infants, there are several things parents can do to decrease the chances of high TSB level. Avoiding unnecessary drugs during labor may help. Oxytocin induction or augmentation of labor has been implicated in jaundice, although several studies indicate that it is actually the glucose/dextrose IV which causes jaundice. One recent Turkish study found that giving the mother a steroid at the same time as the oxytocin resulted in lower TSB levels. Epidural anesthesia with bupivicaine has been shown both to be implicated in jaundice and not to affect jaundice. Although maternal smoking makes jaundice less likely, the other disadvantages outweigh this small benefit.

Early and frequent feeding helps in preventing hyperbilirubinemia. Babies who lose more than average amounts of weight are more likely to be affected. Early and frequent breastfeeding will encourage weight gain in the baby, as well as ensuring a good milk supply in the mother. In addition, colostrum encourages elimination, clearing the conjugated bilirubin from the intestines before it can be reabsorbed.

Some pediatricians suggest prophylactic exposure to light for all newborns. They may recommend taking a naked baby into the sunlight for no more than 5 minutes, twice a day. Parents should not exceed the recommended time, as babies sunburn very easily and should not be exposed to sunlight for longer than 5 minutes. Placing a baby’s bed near a sunny window filters out ultra-violet rays (protecting against sunburn) and may also decrease the chances of hyperbilirubinemia.

Symptoms

Parents should be taught to look for the symptoms of jaundice. In one study, parents who were shown what to look for more accurately diagnosed the TBS levels in their babies than doctors or nurses relying on visual assessment alone.

In a well-lit room or in daylight, the parent may place a finger on the baby’s forehead and press gently but firmly for several seconds. When the finger is removed, the baby’s skin will show a pale white circle. If the skin tone appears yellowish, jaundice is evident. This process may be repeated on the baby’s chest and thighs. Jaundice starts at he top and moves down, so the level of yellow skin roughly corroborates to the TSB. While jaundice is not likely to be significant until it covers the entire body, parents should consult a pediatrician for any suspicion of jaundice, including a yellowing of the whites of the eyes.

Other symptoms which should be reported to the pediatrician are disinterest in eating, general apathy, breathing difficulties, or temperature instability. Dark urine or light stools, or jaundice beginning after the first few days or lasting longer than 2 weeks should also be reported to the pediatrician.

All babies should be evaluated for jaundice 48 to 72 hours after birth. In cases of early discharge (leaving the hospital less than 48 hours after birth) the baby should be seen by a pediatrician at 3-4 days, rather than the two-week visit often recommended.

Diagnosing Hyperbilirubinemia

Although many doctors are experimenting with non-invasive methods of determining bilirubin levels, the most accurate determination remains a blood test for TBS. If jaundice is suspected, the pediatrician will most likely prick the baby’s heel and fill up a small glass tube with blood (similar to a finger prick for hematocrit). This can usually be tested on site. The bilirubin levels at which treatment is recommend vary according to the age and overall health of the baby, as well as the individual care giver’s approach.

Treatment

The most common and relatively non-invasive treatment for jaundice is phototherapy (light therapy). Around 1958, a very intelligent nurse in England noticed that the babies near the window in the hospital nursery were less likely to become jaundiced. Eventually, it was discovered that light causes a chemical reaction in the bilirubin, changing it to a form which can be excreted directly without needing to be conjugated in the liver. Phototherapy units are basically enclosed bassinets with fluorescent lights. The baby is placed naked under the lights, as close as safely possible. Eye protection against the bright lights is almost universally employed.

There are very few risks to phototherapy. Skin rash and diarrhea are the most common; they will go away as soon as the phototherapy is discontinued. Phototherapy is highly effective, and usually reduces the TSB levels rapidly. Continuous therapy is more effective than intermittent. Rebound rises in bilirubin are not likely, so once therapy is discontinued, the baby does not need close medical supervision.

Babies may be hospitalized for phototherapy. Obviously, in an otherwise healthy infant, this is not optimal, since it disrupts the bonding and breastfeeding process, and is expensive and inconvenient. Home phototherapy may be an option; parents should ask the pediatrician whether this is available. If so, a nurse or “phototherapist” may come to the home and set up a portable phototherapy unit or a fiberoptic device such as a “bili-blanket,” which wraps around the baby and allows continued bonding and breastfeeding while the baby receives phototherapy. With home phototherapy, parents will be responsible for monitoring the baby carefully, keeping records of the baby’s feeding, elimination, and temperature. The nurse returns often to check the baby’s bilirubin levels.

In some cases, breastfeeding mothers will be asked to supplement with formula, as this has been shown to decrease the length of phototherapy. However, in most cases, breastfeeding should be continued. Supplements of water or glucose water should not be offered, as they have been shown to make jaundice worse rather than better.

Occasionally, some mothers may be asked to discontinue breastfeeding for 28 to 48 hours in order to diagnose “breast milk jaundice.” Breast milk jaundice is a rare condition, appearing on the 4^th to 7^th day, in which the mother’s milk contains extra fatty acids, decreasing the amount of albumin available to bind with bilirubin. If this is the case, when breastfeeding is discontinued, the baby’s TSB level will drop dramatically. Breastfeeding may be resumed as soon as the TSB level falls to safety, and further treatment is generally unnecessary.

Very rarely, phototherapy and supplementation do not solve the problem. In those cases, if the TSB level continues to rise, exchange blood transfusion may be recommended to avoid brain damage.

Kelli Way, ICCE, CD (DONA), is a childbirth educator and doula in Los Angeles. She is the author of Birth Doula Basics. Eleven years ago, her fourth child had jaundice and was treated with home phototherapy and lots of breast milk.

You may contact Kelli Way at kelliway@loop.com or visit her website at http://www.kelliway.com

Copyright Kelli Way, 1999. This article may not be copied or reproduced without permission.

References

1. Karp, W. Are you afraid of bilirubin?  Pediatrics Online. Medical College of Georgia. 1995
2. American Academy of Pediatrics. Practice Parameter: Management of Hyperbilirubinemia in the Healthy Term Newborn. Pediatrics. 1994. 94(4).
3. Behrman, Kliegman, Arvin, editors. Nelson Textbook of Pediatrics. 15^th Edition. Saunders. 1996
4. Tan, KL. Deceased response to phototherapy for neonatal jaundice in breast-fed infants. Arch Pediatr Adolesc Med. 1998. 152(12): 1187-90.
5. Nathanson, LW. Portable Pediatrician for Parent. Harper Perennial. 1994. P. 24
6. Maisels MJ et al. Jaundice in the healthy newborn infant: a mew approach to an old problem. Pediatrics. 1998. 81(4): 505-11.
7. Phuapradit W et al. Risk factors for neonatal hyperbilirubinemia. J Med Assoc Thai. 1993. 76(8): 424-8.
8. Omigbodun AO et al. Effect of saline and glucose infusions of oxytocin on neonatal bilirubin levels. Int J Gynaecol Obstet. 1993. 40(3): 235-9
9. Johnson JD et al. Oxytocin and neonatal hyperbilirubinemia: studies of bilirubin production. Am J Dis Child. 1984. 138(11): 1047-50
10. Leylek OA et al. Prophylaxis of the occurrence of hyperbilirubinemia in relations to maternal oxytocin infusion with steroid treatment. Gynecol Obstet Invest. 1998. 46(3): 164-8
11. Clark DA, Landaw SA. Bupivicaine alters red blood cells properties: a possible explanation for neonatal jaundice associated with maternal anesthesia. Pediatr Res. 1985. 19(4): 341-3
12. Jouppila R et al. Effect of segmental epidural analgesia on neonatal serum bilirubin concentration and incidence of neonatal hyperbilirubinemia. Acta Obstet Gyencol Scand. 1983. 62(2): 179-82.
13. Gale R, Ferguson JE 2^nd, Stevenson DK. Effect of epidural analgesia with bupivicaine hydrochloride on neonatal bilirubin production. Obstet Gynecol. 1987. 70(5): 692-5.
14. Linn S et al. Epidemiology of neonatal hyperbilirubinemia. Pediatrics. 1985. 75(4): 770-4.
15. Tudehope Detal. Breast feeding practices and severe hyperbilirubinemia. J Paediatr Child Health. 1991. 27(4): 240-4.
16. Rubaltelli FF. Current drug treatment options in neonatal hyperbilirubinemia and the prevention of kernicterus. Drugs. 1998. 56(1): 23-30
17. Madlon-Kay DJ. Recognition of the presence and severity of newborn jaundice by parents, nurses, physicians, and icterometer. Pediatrics. 1997. 100(3): E3.
18. Torres-Torres Met al. Perspectives on neonatal hyperbilirubinemia. Mount Sinai Journal of Medicine. 1994. 61(5): 424-428.