Jaundice in newborn babies

Causes

Jaundice is caused by raised levels of bilirubin in the blood. Bilirubin is formed by the breakdown of red blood cells and is normally present in small amounts in the blood and stools. High levels of bilirubin can be toxic to the developing newborn's brain. This can result in a condition called kernicterus, in which the newborn has irreversible neurological damage that can range from being mild with no clinical symptoms, to severe brain injury and even death.

There are a few reasons why bilirubin levels can be high in newborn babies.

Physiological jaundice

Many newborn babies naturally have raised levels of bilirubin in the first week or so after birth. This is called physiological jaundice.

Prior to birth, bilirubin is removed from the baby's body by the placenta. After birth, it is cleared by the liver and then excreted via urine and stools.

In the first few weeks after birth, babies often have extra red blood cells that eventually break down, which leads to higher levels of bilirubin. Their liver can also take a while to be able to properly process bilirubin.

For these reasons, physiological jaundice often appears around 72 and 96 hours after birth and usually goes away in 1-2 weeks. It is unlikely to cause high levels of bilirubin that will need treatment.

Other medical conditions

Babies can be born with a range of medical conditions that can cause jaundice. If this is the case, bilirubin levels can become high and the baby may need treatment.

Conditions that increase levels of red blood cell breakdown

A range of infections and inherited conditions can increase levels of red cell breakdown. Other causes include:

• Bruising from the birthing process;
• Low birth weight - smaller babies often have higher levels of red blood cells;
• A mismatch of blood types between the mother and baby, in which the mother produces antibodies that can attack the baby's red blood cells, and;
• Hemolytic anemia. In this condition, the baby's immune system attacks its own red blood cells. It can occur due to an inherited autoimmune disorder, or as a result of other medical conditions such as an infection.

Conditions that make it harder to clear bilirubin

A range of conditions can affect the liver, making it more difficult to clear bilirubin. They include:

• Low levels of oxygen in the blood;
• Cystic fibrosis;
• Biliary atresia, a condition in which the baby is born without bile ducts, which causes bile to build up and damage the liver;
• Neonatal hepatitis, which is inflammation of the liver caused by a range of viruses including hepatitis, rubella and cytomegalovirus;
• Some medications, and;
• Sepsis, an infection of the blood.

Breastfeeding and jaundice

Jaundice is more common in babies who are breastfed. However, in most cases, mothers are advised to continue to breastfeed because of the overall health benefits breastfeeding offers the baby. A doctor or midwife can advise you on what is most suitable for the baby.

Breastfeeding jaundice occurs if the mother is unable to produce enough milk, or if the baby has difficulty feeding. In these circumstances, the baby can lose large amounts of weight and this can lead to higher levels of bilirubin in the blood.

Breastmilk jaundice can occur in some babies about a week after birth. The cause is not entirely clear, but it is thought that enzymes in breastmilk may affect how the liver breaks down bilirubin. It usually clears up within a month or so.

Breastfeeding is usually recommended for babies with jaundice, due to its numerous health benefits. 

Signs and symptoms

The main symptom of jaundice is a yellow color to the skin.

In mild cases of jaundice, the face and scalp are usually affected. In moderate cases of jaundice, the yellowness can spread to the rest of the body and if it becomes severe, the palms of the hands and soles of the feet are affected.

Other symptoms can include:

• Yellowing of the whites of the eyes;
• Unexpected levels of drowsiness;
• Problems with feeding, and;
• Light-colored stools and dark urine.

The main symptom of jaundice is a yellow coloring of the skin. 

Methods for diagnosis

Healthcare professionals such as doctors and midwives are aware of the risk of jaundice in newborns and automatically monitor them for any signs. If you are concerned that your baby has jaundice, or you think it may be getting worse, you can speak to your doctor or midwife.

Low levels of jaundice may be assessed using a non-invasive monitor called a transcutaneous bilirubinometer.

For babies that show significant signs of jaundice, a blood test for bilirubin levels via a heel prick test may be recommended. Treatment is generally recommended when bilirubin levels are raised, but still much lower than can harm the baby.

If it is suspected that an underlying medical condition may be the cause of serious levels of jaundice, other tests may be performed in order to confirm the cause.

Types of treatment

Most babies do not need treatment for jaundice beyond monitoring and making sure they are feeding well. The goal of treatment is to lower bilirubin levels.

Feeding

Ensuring the baby is feeding well can help to prevent or treat jaundice. This is because bilirubin is excreted through stools and urine. Feeding frequently (every 2-3 hours) can help.

Signs that a baby is getting enough breastmilk or formula include:

• They produce at least six wet nappies per day;
• The color of the stools is yellow rather than dark green, and;
• The baby seems content and satisfied after feeding.

In babies affected by breastmilk jaundice, the advice is usually to continue with breastfeeding because of the overall health benefits for the baby. If you are experiencing difficulty with feeding, seeking advice from a doctor, midwife or breastfeeding counsellor can help.

Phototherapy

Phototherapy works by exposing the baby's skin to a special blue light. This light causes a process called photo-oxidation, which helps to break down bilirubin and makes it easier to be eliminated through stools and urine. During this treatment, the baby wears only a nappy and protective eye covers, so that as much of their skin as possible is exposed to the light.

Treatment for jaundice with phototherapy is very effective and safe; however, it can cause skin rashes and loose stools. Babies can become overheated and dehydrated if they do not get enough fluids, so this is monitored carefully while they are receiving treatment.

In some rare cases, babies receiving phototherapy treatment can develop a dark grey-brown color in the skin. This is sometimes called 'bronze baby syndrome'. It does not pose a threat to the baby's health and disappears in the weeks after therapy finishes.

The baby's healthcare professionals can advise on a suitable level of phototherapy for the baby.

Phototherapy is usually very effective in the treatment of jaundice. 

Exchange transfusion

Rarely, if bilirubin levels are high and the jaundice has not improved with other treatments, a newborn's blood can be slowly removed and replaced with a blood transfusion, to quickly bring the bilirubin levels down.

Potential complications

While most cases of jaundice cause no health problems for the baby, if bilirubin levels become very high, they can cause kernicterus, which can lead to mental retardation, deafness and death of the baby.

Prognosis

For most babies, jaundice clears with no treatment beyond monitoring and making sure that they are feeding well. For babies that require treatment, phototherapy is usually very effective. Babies with serious underlying medical conditions that are causing jaundice may need more extensive treatment.

Prevention

It is not possible to prevent all cases of jaundice. However, being aware of the problem and checking in with a doctor or midwife if you are concerned that a baby may have jaundice can help to prevent problems. For babies with signs of jaundice, monitoring and early treatment can help keep bilirubin levels within a safe range and prevent serious complications.