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Title: Jaundice in newborn infants

JAUNDICE OVERVIEW — Jaundice is a yellow discoloration of the skin and/or whites of the eyes that is often seen in newborn infants. The discoloration is caused by a yellow substance called bilirubin. Infants with high blood levels of bilirubin, called hyperbilirubinemia, develop the yellow color when bilirubin accumulates in the skin.

Jaundice is not a disease, but is a symptom of an elevated blood bilirubin level. Jaundice is not painful, but serious complications can occur if elevated bilirubin levels are not treated in a timely manner. Jaundice is a marker used to identify those infants who may be at risk for developing severe hyperbilirubinemia. Severe hyperbilirubinemia can be toxic to the nervous system of infants, potentially causing brain damage.

JAUNDICE SYMPTOMS — Jaundice initially causes the skin to become yellowed. Later, the whites of the eyes may have a yellowish tinge. These changes may be hard to recognize in children with a dark skin color or if a baby is unable to open eyelids. The color change:

●Is noticeable in the face first, and may progress down the chest, abdomen, arms, and then finally the legs.
●Can be checked by pressing one finger on your baby\'s forehead or nose. If the skin is jaundiced, it will appear yellow when you release pressure from the skin.
●Can be tracked in some babies by pressing over the bony prominences of the chest, hips, and knees to check if the jaundice is progressing.
●Should be checked before your baby leaves the hospital. If your baby goes home sooner than 72 hours after birth, you will need to monitor the baby\'s skin color at home every day. In addition, your infant should see a doctor or nurse within one to three days after going home.
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, or if the yellow color is more intense, lemon yellow to orange 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
JAUNDICE CAUSES — Jaundice is caused by the accumulation of bilirubin in the blood. Bilirubin is formed when red blood cells are broken down. Bilirubin (a yellow pigment) is naturally cleared through the liver, and then excreted in stool and urine. Bilirubin levels become elevated when bilirubin is produced faster than it can be eliminated.

Jaundice is common in newborns, since two to three times more bilirubin is produced during this period as compared with during adulthood. \"Physiologic jaundice\" or benign jaundice, which affects nearly all newborns, is caused by a mild elevation of bilirubin and is not usually harmful to infants. It develops between 72 and 96 hours after birth, and usually goes away by one to two weeks after birth. In infants who are born at 35 to 37 weeks of gestation and those who are severely jaundiced, the jaundice may require more time to resolve.

Newborns with higher levels of bilirubin in the blood have \"severe hyperbilirubinemia\", a more serious condition than physiologic jaundice. Infants may develop severe hyperbilirubinemia within the first 24 hours of life. If this happens, you must consult your doctor urgently.

One reason that bilirubin levels are higher in infants is that more red blood cells are broken down (and as a result, more bilirubin is produced). This can be related to:

●Bruising and mild injuries from the birth process.
●If the mother and infant\'s blood types are incompatible; the mother\'s immune system may attack the infant\'s red blood cells.
●Inherited causes of red blood cell breakdown (such as deficiency of an enzyme called glucose-6-phosphate dehydrogenase [G6PD], which may occur more frequently among African-American, Mediterranean, and Asian races).
●Asian race or ancestry.
Bilirubin is also more slowly eliminated in the newborn compared with in adults because a newborn’s liver and intestines are not fully mature.

Breastfeeding — Jaundice is common in infants who are breastfed because of two different reasons:

●Breastfeeding failure occurs in infants with inadequate intake of breast milk because of difficulty in feeding or if the mother does not have an adequate milk supply. These infants lose a large amount of weight, thereby increasing bilirubin concentration. Increasing the mother\'s milk supply, frequent feeding, and ensuring good sucking (latch) are the best treatments for inadequate intake jaundice. 
●Breast milk jaundice is thought to be due to the infant’s immature liver and intestines. It typically begins the first week after birth, peaks within two weeks after birth, and declines over the next few weeks. Breast milk jaundice is not a reason to stop breastfeeding as long as the baby is feeding well, gaining weight, and otherwise thriving. Infants with breast milk jaundice rarely need treatment unless severe hyperbilirubinemia develops. All infants with jaundice should be monitored by a doctor or nurse. 
In either setting, the mother should be encouraged to continue breastfeeding because of the overall benefits of human milk.

JAUNDICE DIAGNOSIS — Newborn jaundice can be diagnosed by examining the infant and testing blood levels of bilirubin. A blood test involves collecting a small amount (less than one-half teaspoon or 2.5 mL) of blood. Results of blood testing are available in most hospitals within a few hours.

JAUNDICE COMPLICATIONS — In babies whose bilirubin blood levels reach harmful levels, bilirubin may get into the brain and cause reversible damage (called acute bilirubin encephalopathy) or permanent damage (called kernicterus). Frequent monitoring and early treatment of infants at high risk for jaundice can help to prevent severe hyperbilirubinemia.

JAUNDICE TREATMENT — The goal of 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, which is described below. 

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 s/he 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 a special blue light, which breaks bilirubin down into parts that are easier to eliminate in the stool and urine. Treatment with phototherapy 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 (picture 1). It is important to ensure that the lamps do not generate excessive heat, which could injure an infant\'s skin. In some institutions, phototherapy blankets are used (picture 2). 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.

PREVENTION OF SEVERE HYPERBILIRUBINEMIA — Prevention of severe hyperbilirubinemia is important in avoiding serious complications. Infants who are at risk for hyperbilirubinemia need close surveillance and follow-up. The following information applies to infants who are healthy and late preterm or older (greater than or equal to 35 weeks of gestation).

Screen — Leading experts recommend that all infants have bilirubin blood testing before going home. This is especially true for infants who are jaundiced before 24 hours of age.

Monitor — Parents and healthcare providers should monitor the infant closely if jaundice develops. Hyperbilirubinemia is usually easy to prevent and treat initially, but the complications can be serious and irreversible if treatment is delayed. You should contact your child\'s healthcare provider immediately if you are concerned about worsening jaundice.

Treat promptly — Infants with elevated bilirubin levels should be treated by a qualified doctor or nurse to safely reduce bilirubin levels and prevent the risk of brain damage. Parents and healthcare providers should not delay treatment for any reason.

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