Jaundice in infants is incredibly common and is described as a yellow discoloration of a newborn baby’s skin and eyes. Infant jaundice occurs because the baby’s blood contains an excess of bilirubin. Dr. Bornstein discusses the symptoms, causes and treatment for jaundice.
DEFINITION:
A yellow appearance to the eyes and/or skin
SYMPTOMS:
Yellow sclera (whites of the eyes)
followed by:
Yellow skin beginning on the face and then progressing down the body
CAUSES:
Typically happens in newborns. It is due to the retention of bilirubin in the bloodstream and tissues. This is caused by various reasons, including:
- An incompatibility of blood types between the mother and baby
- Breast milk jaundice
- Breastfeeding jaundice
- Physiologic (a normal expected occurrence)
- Illnesses, including infection, liver disease, toxins, and metabolic disorders
CONTAGION:
Not a contagious illness.
DIAGNOSIS:
The diagnosis is made by first observing the color of the eyes and skin. Then come the blood tests. The blood tests include total and direct bilirubin levels, maternal and infant blood and Rh type, Coombs test, and in more severe cases, a reticulocyte count, complete blood count, and blood culture.
DISCUSSION:
Jaundice in the newborn is typically a common and expected occurrence; however, there are some instances in which it will need to be treated.
Jaundice is caused by excess bilirubin in the bloodstream and tissues. Bilirubin is in the heme portion of hemoglobin and is released into the bloodstream as hemoglobin breaks down. In adults, hemoglobin has a lifespan of 120 days, and in infants, the lifespan is 90 days. Adults have a hemoglobin level of around 10-12 mg/dl, while infants can be around 15-20 mg/dl, meaning more hemoglobin is available, releasing bilirubin more quickly. Before the baby’s birth, all the oxygen comes from the umbilical cord. Because this prenatal oxygen level is less than what you would get by breathing air directly through the lungs, the body compensates by having more hemoglobin, the part of the red cell that carries the oxygen. After birth, this extra hemoglobin is no longer needed, and it breaks down more quickly, releasing the bilirubin into the bloodstream.
Bilirubin is processed in the liver from the unconjugated type (indirect bilirubin) to the conjugated type (direct bilirubin). The conjugated bilirubin can be excreted in the stool. Since the infant’s liver cannot keep up with the amount of unconjugated bilirubin being presented to it, it remains in the bloodstream and tissues, causing yellow skin. If the bilirubin level reaches extreme excess, it can start depositing into parts of the brain (kernicterus), causing damage and cerebral palsy.
The vast majority of jaundice in infants is the unconjugated (indirect) type. Suppose the conjugated (direct) bilirubin level is high. In that case, the liver properly processes the bilirubin, but the conjugated bilirubin cannot get out of the liver and into the intestines for excretion. This typically happens in biliary atresia, when the connection between the liver and intestines does not develop. This type of hyperbilirubinemia (high bilirubin level) is very rare and is not the type of jaundice most people think about when discussing jaundice. However, if the blood test shows a high conjugated bilirubin level, a referral to a specialist is recommended. A surgical procedure called a Kasai procedure will need to be performed to connect the liver to the intestines.
In almost all cases, hyperbilirubinemia will be the unconjugated (indirect) type. The most common is called physiologic jaundice. Physiologic means that it is normal and not unusual or harmful. The physiologic type occurs because the liver cannot keep up with the amount of bilirubin being presented to it. This type rarely needs to be treated and will not cause harm to the child.
- Breast milk jaundice is a common occurrence in breastfeeding infants. It is also known as late-onset prolonged unconjugated hyperbilirubinemia. The cause is thought to be an unidentified factor in milk. Almost two out of three breastfed infants will have signs of jaundice at 2-3 weeks. This is harmless to the infant, and no treatment is necessary.
- Breastfeeding jaundice is common in breastfed infants in the first week of life. This is due to the average 5%-10% weight loss in most newborn breastfeeding infants, and the bilirubin level increases until the infant establishes good oral intake. This type may rarely need to be treated if the levels are getting too high, but breastfeeding does not need to stop.
- ABO incompatibility is a common cause of hyperbilirubinemia. This happens when the infant’s and mother’s blood types are incompatible. This causes hemolysis (breaking down) of the infant’s red blood cells releasing bilirubin into the bloodstream. This happens if the mother is type O and the father is type A, B, or AB. If the infant gets the father’s blood type, there will be an incompatibility. Since a person with type O has antibodies against type A, B, or AB, the mother will have antibodies against the infant’s blood. When blood mixes through the placenta at birth, these antibodies enter the infant’s bloodstream and cause hemolysis.
- Rh incompatibility occurs if a mother is Rh- and a baby is Rh+. The mother can have antibodies against the baby’s Rh factor that will attack the Rh- blood. This causes hemolysis which releases bilirubin. This is why mother and infant blood type and Coombs tests are performed if there is jaundice. A Coombs test will tell if there is hemolysis occurring. This type of jaundice must be treated more aggressively than other unconjugated hyperbilirubinemia, as the bilirubin level can quickly increase to more dangerous levels.
Less common causes of jaundice occur because of:
- Infections
- Toxins
- Metabolic disorders
- Liver disease
In these instances, the underlying cause will need to be treated. Fortunately, this type of jaundice is rare and only considered if the child is acting very ill or if the normal treatment measures are not helping.
JAUNDICE TREATMENT:
The cause of the jaundice and the bilirubin level will determine the treatment. For any direct conjugated hyperbilirubinemia, a referral to a gastroenterologist and surgeon will be necessary to determine the cause of the obstruction from the liver to the intestines. A surgical procedure will likely be performed to correct the obstruction.
For the more common indirect unconjugated hyperbilirubinemia, a different approach is taken. For ill-appearing babies or babies under 24 hours of age with jaundice, an evaluation for an underlying illness or infection will need to be performed. The cause and the jaundice will then need to be treated.
For breastfeeding jaundice, the infant should be encouraged to increase breastfeeding frequency. Many years ago, mothers were instructed to stop breastfeeding for 24-48 hours to let the level down. However, this approach is now discouraged and can inhibit the success of future breastfeeding. Phototherapy can be initiated if the levels are rising despite increased frequency of breastfeeding, for breast milk jaundice where the levels are getting too high, for hemolytic jaundice due to ABO/Rh incompatibility, or for unusually high levels of physiologic jaundice.
Phototherapy involves placing the baby under a blue ultraviolet light. The ultraviolet light changes the indirect bilirubin to a photobilirubin, which can be excreted into the intestines. The phototherapy works in conjunction with the liver to help process the bilirubin and allow it to leave the body. Indirect sunlight through a window can also be helpful for those infants whose levels are getting high but are not high enough to justify phototherapy. The indirect sunlight exposes the baby to the same ultraviolet light as phototherapy.
If levels increase despite phototherapy, more aggressive measures must be taken. The next step in management is to perform a double volume exchange transfusion. This is where some of the infant’s blood is removed through an umbilical catheter, and other blood is transfused into the infant. The new blood will not have the bilirubin, and the level will decrease. This, of course, is only done in extreme situations where the concern of kernicterus and cerebral palsy is high.
ONE DOCTOR’S OPINION:
Over time, opinions about the treatment of hyperbilirubinemia have significantly changed. Infants who had breastfeeding jaundice used to stop breastfeeding, phototherapy used to be started at much lower bilirubin levels with no consideration as to the underlying cause, and intravenous fluids used to be started to try to dilute the bilirubin.
A lack of knowledge about the causes of jaundice caused a more aggressive approach in the past. The type of jaundice that would cause kernicterus was unknown. There was no way to do a study to find out this information. No one would agree to let a child’s level get high to see if it caused brain damage. The only way to get the information was to follow children who presented to their physicians with high levels and watch how they progressed.
The good news is that physiologic, breastfeeding, and breast milk jaundice are generally harmless and are less likely to progress to high bilirubin levels. The hemolytic type is the more troublesome type, and levels are checked in the hospital if the mother has blood type O or Rh- to get a head start on treatment.
However, jaundice due to hyperbilirubinemia is still the number one cause of an infant being readmitted to the hospital after going home. Therefore an infant with yellow skin does need to be checked by their physician.
I try not to readmit to the hospital unless the levels approach the danger zone. I prefer to treat at home to prevent the stress of returning to a hospital with a new baby just after being sent home. I will check bilirubin levels at least once a day at home, and if the child is not improving, I will then put the child in the hospital. The goal is to keep the levels low enough to avoid doing a double volume exchange transfusion and prevent kernicterus. Since these happen very infrequently, increased breastfeeding or indirect sunlight through a window can typically treat jaundice.
This blog was written by Dr. Michael Bornstein, who has 30 years of experience as a pediatrician.
Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.
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