Jaundice, the yellowing of the skin and whites of the eyes caused by elevated bilirubin levels in the blood stream, is a common newborn condition. According to the CDC, 60% of all term newborns and 80% of preterm newborns become jaundice. Jaundice can be very dangerous for a newborn if the bilirubin levels get too high.
Jaundice occurs due to the buildup of bilirubin in the blood. Bilirubin is a by-product of red blood cell breakdown and is normally removed by the liver. Before birth, mom's liver removes the excess bilirubin for baby. Once baby is born, his liver must take over. Since baby’s liver is still developing and immature, it is unable to breakdown the bilirubin effectively and quickly resulting in the buildup of bilirubin in the blood. Once bilirubin is removed by the liver, it is excreted through urine and stool.
Bilirubin is yellow and as it accumulates in the blood stream, the yellow color seeps out onto the skin and whites of the eyes. Jaundice is usually seen first on the face and then the yellow discoloration will move down the body as bilirubin levels increase. Bilirubin levels normally peak by the third to fifth day of life and then will start to drop rapidly.
High levels of jaundice is very concerning since brain damage can occur if not treated. Kernicterus, a form of brain damage, can result from extremely high levels of bilirubin in the blood. If your baby’s bilirubin level reaches concerning levels, your baby will be treated with phototherapy and bilirubin levels will be monitored. On rare occasions, severe jaundice will require treatment by exchange blood transfusion which replaces baby’s blood with fresh donor blood.
Jaundice can occur for a variety of reasons. Here are some common causes:
- Normal physiologic jaundice which occurs in 60% of healthy newborns
- Blood type incompatibility
- Sibling with history of jaundice
- Feeding difficulties resulting in inadequate milk transfer (breastfeeding jaundice)
- East Asian or Mediterranean descent
- Breastmilk jaundice caused by the certain ingredients in breastmilk.
Bilirubin levels are drawn on any baby that appears jaundice (especially within the first 24 hours after birth) or on those babies whose blood type differs from mom’s blood type. Babies born to mothers with an O blood type or with Rh negative blood factor are at higher risk for jaundice. Bilirubin levels vary depending on factors such as gestational age, baby’s age in hours when level was drawn, and the presence of risk factors. Most facilities screen every baby before discharge regardless of the presence of risk factors.
Bilirubin levels can be monitored by a special device called a bilimeter or by collecting a blood sample. A bilimeter measures the bilirubin through the skin by using a special light and allows the bilirubin level to be measured without the need to draw blood. Although a blood sample is the most reliable indicator of bilirubin levels, a bilimeter provides a quick, painless, reliable result and is very cost-effective. If the bilimeter reading is too high, a blood test will be done to confirm the results.
Phototherapy will be initiated if the bilirubin levels becomes concerning. Blue fluorescent or halogen lights are used to help eliminate excess bilirubin from your baby’s bloodstream. A biliblanket, a portable phototherapy device, can also be used to treat jaundice. The blanket is a soft, flexible lighted pad that is placed in direct contact with your baby’s skin. Depending on your baby’s bilirubin level, a biliblanket can be used to provide phototherapy at home.
You may have heard that jaundice can be treated putting your baby in sunlight. Although sunlight can help decrease bilirubin levels, the AAP cautions against this practice for two important reasons:
- Babies can get cold when left undressed in their crib, and
- Babies can get sunburned if exposed to direct sunlight.
During phototherapy, your baby will remain in an isolette (to prevent heat loss) or a crib, will be dressed only in his diaper to maximize exposure to the bililights, and will have his eyes covered to protect his eyes from the light (unless a biliblanket is used). Babies receiving phototherapy need to remain under the lights as much as possible and are only allowed off of the lights during feeding time. The goal is to maximize exposure time to the bililights to assist in the excretion of bilirubin from the bloodstream. To prevent dehydration and help flush bilirubin from the blood, frequent feedings and/or intravenous fluid therapy (IV fluid) will be needed.
Once phototherapy has been discontinued, a follow-up bilirubin level (often referred to as the rebound bilirubin) is drawn to ensure safe bilirubin levels. Some pediatricians will also request an earlier follow-up visit to ensure jaundice has not worsened. The American Academy of Pediatrics recommends the following pediatrician follow-up schedule:
- If discharged from the hospital before 24 hours of age, baby should be seen by the pediatrician by the 3rd day of life.
- If discharged from the hospital between 24 and 48 hours of life, baby should be seen by the 4th day of life.
- If discharged from the hospital between 48 and 72 hours of life, baby should be seen by the 5th day of life
Be sure to notify your baby’s physician if your baby has any of the following symptoms:
- Does not have enough wet or dirty diapers in 24 hours.
- Has difficulty breastfeeding or bottle feeding.
- Is very sleepy or hard to wake up.
- Is very irritable.
- Has a shrill and high-pitched cry.
- Is limp or floppy.
- If jaundice persists for longer than 3 weeks.
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. PEDIATRICS Vol. 114 No. 1 July 1, 2004 pp. 297 -316 (doi: 10.1542/peds.114.1.297)
Bhutani, V. Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. PEDIATRICS Vol. 128 No. 4 October 1, 2011 pp. e1046 -e1052 (doi: 10.1542/peds.2011-1494)
Centers for Disease Control: Facts about Jaundice and Kernicterus
Davidson, D., London, M., Ladewig, P. (2012). Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan (9th Edition). Boston: Pearson.
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Author : Diba Tillery RN, BSN, IBCLC, CPST
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