“My baby is yellowish… “- Neonatal jaundice

[mme_highlight] Neonatal jaundice is a yellow coloration of skin caused by a yellow pigment called bilirubin. If the levels of this substance get too high there is a risk of brain damage. It generally appears between 72 to 96 hours after birth, disappearing by one to two weeks of life. [mme_highlight]

What is Jaundice?

Jaundice is the medical term for a yellowish coloration of the skin or when the white part of the eye turns yellow. It generally appears between 72 to 96 hours after birth, disappearing by one to two weeks of life.

Jaundice is a sign that reflects a high blood concentration of a substance called “bilirubin”. This substance is released to blood by the disruption of red blood cells, but usually the liver does its clearance and bilirubin is excreted in urine and stool. However, if the pace of red blood cells disruption gets too fast, bilirubin is not adequately eliminated and accumulates, causing jaundice. As bilirubin is a yellow pigment, it causes a yellow coloration of tissues.

Why does my baby have jaundice?

Neonatal jaundice can be caused by different reasons:

High turnover of red blood cells: this is a normal situation, because baby’s blood is richer in red blood cells than the adults’ blood and, in addition, these red blood cells have a shorter life than the ones from adults’ blood (approximately 85 days vs. 120 days); as the turnover of red blood cells increases, more bilirubin is produced.
Deficiency of UGT1A1, an enzyme envolved in the clearance of bilirubin. This enzyme does not work properly until around 14 weeks of age, so the bilirubin is not well cleared and accumulates.
Mild injuries occurred during birth can leave to red blood cells destruction, hence causing a raise in bilirubin concentration.
Incompatibility of blood types between mother and child, which causes destruction of red blood cells.
Inherited diseases causing destruction of red blood cells (such as deficiency of glucose-6-phosphate dehydrogenase, an enzyme).
Asian race baby or having asian ancestors also rises the odds of having jaundice.

Can jaundice be related to breastfeeding ?

Yes, in two distinct situations. When the intake provided by breastfeeding is not adequate, because this way the blood concentration of bilirubin increases. The other situation is the called “breast milk jaundice”, which happens due to the babies immature organs and occurs mainly during the first two weeks of life. It is not a reason to stop breastfeeding if the baby is gaining weight, but this situation should be monitored by a doctor.

Does jaundice happen to many babies?

Yes, it is very common in babies. In fact, the so called benign jaundice is physiologic and affects almost all newborns. However, as it consists of a mild elevation in bilirubin levels, there is generally no danger for babies. A concentration of blood bilirubin greater that 1mg/dL is above the upper normal limit for an adult. The highest levels are those above 25 mg/dL, which is called hyperbilirubinemia, which associates with a greater risk for brain damage, as the study below shows.

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Odds of Having Acute Brain Damage (ABD) at Admission and/or at Discharge (logistic regression analysis)
(Study population: 249 newborns with severe hyperbilirubinemia)

High total serum bilirubin: 1 time more risk for ABD (OR 1.09 – 95% CI 1.03-11.6)
Higher admission weight: 17% less risk for lactation mastitis (OR 0.83 – 95% CI 0.74-0.93)
Incompatibility Rh: 48 times more risk for ABD (OR 48.6 – 95% CI 14-168)
Sepsis (general infection): 20 times more risk for ABD (OR 20.6 – 95% CI 4.9-87.5)

OR – Odds Ratio; CI – Confidence Interval
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How can I check if my baby has jaundice?

To check if your baby has jaundice, press one finger on her/his forehead or nose. If it is the case, the skin will appear yellow when you release your finger from the baby’s skin.

What are the symptoms of jaundice?

The yellow coloration that appears in jaundice is generally first noticeable in face, but can also been seen in the chest, belly, and arms; legs are usually the last part of the body affected.

Sometimes, when the level of bilirubin are very high (hyperbilirubinemia), jaundice can be severe. There are some symptoms a baby in this situation can show, although they do not appear only in the case of severe jaundice: if a baby is difficult to wake up, has a high-pitched cry, gets difficult to console and bends her/his body or neck backwards.

How is neonatal jaundice treated?

The most common treatment for neonatal jaundice is called phototherapy, where babies are put under a light therapy, either using a special light or a light blanket over skin. The light breaks the bilirubin molecule, making it easier to eliminate through urine and stool. Generally, this treatment is enough to treat the baby.

Adequate breastfeeding is also very important to prevent and treat this condition, as it promotes the elimination of bilirubin through urine and stool. The study below investigated 22547 infants and shows the estimated number needed to treat (NNT) with phototherapy to prevent one infant from reaching a high bilirubin level with need for exchange transfusion (this is the treatment used for high bilirubin levels when phototherapy is not enough).

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Estimated NNT with Phototherapy to prevent one infant from reaching the exchange transfusion level (first 24 hours of life)
(Study population: 22547 newborns)

Boys, 35 weeks of gestation: NNT= 14 (we have to treat 14 with phototherapy to prevent one baby from needing transfusion)
Boys, 39 weeks of gestation: NNT= 74
Girls, 35 weeks of gestation: NNT= 21
Girls, 39 weeks of gestation: NNT= 113

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Summary and Recommendations

Neonatal jaundice is a common and usually benign condition in neonates. It generally appears between 72 to 96 hours after birth, disappearing by one to two weeks of life.
It can be caused by situations that raise the levels of bilirubin (yellow pigment) or that difficult its elimination, which can be normal in the first weeks of life, because the baby’s organs may be not mature and the turnover of red blood cells is higher. There are also diseases that can cause jaundice.
The most common therapy for neonatal jaundice is that with a special light, which generally is successful.
You should always seek medical advice if: your baby’s jaundice worsens, if your baby bends is body backwards and also if she/he is irritable, difficult to wake up or shows a different pattern of crying (high-pitched).

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References

Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia. N Engl J Med 2001; 344:581.
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:297.
Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed 2011; 96:F461.
Maisels MJ, McDonagh AF. Phototherapy for neonatal jaundice. N Engl J Med 2008; 358:920.
Gamaleldin R, Iskander I, Seoud I et al. Risk factors for neurotoxicity in newborns with severeneonatal hyperbilirubinemia. Pediatrics. 2011 Oct;128(4):e925-31.
Newman TB, Kuzniewicz MW, Liljestrand P et al. Numbers needed to treat withphototherapy according to American Academy of Pediatrics guidelines. Pediatrics. 2009 May;123(5):1352-9.

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