Jaundice in the Newborn

This month, Midwife Emma McNerlin examines the causes and treatment of jaundice, a common newborn condition, and gives practical, evidence-based advice for parents on signs to look for when taking their newborns home. 

By Emma McNerlin

What is jaundice?

Neonatal jaundice is a yellowing of the skin and eyes in newborns (NHS, 2018). In babies with darker skin tones, parents should pay attention to the whites of the eyes and the soles of the feet and palms of the hands when examining for jaundice (NICE, 2010). The yellowing is caused by a build-up of bilirubin (hyperbilirubinemia).

What is bilirubin? 

After birth, adult hemoglobin replaces fetal hemoglobin, a part of the red blood cell responsible for carrying oxygen in utero, in new red blood cells in the baby. (Snakarin et al, 2013). Bilirubin is a byproduct of the breakdown of the fetal red blood cells.

Bilirubin is processed in the liver and excreted in urine and stools. The newborn’s liver is not efficient in processing bilirubin, so it is stored in the tissues, causing yellowing of the skin. By two weeks of age, the baby’s liver is more efficient in processing bilirubin and the yellowing dissipates (Stevenson et al., 2012).

How common is jaundice? 

Jaundice affects around 60% of newborns born at term and 80% of preterm infants (Woodgate et al., 2011). Most jaundice cases are classified as physiological, of which around 95% will resolve within two weeks of birth without treatment. Physiological jaundice is three times more common in breastfed infants than those who are formula fed (NICE, 2010). The most serious form of jaundice—pathological jaundice—is not related to feeding method. It occurs in the first 24 hours of life, usually as a complication of other conditions in the newborn (see Table 1). 

Table 1: Types of Jaundice (Porter et al., 2002)

In extremely rare cases, serious delay or failure to treat pathological jaundice can result in toxic bilirubin levels in the bloodstream. This bilirubin can cross the blood-brain barrier, causing an irreversible brain damage called kernicterus, which affects around 1 in 100,000 births (Dinesh et al., 2021). Globally recognised thresholds and treatment protocols mean that kernicterus is thankfully rare. 

Jaundice treatment and thresholds 

Treatments for jaundice will depend on the time of onset and severity of symptoms. For moderate cases, babies may require phototherapy. This involves UV light or a fiber optic mattress (or both) on baby continuously for at least 48 hours, with only short breaks for feeding every 3 hours. Exposure to light makes it easier for the body to break down and excrete the bilirubin (see Figure 1). 

Figure 1: Phototherapy from Shutterstock

An exchange transfusion may be required in the most severe cases where serum bilirubin levels are extremely high or increasing rapidly. This requires removing the baby’s blood and replacing it through the umbilical vein with donor blood to remove the high levels of bilirubin. In recent years in the USA, there have also been clinical trials using IV immunoglobulin therapy to treat severe jaundice (CDC, 2017). 

The neonatologist will check your baby for jaundice throughout their stay in hospital. This is first done by examining their skin in natural light, and in some cases, a blood test to check serum bilirubin levels. The threshold for treatment will depend on the baby’s gestation at birth, the number of days since birth, and the serum bilirubin levels and other pre-identified risk factors (see Table 1).

Going home with your newborn: considerations for jaundice

You and baby will be discharged from hospital on day 2 or 3. By this stage, your baby may already start to show signs of physiological jaundice. This is not necessarily a cause for concern as only 5% of babies require treatment for it. The neonatologist will declare your baby fit for discharge before you go home, after which an outpatient pediatrician will check baby at one week old. 

The yellowing of the skin may continue for several days at home. It can be stressful for new parents to know if this is normal or not. Other signs that may indicate jaundice is increasing include drowsiness and a reluctance to feed, not waking for feeds, dark-coloured urine, and pale-coloured stools (NHS, 2018). 

Remember—your baby can only excrete the excess bilirubin in their pee and poo. This relies on frequent and sufficient feeds. Beststart.org has created a great resource for new parents on feeding and diapers (see Figure 2). 

Figure 2: Guidelines for Nursing Mothers from beststart.org

Breastfed babies

As stated earlier, jaundice is more likely to occur in breastfed babies. Breastfeeding is a natural thing that doesn’t always come naturally! It’s a skill that you and your baby learn together. Seek help early on for any issues you have with breastfeeding. Investing in a visit from a lactation professional even before you leave hospital can help you avoid a lot of common pitfalls.

Supply issues 

Your milk should come in between day 2 and day 3 after birth. Prior to that, you produce colostrum, which is all that a healthy newborn needs in those first few days. However, certain circumstances can cause a delay in the milk coming in. These include IV Pitocin or augmented labour, C-section delivery, and retained placenta, as well as prolonged separation of mother and baby after birth, and scheduled feeds in hospital. Should you experience a delay in milk coming in, it is important to have lots of skin-to-skin with your baby and feed them often at the breast (at least 10 times in 24 hours). Watch out for signs of dehydration in baby; these include decreased urine output/dark urine, brick red or orange-coloured crystals in the diaper (urates), dry gums, a croaky cry, and a concave dip in the fontanelle (soft spot on the top of the head). If you see any of these signs, consult your doctor as baby may require supplementation. 

Poor position and latch

A poor latch or incorrect position can lead to nipple pain and trauma, as well as inefficient and prolonged feeding. While introducing a nipple shield may seem like a helpful solution, these can exacerbate the issue. Inefficient feeding leads to baby tiring themselves on the breast, transferring inadequate amounts of breastmilk and becoming increasingly drowsy and difficult to wake for feeds. The downward spiral continues as they sleep more, feed less, and don’t remove milk from the breast, increasing the risk of clogged ducts and mastitis in the nursing mother. If the milk is not going in, the poop and pee cannot carry the bilirubin out. If your baby is not waking for feeds or is very drowsy on the breast after leaving the hospital, please consult their pediatrician. 

Make each feed count! 

Just because your baby is latched does not mean they are transferring milk. I hear from many mums who say their babies are feeding for hours at a time, when in fact they are either latching poorly or comfort sucking. Watch out for sucking, swallowing, and pausing from baby. When they stop or take longer pauses, do breast compressions by cupping and squeezing the breast—not the nipple—to have them start drinking again. Switch sides often in the early days to keep baby alert, and don’t forget plenty of skin-to-skin in a quiet, calm environment. 

Formula fed babies 

If your baby is formula fed, they can still develop physiological jaundice. Parents should ensure that baby feeds at least every three hours in accordance with advice from their pediatrician and that the amounts of urine and stools being passed are sufficient (see Figure 2). 

Sunlight and jaundice 

Placing your baby undressed near a window at home can also help their body to break down bilirubin. You should ensure that the room is warm enough and that the baby is not directly in front of the air con unit. Never place a newborn outdoors in direct sunlight as this risks sunburn and dehydration. 

Bringing your baby home for the first time is magical but can also be a little daunting. You can make the transition easier by getting off to the best possible start with feeding as well as taking good care of yourself. If baby has yellow skin and eyes in the first week at home, observe them for drowsiness, sleeping for longer than three hours, not waking for feeds or being reluctant at the breast as well as having decreased urine and/or stool output. These can be signs that their bilirubin levels should be checked, and treatment may be required. 

 **The contents of this article are intended for informational use only and should not be considered as medical advice. If you are concerned about any aspect of your baby’s health, please consult their pediatrician. ****

Main image from Canva.

References 

NHS (2018) Newborn Jaundice. nhs.uk/conditions/jaundice-newborn/

NICE (2010) Neonatal jaundice (NICE clinical guideline 98). Available online at: rcog.org.uk/en/guidelines-research-services/guidelines/neonatal-jaundice-nice-clinical-guideline-98/

Coad, J., Pedley, K. and Dunstall, M. (2019) Anatomy and Physiology for Midwives, 4th Edition. Elsevier Press. 

Snakarin, V. and Orkin, S. (2013) The Switch from Fetal to Adult Hemoglobin. Available online at: ncbi.nlm.nih.gov/pmc/articles/PMC3530042/

Stevenson et al. (2012) Care of the Jaundiced Neonate. Available online at: accesspediatrics.mhmedical.com/content.aspx?bookid=528&sectionid=41538373

Marshall J and Raynor M. (2014) Myles Textbook for Midwives, 16th Edition. Elsevier Press. 

Porter et al. (2002) Hyperbilirubinemia in the Term Newborn. Available online at: aafp.org/afp/2002/0215/p599.html   

Dinesh et al. (2021) Kernicterus. Available online at: ncbi.nlm.nih.gov/books/NBK559120/

CDC (2017) Efficacy of Intravenous Immunoglobulin in Management of Rh and ABO Incompatibility Disease (IVIG). Available online at: clinicaltrials.gov/ct2/show/NCT03130517 

About the Author

Emma McNerlin is a UK trained and registered Midwife, First Aid Instructor, and owner of Bumpsy Daisy Café and Community; a cafe and parenting community centre for new and expecting parents offering birthing classes, hypnobirthing, First Aid workshops, and baby classes.

The views expressed in the articles in this magazine are not necessarily those of BAMBI committee members and we assume no responsibility for them or their effects. BAMBI Magazine welcomes volunteer contributors to our magazine. Please contact editor@bambiweb.org.