Jaundice is the medical word used to describe a yellowing of the skin and white parts of the eyes (sclera). Neonatal jaundice is a very common condition – around 60 per cent of babies born at term and 80 per cent of babies born early (prematurely) develop neonatal jaundice.
It usually develops on day two and three of life and generally fades away by the end of the first week of life. In the majority of cases, jaundice is harmless and fades without treatment. A very small number of babies can develop more significant jaundice that requires treatment. Treatment is needed because extremely high levels of jaundice can damage the brain and cause hearing problems. However, this is a very rare complication that is not expected with current treatments.
What causes neonatal jaundice?
Neonatal jaundice is caused by a high level of a yellow substance called bilirubin in the blood. Bilirubin is made during the normal breakdown of red blood cells. Newborn babies have a higher number of red blood cells in their bodies and therefore make more bilirubin. As their liver is immature when they are born, it is not able to break down all the bilirubin and so the levels of bilirubin in their blood increase. As the liver matures, it becomes better at breaking down bilirubin and clearing it from the body.
Breastfed babies are more likely than formula fed babies to develop jaundice in the first few days of life as it can take time for a mother’s milk supply to build up. However, breastfeeding is best for babies and the nursing staff and doctors will help support you with feeding. Also, breastfed babies can have jaundice that lasts for longer than two weeks – this is called breast milk jaundice. If the baby is growing and healthy with normal stools and urine there is nothing to be concerned about and mothers should continue to breastfeed as normal.
Some babies are at increased risk of developing higher than normal levels of bilirubin in their blood:
- If there are differences in the blood groups of mother and baby it can cause red blood cells to break down more quickly and increase bilirubin levels.
- Blood cell problems, which lead to the blood cells breaking down more quickly.
- Liver problems (more than just immaturity of liver).
- Babies that are born early (premature).
What are the signs and symptoms of neonatal jaundice?
The main symptom of neonatal jaundice is a yellow tinge to the skin and whites of the eyes. The yellow tinge tends to start on the head and face and spread downwards towards the chest and abdomen. In babies who have darker skin, yellowing of the skin can be harder to recognise and yellowing of the whites of the eyes can be easier to see. Babies who develop high bilirubin levels become sleepy and less interested in feeding. If jaundice is caused by a liver problem, the stool (poo) can be pale and chalky in colour and the urine (wee) can be dark. If this is seen, additional tests are needed to check how the liver is working.
How is neonatal jaundice diagnosed?
Usually the first checks for neonatal jaundice will have been carried out at the hospital where the baby was born. All babies who are admitted to Great Ormond Street Hospital (GOSH) are checked again for jaundice and will continue to have regular checks throughout their admission.
Initially, a visual check is carried out – this is best done by taking off the baby’s clothes and checking their skin and the whites of their eyes in natural light. This is done because artificial light can make identifying yellowing of the skin more difficult.
If the baby seems to have a yellow tinge, the levels of bilirubin in the blood will be checked using a bilirubinometer – this is a hand held device, that does not puncture the baby’s skin, that is held against a baby’s skin, usually on the forehead and upper chest.
The final check to confirm whether jaundice requires treatment is a blood test to measure the amount of bilirubin in a small sample of blood. This test will be repeated regularly to monitor bilirubin levels and decide if treatment is needed.
As neonatal jaundice can occur alongside other conditions, additional blood tests and scans may be done to rule out or confirm any other conditions suspected. If jaundice does not clear by two to three weeks of age, additional blood and urine tests may be needed to rule out any underlying problem.
How is neonatal jaundice treated?
Normally, neonatal jaundice develops on day two and three of life and fades without treatment. Babies that develop jaundice should be kept well hydrated, so it is very important to keep feeding the baby regularly as this can help prevent bilirubin levels rising higher.
High bilirubin levels and jaundice that appears in the first 24 hours of life requires treatment to prevent the rare but serious complications that can occur if levels of bilirubin in the body rise too high. Phototherapy (light therapy) is usually the first treatment used. A special kind of light is placed over the baby. The light alters the bilirubin in the baby’s blood and makes it easier for them to pass the bilirubin out of their body. This causes bilirubin levels in the blood to drop. Blood tests to measure the level of bilirubin in the blood will continue to be carried out. When they first start on light therapy the test will need to be done every four to six hours, but once bilirubin levels start to drop the test will not need to be done as often.
While a baby is having light therapy, their eyes will be protected from the light with an eye shield. The nurses will also monitor them regularly to check that they are not too warm or cold and that they are getting enough fluids. Depending on the blood test results, the baby may be able to have short breaks away from the light so they can be fed, have their nappy changed or get a cuddle. If bilirubin levels remain high, phototherapy may need to be given continuously or we may use more than one light to help lower the bilirubin levels, but we will encourage the mother to express breast milk to give to them and take part in their care as much as possible.
Usually babies need light treatment for one to two days. However, sometimes it may need to be given for longer to help keep bilirubin levels down.
If bilirubin levels remain high despite light therapy, an exchange transfusion will be suggested. This is the quickest way to reduce bilirubin levels and involves having a transfusion of donated blood. All blood donated in the UK is thoroughly tested for infection by NHS Blood and Transplant Service. The people who donate blood are carefully selected and the blood they donate is checked to make sure it is suitable. If this treatment is required, the baby will need to be admitted to the intensive care unit for close monitoring.