Jaundice appears in 50-70% of all newborns. However, premature babies are most at risk. It is a yellow discoloration of the skin and eyes due to accumulated bile pigments (bilirubin) in the blood. Bilirubin is derived from the breakdown of hemoglobin in RBCs. Visible jaundice indicates a bilirubin level of at least 5-7 mg/dL.
There are several types of jaundice, most of which fall into the category of normal physiologic jaundice. Any mild jaundice starting between day 3 and 5 is generally not a concern. A slight yellow shade to the face and down to the nipple line is normal in the first five days. It is unusual to see the yellow coloring extending into the extremities or below the nipple line.
Characteristics of normal physiological jaundice include:
- Not visible in the first 24 hours.
- Rises slowly and peaks at the 3rd or 4th day of life.
- Total bilirubin peaks at less than 13 mg/dL.
- Usually resolves in 5-7 days.
- In a premature infant this jaundice may peak around the 5th day.
Breastmilk jaundice is a term for a type of jaundice that is not entirely clear. Studies have shown that breastfed babies may have higher levels of bilirubin for an increased length of time compared to formula fed babies. Other studies propose that this is actually a protective effect and that these higher levels are in fact a good thing. Possible theories are that jaundice is caused by a hormone in the mother’s milk, others are thought that there is a substance in the breastmilk which can interfere with the baby’s ability to break down bilirubin. This type of jaundice seems to only manifest after the milk comes in. Treatment is seldom necessary and usually resolves itself within 2 months. This occurs in 2-4% of babies and peaks around day10-15. Bilirubin levels are 12-20 mg/dL between days 8-15. If breast feeding is discontinued the bilirubin level falls within 24-48 hours.
Most forms of physiological jaundice are harmless and self-correcting. However, occasionally they can cause a baby to become lethargic and disinterested in nursing. Sever hyper-bilirubinemia can lead to kernicterus, which can cause permanent brain damage.
Warning signs necessitating an immediate referral to a pediatrician are:
- Jaundice at birth
- Yellow coloring below the nipples
- Disinterest in feeding
- Concentrated urine
- Any sign of jaundice within the first 24 hours.
Any jaundice with these warning signs may be Pathological Jaundice which is much more serious. Pathological Jaundice is caused by an obstructed bile duct, liver disease, infection or Rh hemolytic disease. It generally manifests within the first 24 hours and should be referred to a pediatrician for evaluation. High levels of bilirubin may be impossible for the baby to eliminate and could lead to kernicterus. Kernicterus is the name given to the disease in which too much bilirubin in the brain causes brain damage.
Characteristics of Pathological jaundice include:
- Visible jaundice in the first 24 hours.
- Levels may rise quickly
- Total bilirubin greater than 13 mg/dL
- Visible jaundice persists after one week
Rh negative mothers should always be treated with extra precaution. At the birth, cord blood
may be drawn to check the baby’s blood type. Rhogam may be given to any mother that delivers an Rh positive baby. Blood typing and direct coombs can be run on the cord blood and the results forwarded to a pediatrician if necessary.
ABO Incompatibility is also of interest as it can sometimes appear as pathological jaundice but is not. This incompatibility happens if blood from an O type mother transfers to her A or B type baby, causing an excess in bilirubin. It may manifest as early as 24 hours and should be immediately referred to a pediatrician to ensure that it is not pathological. ABO-incompatibility jaundice seldom requires treatment. This diagnosis can be confirmed with a blood test. Mothers with O blood type should be offered a blood test with the baby’s cord blood at birth to avoid a blood test later.
Treatment and prevention of jaundice can be safe and easy for a new family. If the baby is showing symptoms within the 2nd to 7th day of life with yellowing not exceeding the characteristics stated above for psychological jaundice, these options may resolve the issue.
- Frequent nursing every 1 ½ -2 hours during the day and at least every 3 hours at night.
- Keep the baby in sunlight with body naked and eyes protected for 5 minutes at a time, taking care to protect the eyes and skin from sunburn. The baby can also be put near a sunny window for 5 minutes at a time, 2-3 time/day.
- Do not give the baby formula because it does not help flush out bilirubin but can make the baby constipated from the iron added. This will only make the jaundice worse.
- Consult with a pediatrician if lethargy and irritability are noted or if the yellowing is below the nipple line. If the baby is still jaundiced after a week, he/she should be seen by a pediatrician.
- Possible treatment with a physician may include: blood testing(plasma bilirubin levels and other blood tests), phototherapy, or an exchange transfusion.
- Shake off any suggestion that something about your milk is bad for your baby. As long as your baby is otherwise healthy, jaundice is short-lived and harmless. If your baby’s jaundice is related to other health problems, your milk is very valuable for him and you should continue to breastfeed.