By Beverly Ann Curtis, APRN, PNP-BC, IBCLC

A common condition in newborns, jaundice refers to the yellow color of the skin and whites of the eyes caused by the presence of a substance called bilirubin in the blood.

Bilirubin is produced by the normal breakdown of red blood cells. Almost all newborns become jaundiced, no matter how they are fed. There are many types of jaundice, some more serious than others. This note discusses jaundice: it’s causes and treatment.

What Causes Jaundice?

While the baby is growing in the womb, the baby needs special red blood cells that easily carry and deliver lots of oxygen (fetal hemoglobin). These cells release oxygen readily to the parts of the baby’s body that need oxygen such as the developing brain, gut and heart. After the baby is born, the baby easily gets oxygen while breathing so there is no more need for these special red blood cells. These red blood cells (fetal hemoglobin) begin to break down and the by-product is called bilirubin. While the liver’s job is to move the bilirubin out of circulation, the liver is immature, or “sleepy” and is slow to process the increasing bilirubin. This causes the bilirubin to be deposited in the baby’s fat, until it can be processed later. Bilirubin’s color is yellow. Once deposited in the fat under the skin, the baby starts to look yellow. This happens in the first several days of life.

Usually the yellow “look” starts in the eyes and face and then travels to include the chest, abdomen, and then, if still rising, to the legs and feet. Once the bilirubin levels begin to clear, it clears from the feet up, with the whites of the eyes usually last to clear. If you are not sure if your baby is yellow, check with your doctor. Always consult your baby’s doctor if the yellow color is a new finding or if you have a question regarding your child’s color, feeding or jaundice.

Types of Jaundice in the Newborn Period

They are physiologic jaundice, jaundice related with poor feeding, breast milk jaundice (human milk jaundice syndrome), jaundice caused by hemolysis or increased bilirubin production, and jaundice caused by inadequate liver function (due to inborn errors of metabolism, prematurity, or enzyme deficiencies).

• Jaundice caused by the normal breakdown of fetal blood cells is called physiologic jaundice. The baby’s body does not get rid of bilirubin very efficiently in the first days of life. This type of jaundice peaks on day 3-4 of life and usually resolves by day 7-10.

• Jaundice related to poor feeding is caused by a lack of calories, dehydration, or insufficient milk intake and occurs in about 13% of breastfed babies. It may happen in babies who are not taking in enough breast milk, latching poorly, or not transferring milk from mother to baby well. Regardless of whether an infant is breast of bottle-fed, if they are not feeding well, they may lose weight which delays the passing of bilirubin causing them to not have enough stools and have a yellow appearance.

• Jaundice caused by a substance in breastmilk also called human milk jaundice syndrome is harmless, occurs in about 2% of healthy thriving babies who are usually several weeks old and have persistent jaundice. It may be caused by a substance in breast milk that blocks or delays the elimination of bilirubin.

• Jaundice caused by hemolysis, or a rapid breakdown of red blood cells, may be from mismatched blood types in mom and baby such as Rh disease, which usually occurs within the first 24 hours of life. It occurs before the baby leaves the hospital and can be concerning or considered harmful.

• Jaundice caused by inadequate liver function impaired by an infection or disease is usually recognized in the first day or two of life before the baby leaves the hospital. This is a concerning and requires medical intervention.

• Jaundice caused by prematurity occurs frequently in infants younger than 37 weeks gestation, since the liver is more immature than the term infant. Premature babies are more at risk for complications; therefore jaundice is treated at a lower bilirubin level than in full term babies.

Your baby should be checked for jaundice anytime the baby appears yellow, when he or she is 36 hours old, as well as between three and four days old, when bilirubin levels usually peak. Therefore, you should have a follow-up appointment with your baby’s provider, to check for jaundice within one to two days of discharge from your birthing facility.

Call the Baby’s Pediatric Provider if:

• Your baby’s skin becomes more yellow or looks yellow on the abdomen, arms or legs.

• Your baby seems very sleepy, sick or difficult to wake.

• Your baby is feeding poorly.

• Your baby is not gaining weight, peeing or stooling well.

• Your baby makes high-pitched cries.

• You are worried about your baby.

• Your baby’s jaundice is not going away

So What’s the Big Deal?

When jaundice levels rise quickly and are high, there can be a complication that is more serious, although very rare. No one knows at exactly what level more serious things begin to occur. But the more serious levels of jaundice can lead to the body depositing bilirubin in other available fat storage area, and those are in the brain. Bilirubin deposits in the brain, though rare, are known as kernicterus. Once kernicterus occurs, neurologic problems may follow and your baby is considered very ill.

Because the rise in bilirubin is unpredictable by just looking at the baby, researchers developed charts to help providers determine the level of jaundice, and the need for intervention to avoid more serious complications. Your doctor may refer to these charts when discussing jaundice with you.

Bilirubin levels can vary rapidly over a period of one day. The change can be quite significant, and may determine the next step for treatment, your provider may choose. Often on the internet, individuals will write comments regarding bilirubin numbers such as,” if your baby’s bilirubin number is below 20, it is not that serious.” This simply is not true. One can’t use the bilirubin “number” as a solitary or simple measure of the seriousness of jaundice. The treatment of jaundice depends on a relationship between several indicators: the bilirubin level, along with age of the infant, and several other factors, including feeding. The baby’s gestational age is a significant factor in evaluation, as well as the age of the baby in hours. Other factors such as the rate of rise of bilirubin over time is important, as well as the blood type and compatibility between mother and child, or the presence of other medical or metabolic issue with the mother or baby.

If your baby’s jaundice level is 9 at 36 hours and then 17, at 48 hours, the rate of rise in 12 hours is considerable and is predictable that it may continue to rise quickly in the next 24 hours, depending on the cause. If the level is 9 and the next day 10.5, the rate of rise is not as significant, however may be concerning if the infant has other risk factors. Jaundice is not normal when the baby looks jaundiced in the first 24 hours of life. Jaundice is considered serious in term newborns when bilirubin levels are greater than 17 milligrams per deciliter of blood, if the bilirubin rises more than five milligrams per deciliter per day, or the direct bilirubin is elevated.

The bilirubin testing is done by a transcutaneous reading (a painless light meter measures the bilirubin level through the skin on the forehead or chest) or by taking a sample of blood, through a heel prick. Most hospitals now are following the protocol set by The Joint Commission and recommended by the American Academy of Pediatrics, requiring infants to receive a bilirubin test at 36 hours of age. This is the standard age for beginning screening. If your child appears jaundice prior to 36 hours of age, it is important that the level be checked when the jaundice is first noticed. Some infant’s may have a bilirubin level that could change significantly overnight indicating a need for phototherapy.

Treatment of Jaundice

Most babies with jaundice, have uncomplicated jaundice, and will not need treatment if the infant is feeding well. Jaundice in formula-fed and breastfed infants will usually clear up in 2-3 weeks.

Frequent and Efficient Feeding: It is recommended that breastfeeding mothers maximize breastfeeding if the baby is jaundiced. Breastmilk acts like a natural laxative moving the first stools through the baby’s system, helping to excrete bilirubin. So, with more feeding, the more breastmilk intake, and the more stooling, the more the bilirubin level is likely to lower and the jaundice goes away. Offer the breast frequently every 2-3 hours, practicing proper positioning and latch. Don’t allow your baby to sleep at the breast but encourage active, frequent feeding, using breast compression during feeds to keep baby actively feeding. Pumping after feedings may help to increase milk supply or maintain it.

If your baby is sleepy with feeds or not feeding well, supplementation with pumped milk or formula may be necessary. Consulting a lactation consultant during this time will help you maintain your breastfeeding and milk supply until the jaundice resolves. Frequent bilirubin checks, feeding and weight checks, and communication with your physician during this time will help you identify successes with treatment and keep you informed of your baby’s progress. Be sure to understand the plan of supplementation if necessary, pumping to increase your milk supply and when supplements are no longer necessary. Remember jaundice may cause your baby to become sleepy, have difficulty feeding and difficulty getting sufficient milk from the breasts. This is typically a short-term difficulty that resolves on its own rather easily, once the jaundice begins to improve, usually in 24-72 hours.

Remember, it is rarely necessary to stop breastfeeding when your child has jaundice. If it is suggested that feeding is supplemented, supplementation during this time is usually transient, can be done after breastfeeding with pumped mother’s milk and, if necessary, formula. Call your provider with questions or if you are concerned about your infant. Remember the Lactation Consultant and the baby’s provider are great resources when your baby is jaundiced.

Phototherapy: An intervention to speed up or help with clearing of the bilirubin is phototherapy. Your baby is placed under special lights that work to break down the bilirubin deposited under the skin. This can be done at home with a special blanket with fiber-optic light called a bili-blanket, ordered by your physician through your insurance or in the hospital with a special bed with phototherapy lights or a fiber-optic blanket. Occasionally mother and baby are separated during this time, depending on the level of jaundice, the need for phototherapy, the infant’s feeding patterns and other medical complication or concerns.

Maintaining your milk supply by pumping both breast simultaneously after breastfeed or every 2-3 hours, using a pump supplied by the hospital (a multi-user rental pump) or if necessary, your own double pump, is important in this transitional time. Your baby will be weighed daily and have frequent bilirubin checks. Consulting with a lactation consultant will give you the support you need to maintain your breastfeeding and milk supply until the jaundice resolves. Discuss with the attending physician alternative feeding methods such as supplementation with your pumped milk, donor milk, or formula.

Follow the advice of your provider while discussing the importance of breastfeeding for you and your baby. Many mothers find by maintaining milk supply and breastfeeding as a priority, they are able to continue to breastfeed well, through jaundice and once jaundice is resolved.

Bev Curtis is the former Executive Director of the Breastfeeding Center of Pittsburgh.