GENERAL INFORMATION ABOUT JAUNDICE AND BILIRUBIN
- What is jaundice?
- What causes jaundice?
- What is bilirubin?
- What causes the bilirubin to build up?
- How long does jaundice last?
- Does jaundice come back?
- Is jaundice harmful?
- How will I know if my baby has jaundice?
- What if my baby has darker skin?
- Does breastfeeding cause jaundice?
- Why do some babies get jaundiced but not others?
- Is my baby likely to get jaundice?
TESTING FOR JAUNDICE
- How do they test for jaundice?
- How accurate are bilirubin tests?
- Can I ask for a bilirubin test?
- What is a normal bilirubin level?
TREATMENT OF JAUNDICE
- How is jaundice treated?
- How long does it take for phototherapy to work?
- Someone told me to put my baby in a sunny window for jaundice. Does this work?
- Can phototherapy be done at home?
- Does jaundice always have to be treated?
- What is a blood exchange transfusion?
PREVENTING JAUNDICE
- Can jaundice be prevented?
- How can I tell if my baby is getting enough to eat?
- Where can I get help with breastfeeding problems?
THE BABY AT HOME WITH JAUNDICE
- What should I do if my baby already has jaundice?
- How can I tell if jaundice is getting worse?
- What else should I look for when my baby has jaundice?
- If I am breastfeeding, should I give my baby formula?
- Should I give my baby water?
- What should I do if my jaundiced baby will not eat?
- When should I call my baby's healthcare provider or seek medical help because of jaundice?
- What should I tell my healthcare provider?
- When is it better to go to the Emergency Room?
GENERAL INFORMATION ABOUT JAUNDICE AND BILIRUBIN
What is jaundice?
The word jaundice actually means yellow. When someone says “your baby is jaundiced” or “your baby has jaundice”, they mean the same thing – “your baby looks yellow”.
What causes jaundice?
Babies become jaundiced when a chemical called bilirubin builds up in their bloodstream and body tissues, including the skin.
What is bilirubin?
Bilirubin is a waste-product of old red blood cells that the body no longer needs. Under normal circumstances, the liver filters the bilirubin from the blood and passes it to the bowel to be removed from the body in the bowel movements.
What causes the bilirubin to build up?
Some newborn babies produce bilirubin faster than their bodies can eliminate it.
This can happen because…
- Early in life, newborn babies have to take their fetal red blood cells out of circulation and replace them with new, adult-type red cells. Disposing of the fetal red blood cells can load their bodies with a lot of bilirubin in a short amount of time.
- The body systems, especially the liver, that usually process bilirubin and change it into an easily disposable form are not very efficient in the newborn, especially if the baby is a few weeks premature.
- The only way for bilirubin to actually leave the body of a newborn is in the bowel movements. Babies who don’t nurse vigorously or often enough might not have enough bowel movements to eliminate the bilirubin from their bodies.
How long does jaundice last?
Newborn jaundice is usually gone by about 2 weeks of age. However, it should be “fading” (going away steadily) after it peaks around the 4th or 5th day of life. In other words, your baby should not still look as jaundiced at one week old as he or she did when 4 or 5 days old. If so, you should call your doctor and ask for a bilirubin test, even if your baby already had one. The bilirubin level changes over time, and it could still be going up.
In some breastfed babies, the skin can continue to look a little bit yellow for up to 12 weeks. This is related to the breastmilk, and is normal as long as your baby is otherwise healthy and thriving (eating well, gaining weight, developing normally).
Does jaundice come back?
No. Newborn jaundice is limited to the newborn period and does not return.
Is jaundice harmful?
The amount of jaundice experienced by most newborns is not harmful. However, at very high levels, bilirubin is toxic (harmful, damaging) to the brain. What happens is that when the bilirubin level in the blood rises very high or very fast, bilirubin starts to move from the bloodstream into the brain. In the brain, bilirubin can directly harm the brain cells, and actually cause permanent brain cell damage.
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No one knows for certain how high the bilirubin has to get to cause brain damage, or how long it must remain high to cause brain damage. Therefore, if your baby has a high bilirubin level, it is important that it be treated without delay.
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How will I know if my baby has jaundice?
You may have noticed nurses and doctors in the hospital checking your baby for jaundice by pressing their fingers on your baby’s skin to check the color. This is called the visual method of checking jaundice. Press lightly on the skin, as if you are checking a peach to see if it is ripe, and look at the color of the spot where your finger was. If it looks yellow (rather than white), that is jaundice.
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The visual method is only used to decide which babies need a blood bilirubin test or a transcutaneous (“through-the-skin”) jaundice test. The visual method is not accurate for deciding how severe jaundice is. It must only be used under good daylight or fluorescent lighting conditions (next to a window is ideal). The baby should be undressed so different parts of the body (face, chest, abdomen, legs) can be compared.
You may have read or heard that jaundice starts in the face and moves downward (to the chest, then abdomen, then to the arms and legs) as it gets more severe. This is true but it is a very unsafe way to watch a baby’s bilirubin level. It is very important to have a qualified health professional evaluate your baby’s jaundice in person (not over the telephone) first.
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What if my baby has darker skin?
It can be harder to see jaundice in darker skinned babies. Some parents will notice that their baby’s skin color is different, although they might use words such as tan rather than yellow to describe how it looks. Try pressing your finger on the baby’s gums to see the color after you lift your finger. If the spot where your finger was appears yellow, that is jaundice. Another sure place tolook is the white part of the baby’s eyes. If the white part of the eyes appears yellow, see your baby’s doctor.
Does breastfeeding cause jaundice?
Jaundice is more common in babies who are breastfed. However, in the first week of life, it is not the breast milk that is causing jaundice in babies who are nursing, but insufficient breast milk. Some babies do not get enough breast milk in the first 3 or 4 days of life. If they don’t take in enough milk, they won’t have bowel movements, and if they don’t have bowel movements, their bodies won’t eliminate bilirubin.
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Reasons that some nursing babies don’t take enough milk:
- Not feeding often enough. Breast fed babies need to nurse at least 8-12 times per day (every 2-3 hours). When possible, nurse the baby in a quiet room, away from noise and other activities and distractions so both you and the baby can relax and concentrate on the feeding.
- The baby is not latching on correctly, so your baby is sucking only on the nipple and not stimulating the flow of milk. This will make your baby frustrated at the breast. Your baby may suck vigorously for a while and then pull away and cry. If necessary, seek help to get your baby to latch on correctly; this is critical for your baby to get enough milk.
- Over-use of a pacifier. It is important that in these early days that you nurse the baby when your baby acts hungry, rather than using the pacifier. Later on, after your milk supply is well-established and the period of jaundice is over, you can re-introduce the pacifier if you feel your baby just needs to suck.
The baby is sleepy or fussy at the breast, even after crying loudly before the feeding. It is important to respond to your baby’s hunger cues before your baby gets to the point of crying, whenever possible. Early signs of hunger are rooting (when the baby turns his or her head when touched as if looking for food) and sucking on pacifier or fingers. Babies put to the breast when they are in this state.
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Why do some babies get jaundiced but not others?
We don’t know for certain why some babies get jaundiced while others don’t, but there are some definite risk factors for jaundice. Babies that have one or more of these risk factors are more likely than other babies to become jaundiced:
- Babies born more than 2 weeks before their due date
- Babies who had a brother or sister who had jaundice
- Babies who are breastfeeding, especially if they aren’t taking to the
breast very well
- Babies who have bruising or scalp hematomas from birth
- Babies of East Asian race
- Boys
Is my baby likely to get jaundice?
MISSY - Needs to insert answer. Not included in the file.
TESTING FOR JAUNDICE
How do they test for jaundice?
There are 2 types of tests for jaundice. The best test is a blood test called a bilirubin test. (sometimes also called a serum bilirubin or a blood bilirubin test). This test measures the amount of bilirubin in the baby’s blood at a certain point in time.
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A blood or serum bilirubin test (the kind they send to the laboratory) takes about an hour to run and get the results back. The test is not very expensive, ranging from a low of about $25 to a high of about $75 in some areas. When the results come back, they are usually phoned to the nurse or clinic, who contacts the doctor. The doctor then decides if the results indicate that the baby needs treatment for the jaundice, or if the jaundice should just be watched, and how closely it should be watched.
The other type of test is a transcutaneous bilirubin test. Transcutaneous means “through-the-skin”. In other words, it is an instrument that measures the yellow color of the skin and gives an estimation of the blood bilirubin level. Sometimes doctors or nurses will refer to this test as a “Tc bili” or a “Bili check”.
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How accurate are bilirubin tests?
The blood test is more accurate than the skin test. The skin test is usually used just to decide if a blood test is needed.
Although any laboratory test can be inaccurate from time to time, it is always best to assume it is accurate until proven otherwise. In other words, if your baby has a laboratory bilirubin test done that comes back very high (higher than 20 mg/dL), don’t let clinic or hospital personnel, including your doctor, talk you into waiting around to “repeat” the test. Insist on starting treatment for your baby immediately, and having the test repeated while treatment is underway. If the second test comes back lower, fine. If it comes back high, you will be greatly relieved that you didn’t waste time and risk brain damage to your baby.
Can I ask for a bilirubin test?
Yes, you can. Tell your baby’s health care provider that you are concerned about your baby’s jaundice and that you would like to have a bilirubin test done.
What is a normal bilirubin level?
Unfortunately, bilirubin is not like blood pressure or cholesterol, where you can look up what “normal” is, and then compare your baby’s bilirubin level to that normal value. It’s much more complicated.
A very wide range of bilirubin levels is considered normal in the first week of life for healthy term newborn babies. This is because the normal level changes over time as the baby matures during that first week. Doctors and nurses uses special graphs to precisely determine what is normal (or too high) for each individual baby at a specific point in the baby’s life.
What this means is that a bilirubin level that sounds very low, like 8, could be “normal” if it happens when the baby is 48 hours old, but could be quite serious if the baby is only 12 hours old.
- (hungry but still calm) usually feed better.
TREATMENT OF JAUNDICE
How is jaundice treated?
The most common way to treat jaundice is with phototherapy. “Photo” means light, so phototherapy is “light therapy”. The baby is undressed and placed under special lights that penetrate the skin and change the bilirubin chemical to a form that the baby can eliminate from the body more easily.
The good thing about phototherapy is that it starts to work immediately. Circulating bilirubin starts changing into a non-toxic form. It doesn’t hurt the baby.
How long does it take for phototherapy to work?
This depends on how high a baby’s bilirubin is, and how fast it is rising. Some babies will need phototherapy for as little as 24 hours, while others might need phototherapy for 3 or 4 days (or even longer). Your baby’s doctor can give you more information about how long your baby will need phototherapy, and why.
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There are several different types of phototherapy instruments. Some are used only when jaundice is fairly mild. Sometimes nurses will use two or three different phototherapy units at once to increase the intensity of the light and the coverage of the baby’s skin. This if often referred to as “double” or “triple” phototherapy.
Here is a brief rundown of different phototherapy devices you might encounter:
- The Bili Bed
The Bili Bed is a lighted platform that fits into a standard hospital basinette. On top of the platform is a terrycloth “sleeper” that the baby is zipped into. When the unit is turned on, the baby receives phototherapy from underneath. The baby’s eyes don’t need to be covered with this type of unit, and the baby can usually stay in the mother’s room if the mother is still hospitalized. This type of phototherapy is ideal for term and near term babies with moderate jaundice, who are rooming in with their mothers. It is not, however, adequate by itself to treat severe jaundice, especially the type caused by ABO incoompatibility.
- The Bili “Blanket” or Wallaby
The Bili Blanket or Wallaby (two different brands of the same thing) is a fiberoptic blanket. Inside the vinyl blanket are many thin tubes that give off a bluish-colored light. The blanket can be wrapped around the baby’s midsection while the baby is held for feeding, or the baby can lie on top of the blanket for “double” phototherapy when lights are also used from above. Like the Bili Bed, a bili blanket is not adequate by itself to treat severe jaundice.
- Overhead Phototherapy Lights
The traditional lights used in the hospital are overhead phototherapy lights, and they come in many different forms. Some are in banks (rows of fluorescent tube lights), some are spotlights (one or more circular halogen bulbs) and some new instruments use light-emitting diodes. Some give off a white color, and some give off a distinct blue color. The same hospital might have several different types of phototherapy units, but generally they are all designed to do the same thing.
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Someone told me to put my baby in a sunny window for jaundice. Does this work?
Sunlight can reduce jaundice, but this is a very unsafe and ineffective way to treat newborn jaundice. Babies with dangerously high bilirubin levels need to be evaluated in person by professionals, have bilirubin testing done in a laboratory, and have effective treatment using phototherapy lamps.
Can phototherapy be done at home?
In certain cases, it is possible for phototherapy to be done at home, but it is not possible for all babies. Home phototherapy is not as efficient as hospital phototherapy, so it takes longer for jaundice to resolve. It is not used for babies with very high bilirubin levels or for those whose bilirubin levels are rising very fast.
Does jaundice always have to be treated?
Mild jaundice might not be treated. Instead, your health care provider might elect to recheck your baby’s bilirubin level in 24 hours. However, if you take your baby home from the hospital with jaundice, keep the following in mind:
- Your baby’s bilirubin level will probably continue to go up somewhat. It is
very important to go in on time to have the follow-up bilirubin checked. If
your healthcare provider did not order a follow-up bilirubin, ask for one.
- Make sure your baby is getting enough to eat. “Enough” means that the
baby is wetting 6-8 diapers per 24 hour period, having several bowel
movements and is satisfied after feeding. If your baby is nursing and the nursing is not going well, arrange for breastfeeding consultation and get a breast pump to use if you need to supplement your baby.
- If you observe that your baby’s jaundice is worsening or your baby
is showing signs of the harmful effects of jaundice (excessive sleepiness,
refusal to feed, high-pitched cry, irritability, arching of the back or neck,
fever, vomiting) call your health care provider and/or take your baby to
the emergency room.
What is a blood exchange transfusion?
A blood exchange transfusion is another way of treating jaundice, especially when the bilirubin has risen very high in a short period of time. In an exchange transfusion, small amounts of blood are removed from the baby’s body using an umbilical IV and replaced with equal amounts of fresh donor blood. This is repeated until twice the baby’s entire blood volume has been replaced. This removes much of the bilirubin from the baby’s bloodstream.
PREVENTING JAUNDICE
Can jaundice be prevented?
Jaundice can’t be prevented; in fact, a little jaundice is natural and harmless. Severe jaundice, however, can and should be prevented. The 2 most important things parents can do to prevent severe jaundice in their baby are:
- Keep your baby’s follow-up appointments, as scheduled, with your baby’s healthcare provider. These appointments are carefully timed to check your baby for jaundice before it becomes severe. (The ideal time for a health professional to
check your baby for jaundice is when your baby is between 3 and 5 days of age.
If your appointment is later than this, call to reschedule it).
- Make sure your baby is getting enough to eat, particularly if you are breastfeeding. If your baby is not getting enough to eat and you must supplement
temporarily with formula, be sure to pump your breasts to maintain your milk supply.
How can I tell if my baby is getting enough to eat?
Babies who are getting enough to eat will have a wet diaper about every 3 hours, and
MISSY NEEDS TO FINISH THIS SENTENCE
Where can I get help with breastfeeding problems?
Start with the postpartum discharge information you were given when you left the hospital after having the baby. If the hospital provides outpatient lactation services, you should be able to call for an appointment.
You can also perform an internet search using terms such as “lactation consult” and the name of your city to find lactation services in your area.
If you just want to ask questions, you can call the Breastfeeding Helpline at 1-800-994-9662.
If none of these work for you, call your health care provider and ask for lactation assistance.
THE BABY AT HOME WITH JAUNDICE
What should I do if my baby already has jaundice?
If your baby has already been seen by a health care provider, and had a bilirubin check, hopefully you have made a follow-up plan with that health care provider to recheck your baby’s bilirubin in about 24 hours, unless your baby’s jaundice is already going away, and your health care provider doesn’t feel this is necessary.
However, if your baby is less than 5 days old the jaundice is probably still increasing so you do need to have a plan for someone to re-check your baby’s jaundice. This could be done either by having a blood bilirubin test or having your baby seen by your health care provider at about 24 hours after discharge. Again, the reason for this is to try to catch the “peak” of your baby’s jaundice, which is most likely to occur when your baby is about 3-5 days (72-120 hours) old.
How can I tell if jaundice is getting worse?
Undress your baby in good light (daylight, if possible). Go outside if it is warm, or near a bright window. If it is dark, use bright room lights. Compare different parts of the baby’s body, but especially look for jaundice (yellow color) on the legs, arms, and lower abdomen by pressing your finger on the baby’s skin and releasing it. Look for yellow color on the spot where your finger was. Check the whites of your baby’s eyes for yellow color.
Some people have difficulty describing their baby’s color as “yellow” because what they see is orange or tan instead. All of these colors indicate jaundice in a newborn.
What else should I look for when my baby has jaundice?
- Pinkish-orange spots on the diaper that look like face make-up. This can be a sign of dehydration, and might go along with increasing jaundice.
- Not having enough wet diapers or bowel movements
- Excessive sleepiness (won’t wake up to eat), or excessive wakefulness (won’t sleep at all).
- Refusing to eat (possibly spitting up what he or she does eat).
- High-pitched cry
- Limp or tense, or alternating between the two
- Arching his or her back or neck
- Fever (temperature higher than 100oF)
If I am breastfeeding, should I give my baby formula?
If your baby is nursing well (nursing 8-12 times per day, latching on well, sucking well, with evidence of swallowing), and having normal wet diapers and bowel movements, there is really no reason to switch to formula.
However, if you do not think your baby is getting enough to eat, and you wish to give your baby formula, it is best to offer the breast first, then give the bottle. It is very important that you pump your breast afterwards to maintain your milk supply. Save your pumped milk in the refrigerator or freezer.
Should I give my baby water?
No. Newborns should not be given water or sugar water. It will not help jaundice, and may actually make jaundice worse if it causes your baby to take less breast milk or formula. Healthy newborn babies should get all of their fluids from breast milk or formula.
What should I do if my jaundiced baby will not eat?
First. call your health care provider to make an appointment to see him or her in person the same day. Ask for a bilirubin test. If you feel your baby’s jaundice is worse, tell your health care provider on the telephone and arrange to have the bilirubin test done before your appointment to avoid delays.
In the meantime, try to get your baby to take some expressed breast milk or formula by another method. Some babies will “suck” and swallow small amounts of milk from a spoon, syringe, or clean eye dropper; others will suck milk from their mother’s finger. If you can’t get the baby to latch on or suck from the bottle or breast, any amount of milk you can get your baby to take by another method is better than nothing while you are awaiting test results.
After your appointment, if you have been given the “all clear”, breastfeeding moms should seek lactation assistance, if possible. If you don’t have any resource information at all, and don’t know who to call with breastfeeing questions, you could start with the Breastfeeding Helpline, at 1-800-994-9662. Questions can be answered in both English and Spanish.
When should I call my baby’s healthcare provider or seek medical help because of jaundice?
Of course, it’s always best to try to see your health care provider before something becomes a crisis situation. When you first start to realize that your baby is more jaundiced, that is when you should call. It always takes time to arrange for laboratory testing and so forth, and in the meantime, your baby’s bilirubin could keep on going up.
You should also call if your baby refuses to eat or shows any of the signs listed here:
- Pinkish-orange spots on the diaper that look like face make-up. This can be a sign of dehydration, and might go along with increasing jaundice.
- Not having enough wet diapers or bowel movements
- Excessive sleepiness (won’t wake up to eat), or excessive wakefulness (won’t sleep at all).
- Refusing to eat (possibly spitting up what he or she does eat).
- High-pitched cry
- Limp or tense, or alternating between the two
- Arching his or her back or neck
- Fever (temperature higher than 100oF)
What should I tell my healthcare provider?
Because you might be talking to someone who doesn’t know you or your baby, be sure to have the following information ready:
- The date and time of your baby’s birth (how many hours old your baby is)
- Your baby’s birthweight and gestational age, if you know (how many weeks early your baby was born)
- How your baby is feeding now (well, poorly, how often, taking any formula)
- How many wet diapers today, how many bowel movements
- Any episodes of vomiting
- Any fever (temperature higher than 100.4)
- How your baby is behaving (sleepy/not sleeping, crying a lot, arching)
- If your baby has any other risk factors for jaundice (bruise on the scalp, vacuum delivery, different blood type than yours, looked jaundiced in the hospital, lost a lot of weight after birth, did not nurse well, brother or sister had jaundice)
- If your baby had a bilirubin test done before, and what the result was.
If you are concerned about your baby’s jaundice, tell your healthcare provider so, and that you want a bilirubin test done immediately.
When is it better to go to the Emergency Room?
Sometimes your health care provider will tell you to go directly to the Emergency Department, because your baby needs immediate treatment for jaundice, dehydration, or both. Or, you might decide that you need to go the Emergency Department because you can’t get in to see your health care provider, the office or clinic is closed, or your baby seems much worse and you think he or she needs urgent treatment.
Whatever the reason, keep this in mind: if at all possible, take your baby directly (or have him or her taken, if using an ambulance) to the Emergency Department of a hospital that provides Level III neonatal intensive care. Level III neonatal intensive care units (NICUs) are usually found in large medical centers, children’s hospital’s, and university hospitals. If your baby needs a blood exchange transfusion for treatment of jaundice, this procedure can only be done in the Level III NICU, so valuable time will be wasted if your baby has to be transported from another hospital first before the exchange transfusion can be done.
