It can be a scary sight for new parents – a sickly, yellowish hue on their newborn’s palms, soles of the feet, and in the whites of the eyes. It’s jaundice, and in infants, it can’t be prevented.
As disturbing as it can be to see, though, it isn’t necessarily a cause for immediate concern. According to pediatric gastroenterologist Naim Alkhouri, MD, jaundice in newborns – neonatal jaundice – occurs frequently and might not require treatment.
“Neonatal jaundice can be a common finding in the first two weeks of life,” he says. “The majority of cases can spontaneously resolve.”
There are, however, instances where treatment is necessary.
Jaundice is the yellow discoloration of skin or the whites of the eyes due to an increase in the bile pigment bilirubin in the blood. Bilirubin is the yellow byproduct from the breakdown and excretion of red blood cells from the body.
There are two jaundice forms: physiologic and cholestatic. While physiologic jaundice occurs frequently and can disappear easily, Dr. Alkhouri says, cholestatic jaundice can strike at any point and can indicate the presence of liver disease.
Approximately 60 percent of newborns will develop jaundice shortly after birth. However, according to neonatologist William Zaia, MD, only about 1 percent of babies are hospitalized for this condition.
It’s important to remember that after a child is born, jaundice can appear either before or after she leaves the hospital, Dr. Alkhouri says.
Causes: Physiologic jaundice usually results from the increased production or impaired uptake of bilirubin from hemoglobin in the blood, or what doctors call unconjugated hyperbilirubinemia. It can also come from breast milk jaundice, which develops when proteins in breast milk block the liver from breaking down bilirubin. Breast milk-induced jaundice is uncommon and usually not severe.
Risk factors: While jaundice can affect the majority of infants, there are several factors that can put a child at greater risk. Breast-fed babies, infants of mothers with diabetes, East Asian children, premature or low-birth-weight infants, children with a previous sibling with jaundice, and babies born at high altitudes are often more likely to develop the condition. Breast-fed babies tend to have higher physiologic jaundice than formula-fed babies. However, breast feeding is encouraged and, when not yet established, supplements with expressed maternal breast milk and/or formula may be recommended by the caregiver to prevent bilirubin from rising to dangerous levels.
Negative outcomes: If hyperbilirubinemia levels rise too high – above 25 mg/dL – the risk for bilirubin-induced neurologic dysfunction jumps. This condition occurs when bilirubin crosses the blood-brain barrier and binds to brain tissue. The result is neurological damage.
Diagnosis & treatment: Pediatricians assess newborns every 12 hours during the hospital stay. They decide whether to test for jaundice based on visual evaluation in combination with any known risk factors, including breastfeeding. Yellow palms and foot soles, dark urine, and pale or yellow- or orange-colored stools can indicate jaundice.
In mild cases, providers will likely opt for a wait-and-see approach with infants. Any cases lasting longer than two weeks require further investigation, Dr. Alkhouri says, to determine whether it’s unconjugated hyperbilirubinemia or cholestatic jaundice.
Two therapies are available, if warranted:
Phototherapy: Exposing babies to a specific light wavelength can alter bilirubin into a form that the liver can more easily break down and excrete from the body. “Phototherapy can be administered at home, but do not expose a naked infant to sunlight,” Dr. Alkhouri says. “The risk of sunburn is too great.”
Exchange blood transfusion: In more severe jaundice cases, doctors will remove a small amount of the baby’s blood and replace it with blood from a matching donor.
This jaundice form is associated with higher levels of conjugated – or water-soluble – bilirubin, indicating a problem with liver and bile duct function. It affects approximately 1 in 2,500 infants, Dr. Alkhouri says, and liver transplants can be necessary in some cases.
Causes: One of the most common causes of cholestatic jaundice is biliary atresia, a blockage of the bile ducts outside the liver, he says. The condition is universally fatal within two years if left untreated. In some cases, genetic or metabolic disorders can put infants at risk for cholestatic jaundice, as well as infections and certain medications.
Symptoms: Cholestatic jaundice has many of the same characteristics as neonatal jaundice – yellow skin, pale or clay-colored stools, and dark urine. Yellow sclera – a yellowing of the whites of the eyes – can also be present.
Serious-case treatment: If cholestatic jaundice is diagnosed, the infant should be immediately referred to a pediatric gastroenterologist for further evaluation, Dr. Alkhouri says.
To reach that goal, Dr. Zaia and fellow neonatologist and Chairman of Cleveland Clinic’s Department of Neonatology Ricardo Rodriguez, MD, created a care path that involves testing bilirubin levels for all newborns with risk factors for jaundice at 12 hours of age by flashing a light onto the infant’s head or chest. This light removes any artificial light tint from the room, revealing the skin’s true color. Doctors can determine the bilirubin level based on the shade of the skin.
If the bilirubin level is high, the pediatrician will test the blood-bilirubin level and start phototherapy if that level is high, as well, Dr. Zaia says.
All follow-up bilirubin tests are blood tests. If needed, an exchange transfusion is also included in the care path. Parents receive information about jaundice, risks, management and follow-up both before and after the infant’s discharge. Breastfeeding is encouraged, but bottle-feeding is allowed if breastfeeding is unsuccessful.