Module 5: Jaundice
Most parents will hear the term jaundice in the first week of their infant’s life, and it can feel like a confusing and scary diagnosis. While some newborns end up needing treatment, the majority do just fine with a consistent feeding regimen and close monitoring.
How Common Is Jaundice?
Super common! About 3 in 5 infants (60%) will have jaundice. In most babies, this is physiologic jaundice, meaning that it’s an expected finding due to immaturity of the infant’s liver. The liver metabolizes a substance called bilirubin, which is waste from broken-down red blood cells. Since the liver isn’t fully mature at time of delivery, it may struggle with clearing bilirubin more quickly than it’s receiving it, and levels rise. As your newborn grows, the liver is able to meet it demands, allowing levels to go down and stay down.
What And How Is Jaundice Tested?
When: Jaundice is checked in the first 5 days of life. This is why a newborn visit with your PCP is recommended soon after discharge from the hospital.
How: There are two ways to test for jaundice.
Transcutaneous Bilirubin Meter: This is held above the skin and estimates bilirubin levels. The upside is that it’s non-invasive, easy to carry out, and results are instant. However, it’s much less accurate than the other option. As a result, it’s used more for screening in the nursery, rather than for trending after detecting high levels.
Blood Draw: This is usually from the foot, and is very accurate. This makes it ideal for close trending of higher levels to determine if treatment is needed. In those who end up receiving phototherapy, it also determines when the lights can be discontinued.
Can I Tell How Jaundiced My Newborn Is By Looking At Him/Her?
Yes and no. The exam is helpful in some ways. Jaundice first appears in the eyes and face, then goes downwards as it worsens. An infant with yellow skin down to the abdomen will typically have higher bilirubin levels than one with just a yellow face. However, this rule of thumb is limited when it comes to darker skin tones, so we can’t rely on it alone.
Your PCP will usually use additional information to determine if further testing is necessary. This includes feeding amount/frequency, weight gain or loss, if stools have started transitioning (meconium to yellow seedy stools), and how alert and hydrated your infant is on exam.
How Do I Know If Jaundice Is Getting Better Or Worse?
The only way to know for sure is with labs. However, there are other signs on examination we can use to help make a determination.
Improvement: Weight gain, transitioning of stools (dark/tarry to green/sticky to yellow/seedy) and fading of yellow skin/eyes. Most bilirubin is cleared through the stool, so the more dirty diapers you see, the lower levels will get.
Worsening: Seeming lethargic, extended sleeping, not waking for feeds, a sunken fontanelle, more obvious yellowing of the skin and eyes, and listlessness. If you notice these signs, contact your doctor or go to the ER immediately.
How Is Breast/Chest-Feeding Related To Jaundice?
Breastfeeding Jaundice: There can be difficulties establishing breast/chest-feeding in the first week of life, either due to supply, troubles with latching, tricky anatomy with the nipple or areola, or confusion surrounding hunger and fullness cues. As a result, the infant consumes less milk, creates and excretes less stool, and it takes longer for jaundice to resolve.
Breast Milk Jaundice: Infants who are breast/chest-feeding and gaining weight well can sometimes still have elevated levels. This is suspected to be due to a component of breastmilk that can slow metabolism and elimination of bilirubin. This type of jaundice can last up to weeks, though isn’t the kind that causes neurologic damage. There isn’t anything to do other than keep feeding and see your doctor as recommended (they may continue to trend levels routinely until they’re consistently decreasing).
Should I Supplement If I’m Breast/Chest-Feeding?
This is a question with lots of debate, and the answer is that it depends on your individual situation. In infants with feeding difficulties that are struggling to gain weight (especially if there’s no access to or means of affording lactation consultants), formula supplementation is often helpful until bilirubin levels stabilize. If there are other causes contributing (like a red blood cell mismatch between mother and infant, which increases breakdown and leads to higher bilirubin levels), supplementing temporarily can help mitigate the severity of jaundice.
If exclusive breastfeeding is important to you, you can also try pumping, syringe feeding, and SNS (supplemental nursing system) feeding if you have pumped milk available. Or, you can reach out to a lactation consultant to troubleshoot feeding difficulties and ensure successful milk transfer. An additional option is fortifying your breastmilk with formula for extra calories (consult your PCP).
It’s best to discuss this with your Pediatrician to figure out the right solution for you and your family. Just remember, if supplementation is needed, that’s totally OK! A temporary supplement will usually not disrupt breastfeeding long-term if that’s your ultimate goal, as long as you pump during that time to maintain supply and continue skin-to-skin.
When Is Jaundice Bad Enough To Need Treatment?
It depends on how old your newborn is (in terms of hours of life), in addition to any other risk factors (such as prematurity or a known mother/infant red blood cell antigen mismatch). Often, it’s a bilirubin level around 15 and above, though can be higher or lower depending on age and risk.
What Is Phototherapy?
This is a treatment that uses a special type of blue light to hasten bilirubin removal from the body. It involves units that shine light onto your newborn from different directions, and can come with or without a special blanket (Bili Blanket). Your baby will wear eye protection when receiving phototherapy, since extended exposure to this type of light can cause retinal damage.
The amount of time that this therapy is applied depends on how quickly your infant’s bilirubin levels come down, though is typically 1 day or less. You can remove your infant for short durations to feed them and do skin-to-skin. However, the majority of their time should be spent in the incubator.
What Will Happen If My Child Gets Admitted To The Hospital?
The hospital will draw labs to trend your baby’s bilirubin levels every few hours while he or she continues phototherapy. They may order additional labs to see if there’s issues with the infant’s red blood cells or an infection. They’ll encourage feeds every 2-3 hours and may get a lactation consult to help you with feeding if you’re having latching issues. Once levels go below a certain level (usually 13-14), they can go home. In rare cases, the hospital may re-check the jaundice level again after the lights are off to ensure the level stays low.
What Are Other Jaundice Therapies?
Home Bili Blanket: Some health systems and doctor offices will recommend home treatment with a Bili Blanket for mild jaundice, depending on access and insurance coverage. This is a mat that remains underneath your infant and emits blue light upwards. It’s combined with lab draws to ensure it’s effective. The upside is that it avoids a hospitalization, while the downside is that it can’t be used for severe jaundice requiring more intensive phototherapy.
Sunlight: Sunlight can work similar to phototherapy, though it’s important to make sure that it is indirect (through a window and away from harsh rays) and controlled (15 minutes 2x/daily), since it also contains harmful UV rays that can cause sunburns. This treatment is meant for mild jaundice, and works best in when the child is in just a diaper (ensure your home’s temperature is appropriate so that your infant doesn’t get too cold).
Feeding: This is the ultimate treatment. Make sure to feed, feed, feed once your newborn demonstrates hunger cues! Usually, this is every 2-3 hours in the first week, though some infants may cluster feed, opting for more frequent, smaller feeds. Try not to let your infant go longer than 3 hours without feeds if they’re jaundiced, including overnight, even if that means you need to wake them. Keeping a feeding diary of frequency and volume is helpful.
