is the term used when a newborn has an excessive amount of bilirubin in
the blood. Bilirubin is a yellowish-red pigment that is formed and
released into the bloodstream when red blood cells are broken down.
Jaundice comes from the French word
jaune, which means yellow; thus a jaundiced baby is one whose skin color
appears yellow due to bilirubin.
Normally, small amounts of bilirubin are found in everyone's blood.
It is formed and released into the bloodstream when red blood cells are
broken down. It is then carried to the liver where it is processed and
eventually excreted from the body. When too much bilirubin is made, the
excess is discarded into the bloodstream and deposited in tissues for
temporary storage. In the neonate, however, there is more bilirubin than
can be handled due to immature liver functioning and extra red blood cells
that break down. Thus, the extra bilirubin remains in the tissues.
Neonatal jaundice affects 60 percent of full-term infants and 80 percent
of preterm infants in the first three days after birth.
Infants of East Asian and Native American descent have higher levels of
bilirubin than white infants, who in turn have higher bilirubin levels
than infants of African descent. There is an enzyme, glucose-6-phosphate
dehydrogenase (G6PD), deficiency that is more prevalent in infants of East
Asian, Greek, and African descent which causes neonatal jaundice to appear
at approximately the same time as physiological jaundice.
Sickle cell anemia
does not predispose newborn infants to jaundice.
Causes and symptoms
Typically, neonatal jaundice occurs in otherwise healthy infants for two
reasons. First, infants have too many red blood cells and it is a natural
process for the body to break down these excess red blood cells to form a
large amount of bilirubin. It is this bilirubin that causes the skin to
take on a yellowish color. Second, the newborn's liver is immature
and cannot process bilirubin as quickly as the infant will be able to when
older. This slow processing of bilirubin has nothing to do with liver
disease. It merely means that the baby's liver is not as fully
developed as it will be; thus, there is some delay in eliminating the
Breastfeeding is an important risk factor for hyperbilirubinemia in
healthy infants and is related to inadequate maternal milk supply in the
first few days, decreased caloric intake and delayed passage of meconium.
Nonetheless, this is not a reason to give formula or stop breastfeeding.
The breastfeeding mother just needs to nurse the baby more frequently and
for longer periods of time to enhance the production of breastmilk. Other
factors that cause neonatal jaundice are ABO incompatibility and Rh
incompatibility. Both of these conditions result in a very fast breakdown
of red blood cells. It is also possible for jaundice to appear in infants
with physical defects in the organs that work to eliminate bilirubin from
the body. An abnormal increase in red blood cells is frequently seen in
infants who are large or small for their gestational age, as well as in
trisomy syndromes, twin-to-twin transfusion syndrome, maternal-fetal
transfusion, use of oxytocin in labor, Asian male babies, presence of
bruising and cephalohematoma, and a
history of neonatal jaundice.
As the excess bilirubin builds up in the newborn, jaundice appears first
in the face and upper body and progresses downward toward the toes. Most
babies with jaundice have physiologic jaundice, which is the type caused
by the natural process of breaking down red blood cells. If the
baby's jaundice is caused by any other conditions, however, the
healthcare giver will provide the parents with additional information for
caring for the baby.
With short neonatal hospital stays, jaundice will not have peaked or
become apparent at the time of hospital discharge. Therefore, infants at
risk for severe hyperbilirubinemia should be identified so they can be
observed closely both while in the hospital and after discharge. The
parents need to be instructed on how to evaluate the infant for jaundice.
They should look for it first in the face and upper body and if it
progresses downward this means the concentration is getting too high and
it is time to call the pediatrician. If there is an area of their living
quarters that gets sunlight, it helps to let the baby lie there in only a
diaper for a short period of time each day.
Jaundice can be observed with the naked eye, but it is too difficult to
estimate the variation in levels of bilirubin in that manner. Thus, if an
infant begins to appear jaundiced, bilirubin levels will be ordered to
determine the severity. Jaundice usually becomes apparent when total
bilirubin levels exceed 5 mg/dL; however, the clinical significance of
bilirubin levels depends on postnatal age in hours. A bilirubin level of
12 mg/dL may be pathologic in an infant younger than 48 hours but is
benign in an infant older than 72 hours. In the determination of cause, it
is suggested that laboratory testing be reserved for infants with
nonphysiologic jaundice. In up to 50 percent of infants with severe
and lower gestational age were the only causes identified despite
The mainstay in treatment of hyperbilirubinemia is phototherapy, which is
safe and widely available. Its effectiveness was demonstrated in a study
by the National Institute of Child Health and Human Development. Multiple
factors can influence the effectiveness of phototherapy, including the
type and intensity of the light and the extent of skin surface exposure.
Special blue fluorescent light has been shown to be most effective,
although many nurseries use a combination of daylight, white, and blue
lamps. In the early 2000s, fiberoptic blankets have been developed that
emit light in the blue-green spectrum, which is light at a wavelength of
425–475 nm. Light at this wavelength converts bilirubin to a
water-soluble form that can be excreted in the bile or urine. The
intensity of light delivered is inversely related to the distance between
the light source and the skin surface. Since phototherapy acts by altering
the bilirubin that is deposited in the tissue, the area of the skin
exposed to phototherapy should be maximized. This has been made more
practical with the development of fiberoptic phototherapy blankets that
can be wrapped around an infant.
Home-based care for neonatal jaundice has become more prevalent than
hospital care, and the availability of fiberoptic blankets has made it
possible. Infants receiving home phototherapy need daily visits by a
nurse, who performs a physical examination and measures the total serum
bilirubin level. If bilirubin levels continue to rise, hospital
readmission should be considered. Discontinuation of home phototherapy is
safe once the total serum bilirubin level has decreased to less than 15
mg/dL in healthy full-term infants older than four days. Office evaluation
within two to three days of discontinuing home phototherapy is
Potential side effects of phototherapy used for elevated bilirubin levels,
, increased water loss, skin rash, and transient bronzing of the skin.
Many infants who are readmitted to the hospital because of
hyperbilirubinemia are mildly to moderately dehydrated. Breastfeeding
should be increased to every two to two and a half hours. Increased
feedings can increase peristalsis and meconium passage, decreasing
bilirubin resorption into circulation.
Full-term infants rarely require an exchange transfusion if intense
phototherapy is initiated in a timely manner. It should be considered if
the total serum bilirubin level is approaching 20 mg/dL and continues to
rise despite intense in-hospital phototherapy. Exchange transfusion
corrects anemia associated with the destruction
A newborn baby undergoes phototherapy with visible blue light to
treat his jaundice.
(Photograph by Ron Sutherland. Photo Researchers, Inc.)
of red blood cells and is effective in removing sensitized red blood
cells before they are destroyed. It also removes about 60 percent of
bilirubin from the plasma, resulting in a clearance of about 30 percent to
40 percent of the total bilirubin. If a transfusion is not performed and
bilirubin levels get higher, the infant progresses through three phases.
In the first two to three days the infant is lethargic, has muscle
weakness, and sucks weakly. Progression is marked by a tensing of the
, seizures, and high-pitched crying. In the final phase, the patient is
hypotonic for several years.
The prognosis for physiological neonatal jaundice is generally very good.
Very few infants ever have bilirubin levels greater than 20 mg/dL, which
is the level that is correlated with kernicterus (an abnormal accumulation
of bile pigment in the brain and other nerve tissue that causes yellow
staining and tissue damage). It rarely occurs with bilirubin levels lower
than 20 mg/dL but typically occurs when levels exceed 30 mg/dL. Levels
between 20 and 30 mg/dL associated with
and hemolytic disease may increase the risk of kernicterus. There are
long-term neurological problems when this occurs. Affected children have
marked developmental and motor delays in the form of
may also be present.
Elevated bilirubin in the neonate is the most common reason for hospital
readmission in the first two weeks of life. Kernicterus is still
relatively uncommon but has been on the rise with the mandated early
postnatal discharge policies. Bilirubin-induced complications can be
prevented by introducing a neonatal jaundice protocol to identify infants
at risk for significant bilirubin increases, by ensuring adequate parental
education and providing for follow-up care.
—The reaction that occurs with blood groups that are of a
—A benign swelling of the scalp in a newborn due to an effusion
of blood beneath the connective tissue that surrounds the skull, often
resulting from birth trauma.
—A potentially lethal disease of newborns caused by excessive
accumulation of the bile pigment bilirubin in tissues of the central
—A greenish fecal material that forms the first bowel movement of
—A hormone that stimulates the uterus to contract during child
birth and the breasts to release milk.
—Slow, rhythmic contractions of the muscles in a tubular organ,
such as the intestines, that move the contents along.
—A factor of blood classified as negative or positive and related
to the reaction that occurs between different types.
—An abnormal condition where three copies of one chromosome are
present in the cells of an individual's body instead of two, the
Klaus, M. H., and A. A. Fanaroff.
Care of the High-Risk Neonate
, 5th ed. Philadelphia, PA: Saunders Company, 2001.
Olds, Sally, et al.
Maternal-Newborn Nursing and Women's Health Care
, 7th ed. Saddle River, NJ: Prentice Hall, 2004.
Seidel, H. M., et al.
Primary Care of the Newborn.
St. Louis, MO: Mosby, 2001.
Morantz, C., and B. Torrey. "AHRQ report on neonatal jaundice:
Agency for Healthcare Research and Quality."
American Family Physician
(June 1, 2003).
Association of Women's Health, Obstetric and Neonatal Nursing.
2000 L Street, NW, Suite 740, Washington, DC 20036. Web site:
American Academy of Pediatrics.
141 Northwest Point Blvd., Elk Grove Village, IL, 60007. Web site:
American College of Obstetricians and Gynecologists.
409 12th Street, SW, PO Box 96920, Washington, DC 20090. Web site: