Jaundice: a Physiological Process

What is Jaundice? 
Jaundice describes when a baby has a high level of bilirubin in the blood. Bilirubin is a yellow pigment which is byproduct of the breakdown of red blood cells that would usually be cleared from the body by the liver(1). The trouble is that the newborn liver is not mature enough to break down such large quantities of bilirubin just yet(2), so much of it remains in the blood stream until it is processed. More than half of full-term babies have bilirubin levels which cause them to be yellow, or jaundiced, which is a normal, physiological occurrence(3). Jaundice will usually resolve within the first week to several weeks of life and normal levels peak between the 3rd and 5th day before starting to fall. Bilirubin may also benefit our babies’ bodies as they mature since they have very few antioxidants in their systems and bilirubin is an antioxidant! It is important to consider the bilirubin levels in relation to the baby’s gestational age as well as their age at the time of the test(3). While most cases of jaundice are normal, and resolve with frequent breastfeeding, there are instances of pathological jaundice which present as rapidly rising levels or high levels of bilirubin within the first day or two(2).

Causes  
Three factors contribute to normal, physiologic newborn jaundice. The increased bilirubin production, increased re-absorption, and limited ability of the liver to process the large amounts of bilirubin(2). What is commonly referred to as “breast milk jaundice” does not really exist. This could be more accurately called “lack of breast milk jaundice” or “starvation jaundice” which may result from inadequate intake due either to supply being slow to expand or a poor latch(3). Although jaundice is usually physiologic, sometimes there is a pathological cause behind jaundice, especially if it occurs within the first day or two of life. One is ABO blood incompatibility[2] and occurs when a mother is O type and her baby is either A, B, or AB blood type this may result in higher levels, but resolves like physiologic jaundice with frequent feeding and time in most cases. Additionally, any condition which may interfere with processing of bilirubin by the liver or that increases re-absorption of bilirubin by the bowel, or any condition which causes there to be additional blood cells for breakdown, such as bruising during birth(2) may result in higher levels of bilirubin.  Some ethnic groups have higher physiologic bilirubin levels as well, such as Chinese, Japanese, Korean, Native American, and South American babies. Induction by synthetic oxytocin, called Pitocin, also increases instances of newborn jaundice(4).

My oldest son, Aiden, was pretty orange. he is 10 days old in the picture above. He was never lethargic or ill, just going through a normal process.  Two of our three kids had ABO incompatibility. He had a good "tan" for several weeks and people regularly commented on what a nice complexion he had! "Yea, Bilirubin can do that!"

Symptoms
For normal jaundice the baby’s skin will appear yellow usually on the face, including the whites of the eyes and may descend down to the chest, belly, and in severe cases even down to the legs and feet(1). Generally these babies wake to feed regularly and poop normally (at least the number of poopy diapers a day as days old the baby is). If the jaundice is pathological in nature the baby will be extremely sleepy, difficult to wake, will not wake regularly for feeding1 and may not be having normal amounts and types of poopy diapers.

Treatment
The goal of treatment is to prevent a condition called kernicterus which is a dangerous neurological disease that may be linked to high levels of bilirubin, although not all babies with high bilirubin will get kernicterus and not all babies with kernicterus had high bilirubin(3). More often than not, frequent breastfeeding will eventually, and physiologically, clear the bilirubin1 without interrupting breastfeeding or potentially disrupting it by introducing an unnecessary supplement. Additionally, colostrum has a laxative effect on the baby which helps with passing excess bilirubin and reducing the occurrence of jaundice(5) so breastfeeding frequently in the first days is extremely important. The doctor will base treatment options for the baby on the bilirubin level, the baby’s chronological age, gestational age, and how well the baby is feeding (ideally)(3).

If the baby’s levels are troublesome the treatments include a few options. Many physicians choose a watchful waiting approach to monitoring the baby with levels below 20mg/dL, and some will simply monitor a baby in the 20-25mg/dL range if the levels are not rising rapidly and if they appear to be reaching peak(2). At home it is important to breastfeed at least every 2 hours, and to identify and address any breastfeeding difficulties(3,2) which may be interfering with the baby getting enough breast milk. By increasing and improving breastfeeding, the baby will be prompted to poop more which will help get the bilirubin moving out of the system more quickly(2). It may also benefit the baby to be in the sunlight as UV light helps to break down bilirubin. The baby can be laid or held in front of sunny windows with the body uncovered as much as possible or, if the weather is warm enough, taking the baby out in minimal clothing.

If the baby’s levels become too high or are rising very rapidly, this is suggestive of a pathological jaundice that may require medical treatment for the jaundice and its cause. It may become necessary to use photo-therapy, special blue lights which emit UV rays similar to sunlight, to help treat the baby’s jaundice while continuing to breastfeed frequently. In some cases this photo-therapy can even be done at home(1), so you and your baby will not need to be admitted to the hospital during treatment. Sometimes the baby will need to be hospitalized for this treatment and others, but breastfeeding should continue throughout treatments. Rarely a baby may be so severely jaundiced that they require an exchange transfusion but this is unusual and unlikely(1).

Outlook
Generally normal physiologic jaundice resolves in a few weeks, it is a normal process with no after effects. In extremely rare cases bilirubin levels may cause complications such as cerebral palsy, deafness, or kernicterus as discussed above. Not only are these complications extremely rare, it is also very unlikely that levels capable of causing these complications would go unnoticed and untreated.

Summary
Jaundice is usually a normal process for more than half of newborn babies which peaks between the 3rd and 5th days of life and may take a few weeks to completely resolve. Frequently breastfeeding problems can contribute to rising bilirubin levels so every effort should be made to address the breastfeeding relationship in order to bring levels down. The more the baby breastfeeds effectively, the faster levels drop. The levels at which complications occur are not fully understood, so monitoring the baby’s health while breastfeeding frequently is usually recommended. A baby with extreme or pathologic jaundice will be extremely drowsy, difficult to wake, and will not feed or poop well. The American Academy of Pediatrics does not recommend or advise supplementation with formula in most cases of jaundice and encourages continued frequent breastfeeding.

Resources and Further Reading
1.    www.nlm.nih.gov/medlineplus/ency/article/001559.htm
2.    The Breastfeeding Answer Book, La Leche League International
3.    Dr. Jen’s Guide to Breastfeeding, Dr. Jennifer Thomas
4.    http://www.llli.org/docs/lad/ChildbirthandBreastfeeding.pdf
5.    http://www.llli.org/faq/colostrum.html

---