Jaundice, Part II: What is Jaundice and How is it Treated?

This is the second in a two-part series on jaundice, a relatively common and usually mild condition that occurs in newborn babies. In Part I, I described my own experience with jaundice in my fourth baby. Here in Part II, we'll look at jaundice from a clinical perspective.

What is newborn jaundice?

Jaundice in newborns is caused by rising bilirubin levels in the blood. Bilirubin is a byproduct of the breakdown of red blood cells, which all babies have an excess of at birth. Normally, bilirubin is processed by the liver and excreted through bowel movements. While many babies will effectively and efficiently process this excess bilirubin, some babies have too much bilirubin, or their liver can't handle all of the bilirubin they're producing, which causes it to build up in the blood. When this happens, some of the bilirubin is passed to the skin, which will give the whites of the eyes and the skin a yellow-ish tint. If the bilirubin levels in the blood reach high levels, treatment may be recommended.

There are three basic types of jaundice found in newborns:

• Physiological Jaundice is the normal course of elevated bilirubin caused by the breakdown of red blood cells in the newborn baby. This type of jaundice is normal and not dangerous unless bilirubin levels reach a certain threshold. Most babies will require no special treatment.
• Breastfeeding Jaundice occurs when a breastfed baby isn't getting enough to eat in the first several days of life. Because he is not feeding well, he is not having enough bowel movements to clear out the bilirubin from his system. If bilirubin levels reach a certain threshold, various treatment scenarios may be proposed. Otherwise, assistance with improving breastfeeding is typically all that is needed.
• Breastmilk Jaundice occurs in a very small percentage of babies and is when an exclusively breastfed baby has elevated bilirubin levels but no other symptoms of jaundice and is feeding well and growing as expected. This is not a dangerous condition and will typically resolve within 6 to 10 weeks without intervention.

Notice that all three types of newborn jaundice usually resolve without treatment. Once good feeding is established and the baby's digestive system is kicked into gear, he will clear out the bilirubin on his own. 

Jaundice occurs more commonly in premature babies or babies whose liver may otherwise be compromised. It also may be caused or complicated by blood type incompatibility between the baby and the mother, birth injury, medications, or infection.

My oldest son N with jaundice. You can see how yellow his forehead looks. He was being treated in the hospital and was taken off the lights for a feeding in this picture.

When does jaundice need to be treated?

The trouble with elevated bilirubin is that it is known, at high levels, to cause a totally preventable, irreversible, severe brain damage called kernicterus. Kernicterus occurs when bilirubin literally stains the brain cells. Babies with kernicterus will suffer lifelong mental retardation, which may include both physical and cognitive delays. Kernicterus happens when the bilirubin levels in the blood are so high that bilirubin is conducted into the brain. It is not known what these levels need to be to cause kernicterus, and it is not clear if simple physiological jaundice, breastfeeding jaundice, or breastmilk jaundice alone can cause this terrible outcome or if other complications are involved. It is clear, however, that by reducing bilirubin levels before they reach a high concentration will prevent kernicterus.

To determine if your baby is at risk for needing additional treatment for jaundice, your pediatrician will order a blood test to measure your baby's bilirubin level. This will be plotted on a chart along with the baby's age (see below). There are four identified curves on this chart: Low Risk, Low Intermediate Risk, High Intermediate Risk, and High Risk. If your baby's bilirubin levels fall into the High Intermediate or High Risk zone, treatment will likely be recommended.

Find your baby's age along the bottom and plot the Serum Bilirubin level on the vertical axis 

to see which zone your baby's jaundice risk falls in.

Aside from kernicterus, jaundice may cause other difficulties in the early days of your baby's life, which may prompt your doctor to recommend treatment or management. High levels of bilirubin may cause your baby to become sleepy and uninterested in eating. This will make it more difficult for your baby to clear out bilirubin, and it will mean fewer feedings at the breast, which may cause a delay in your breastmilk increasing in volume, or it may cause a low supply due to lack of stimulation. This, in turn, will mean your baby is not getting enough to eat even when he does wake to eat, which will make him more dehydrated and lethargic, which will make him less likely to wake to feed, which will further reduce the amount of calories and fluids he takes in, which will worsen the jaundice and continue the cycle. This is a very dangerous cycle because you end up with a starving baby and a delay in milk production or a reduced supply. In this case, treating both the feeding issues and the jaundice are priorities.

Most pediatricians will recommend treating any kind of jaundice before bilirubin levels reach 20mg/dL in the blood. Most babies will not reach this critical point, but some may approach it, and it is important to know what the treatment options are so that you can make an informed decision about whether, when, and how to treat your baby for jaundice.

How do we treat jaundice?

The simplest treatment for jaundice is feeding. If your baby has not been feeding well, increasing the number and quality of feedings will help stimulate bowel movements and clear out the bilirubin. Make sure your baby is eating at least 12 times a day and that when he feeds, he is actually taking in colostrum or milk. Watch for signs of a deep suck and swallowing when your baby is feeding. Make sure he is actively sucking and swallowing for at least several minutes at a time. If he falls asleep at the breast after a very short time, try to stimulate additional sucking by massaging the breast while he is latched on. You can try to wake the baby by burping him or changing his diaper and then return him to the breast for further feeding. Also, be sure to monitor diaper output. 

If your breastmilk has not increased in volume by the end of the third day postpartum (72 hours), it is important to feed your baby from some other source, whether donor breastmilk or formula. The number one rule, here, is feed the baby. Ideally, this supplementation would occur at breast using a feeding tube or syringe so that the baby can continue to stimulate milk production while receiving the supplemental milk or formula. A three to four-day-old baby does need more than colostrum, though colostrum is enough for a baby in the first and second days of life.

If the baby is feeding well but bilirubin levels remain in the High or High Intermediate Risk zones on the above chart, phototherapy may be recommended. Phototherapy involves the use of a special blue light that shines on the baby, with a maximum amount of skin exposed to the light. The light breaks the bilirubin down into a water soluble form that the baby can excrete through his urine. This, in addition to regular bowel movements, will bring down his bilirubin levels much more quickly. Phototherapy can be done in the hospital nursery or at home using a portable phototherapy device. Your doctor will likely have a preference as to whether to keep your baby in the hospital (or readmit him) to use the hospital phototherapy bed or whether to have a home healthcare service bring you a home phototherapy machine to use. It typically takes 12 to 24 hours, or up to two days at the outside, of phototherapy to bring down bilirubin levels to an acceptable range. It is important for the baby to continue to feed regularly while under phototherapy. Continue breastfeeding about every two to three hours. Phototherapy is not invasive and not painful for the baby. The baby is kept warm and generally just sleeps while under the lights.

Baby N on home phototherapy. A pad that emits light is against his back, connected to a machine 

by the gray tube you can see emerging from his blankets.

Some pediatricians may recommend supplementing with formula for 12 to 24 hours, or even a course of "interrupted breastfeeding" for 12 to 24 hours, to clear out breastfeeding or breastmilk jaundice. This path only becomes necessary if breastfeeding is not going well and the baby is clearly in need of feeding beyond what he is getting from his mother alone. Supplementation with formula will help to treat the jaundice, as it will cause the baby to pee and poop much more than from colostrum and early milk alone. It will also help to rouse a baby who is lethargic from lack of feedings and/or high bilirubin levels and may be helpful in severe cases. However, be aware that introducing formula may have other long-term consequences to your baby and your breastfeeding relationship. It is important to weigh the risks and benefits of supplementation. If possible, discuss these risks with your pediatrician and a lactation consultant before making your final decision. If you do choose to supplement, be sure you do not reduce the amount of at-breast feeding your baby does. If you cannot be with your baby, you should pump your breasts every two to three hours, or in between feedings, to stimulate your own milk production. It may be possible to supplement your baby with your own pumped milk rather than formula, if you are able to produce for a pump.

How long does it take for jaundice to go away?

Bilirubin levels will generally peak between days four and six of your baby's life and then taper off into a normal range in about one to two weeks. Your doctor may want to monitor your baby's bilirubin levels until they begin to fall by ordering daily blood tests. Assuming your baby is otherwise healthy and feeding well, once it is clear that his bilirubin has begun to fall, no further treatment will be necessary. Typically, once bilirubin levels peak and begin to drop, they will continue this downward trend.

The exception to this is breastmilk jaundice. Babies with breastmilk jaundice may appear yellow and have elevated bilirubin for up to about 10 weeks of age. Breastmilk jaundice is not dangerous and will go away on its own. As long as the baby is otherwise healthy, alert, feeding and growing well, and meeting milestones, you can simply wait until the jaundice resolves. Some pediatricians may recommend interrupting breastfeeding (stop breastfeeding and give formula) for one to three days to clear out breastmilk jaundice. While this will effectively "treat" the jaundice, it may have a negative impact on your breastfeeding relationship as well as introducing other risks of formula feeding. Unless there is other cause for concern, this is probably not a necessary step in simple breastmilk jaundice.

In the first week of life, while bilirubin is still elevated, watch your baby for sleepiness, not waking to feed, floppiness, and dehydration (urine crystals in the diaper, dry mouth, sunken fontanel). Examine your baby in natural light to look for increased yellowing. Contact your pediatrician immediately if you have any cause for concern.

Also, be aware that jaundice tends to run in families. If you have one baby with jaundice, there is an increased chance that a future baby will have jaundice as well. Jaundice is more common in boys than girls, as well. Indeed, all four of my boys had jaundice! 

I hope this information* helps you to have an meaningful conversation with your pediatrician if your baby is diagnosed with jaundice.

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*Please note that I am not a medical professional and cannot offer medical advice. This information is provided for your education only and should not be used in place of the advice of your pediatrician during an in-person examination.

Jaundice, Part I: Baby Boy Turns Yellow

This is the first in a two-part feature on jaundice. In this post, I'll tell you Baby Boy #4's jaundice story, and in the next post I'll address jaundice from a more clinical perspective. Now that Baby Boy has been named, we'll call him Y.

At 5:30 a.m. on Tuesday morning, when Y was about 27 hours old, the nursery did a heel stick to draw blood for his PKU test. This is a standard newborn screening done at approximately 24 hours of age. At the same time, they checked his bilirubin levels to see if he was at risk of needing treatment for jaundice. Most people know jaundice as a yellowing of the eyes and skin due to various problems associated with the liver. In newborns, it's a relatively common condition due to the breakdown of excess red blood cells in the baby's body after birth. Most babies will clear out the bilirubin on their own without needing special interventions, but some babies will have bilirubin levels high enough to elicit concern, as very high levels of bilirubin may cause irreversible brain damage called kernicterus.

But back to Baby Y. When the pediatrician came in to check him over and report on his test results, the first words out of her mouth were, "Did any of your other kids have jaundice?" When I told her all three had, and two had required home phototherapy, she nodded. She showed me his bilirubin level, which was 8.6. For his age, this was considered "high intermediate risk". If the number climbed into the "high risk" zone, he would require treatment. The chart below is the standard risk chart for newborn jaundice. You find the baby's age in hours along the bottom, then plot the bilirubin level on the left and see what curve you fall along. A level of 8.6 in a 28-hour old baby was near the high end of the high intermediate risk zone.

The question then was, do we take a wait-and-see approach, or do we take it on more aggressively, knowing that (a) all three of his brothers had relatively high bilirubin levels, and (b) he was already nearing the high risk zone? Levels usually peak between 4 and 6 days of age and then fall off gradually. To clear out bilirubin, the baby needs to poop, which means the baby needs to eat. Since breastmilk supply doesn't usually increase until day 3, and most babies under 3 or 4 days of age are still clearing out meconium, it takes a few days for the excess bilirubin to be excreted. I was still only producing a small volume of colostrum, and Baby Y wasn't pooping much, so we knew his levels would continue to rise for another day or two, at least. But we didn't know if they'd rise sharply or level off. There's really no way to know what will happen in any given baby.

I had been planning to go home on Tuesday, though I was technically entitled to another night in the hospital if I wanted to stay. The pediatrician suggested that I stay Tuesday night and let Baby Y have jaundice treatment through the night. In this way, we might be able to bring down his bilirubin levels to the low intermediate risk zone and then, even if the levels continued to rise a bit for another day or two, they would likely stay on that low intermediate risk curve. If we didn't treat Tuesday night, we would need to monitor him closely (by taking blood daily to measure his bilirubin levels), and if his numbers rose into the high risk zone, then we would need to treat, which might entail readmission to the hospital for him, meaning I'd have to find a place to stay because I would no longer be an inpatient there.

This put us in a tricky position. On the one hand, I really didn't want to spend another night in the hospital. I wanted to get home to my other three kids, I wanted to come back to life and out of the sickly-feeling, "I'm in the hospital" mode. On the other hand, it seemed the easiest way to ensure that Baby Y's jaundice would be managed with the least amount of hassle. A secondary, but real, consideration was that if his jaundice became severe, his bris would have to be delayed. This had happened with our second baby, and we needed to know if that would be necessary for Baby Y. It seemed that treating him Tuesday night would stave off this potential complication as well.

The pediatrician suggested that we talk it over and that she order another blood test for the afternoon. If the number still placed him on that high intermediate risk curve, or, G-d forbid, was even higher, then that might help us decide for sure whether to stay the night or not. I agreed that this was a good suggestion. So, at 36 hours of age, his blood was taken again, and his bilirubin level was 10.7, still on the high end of the high intermediate range, and likely to continue to rise for at least another day or more. We decided to take the aggressive approach. The goal was to keep him under the "bili lights" for the night, in the hope of getting his bilirubin levels to level off or even drop. If the numbers fell into the low intermediate risk range by morning, then we could feel comfortable going home and not worry so much about having to be readmitted for treatment or taking blood daily to monitor him. A clinical approach, visually examining his color, looking at other symptoms, would be enough to monitor his health, and further testing or treatment would only be required if any other symptoms gave his doctor or me cause for concern. (I will discuss all of these symptoms and risks of jaundice in part II of this article.)

At about 7:00 p.m., Baby Y was whisked off to the NICU to be placed under the bili lights. Basically, bili lights are flourescent, blue lights that break down the bilirubin into a water-soluble form that the baby can then pee out, in addition to the bilirubin being excreted in his bowel movements. It's important to maximize the amount of skin exposed to the lights, so the baby is placed in his bassinet in only a diaper, on top of a pad that shines light up against his back. The bassinet is then placed under a second light that shines down from above him. He wears eye covers to protect his eyes from the bright lights, and he basically just sleeps there. The baby should eat about every three hours but should not be off the lights for more than 30 minutes at a time. The idea is to find a balance between maximizing his time under the lights while still getting milk into him so that he can pee and poop. It's a tricky thing, especially with a newborn who wants to nurse a lot but is still getting colostrum and not the mature milk that will encourage more wet and poopy diapers!

It was strange for me, to spend a night in the hospital without my baby by my side. It was also strange to visit him in the NICU, my otherwise big, healthy boy in there with the sicker babies who needed so much more care. We got off to a bit of a rocky start, too. He was there only about 45 minutes before he was brought back to my room, screaming. "He says he's starving!" my nurse said. I nursed him, then wheeled him back to the NICU to go back under the lights. The nurses there were trying to get him to take a pacifier, but he was protesting it.

I was advised that if he was going to need to eat so often, the lights wouldn't be very effective. The protocol was three hours on, 30 minutes off, but he wasn't willing to go three hours without nursing. And normally I would have been perfectly fine with that! A two-day-old baby shouldn't necessarily go three hours without nursing, both for his sake and for mine! His suckling encourages my milk production to increase, as well as nourishing him and stimulating his digestive system. I was happy to feed him every hour or two, but that would render our night in the hospital ineffective. I was frustrated, and so were they.

One of the nurses told me that giving him a little formula would probably help, since it would fill him up so he could wait longer to nurse again, and it would make him pee. Without peeing, he wouldn't clear out the bilirubin. "You have to decide what's your priority - breastfeeding or treating the jaundice," she said. I felt a bit threatened or judged, like maybe by clinging so hard to the "exclusively breastfeeding" mantra, I might be causing my baby harm or wasting my time (and hers?). I was taken aback. I had made it clear that he was not to receive formula, his case of jaundice wasn't severe (yet?), and I was educated enough to know that giving even one bottle of formula when supplementation wasn't medically necessary could cause long-term harm. But I'll tell you something, in all honesty: I almost gave in. I was desperate for him to stay longer under the lights. I was so nervous about "wasting" our extra night in the hospital. I really wanted this treatment to work. And if a couple ounces of formula was all he might need...I hesitated. I felt like I was already breaking so many "rules." Here I was, a trained Lactation Educator, on my fourth baby, a self-proclaimed breastfeeding advocate and expert, and my baby was spending a night in the nursery, being offered a pacifier, and now I was thinking about delaying feeds and supplementing with formula besides.

I gathered myself. "Breastfeeding is my top priority," I told the nurse. "I don't want to mess up his gut with a bottle of formula if he doesn't really need it." If my head had been more in the game, I would have known what to do immediately, but since I was groggy from two nights without sleep, thrown by this change of plans, and caught off guard by this sudden suggestion of formula, I couldn't think of a solution. "Maybe he'll go longer this time," I said, and went back to my room.

The first thing I did back in my room was Google "formula supplementation for newborn jaundice" on my phone (thank G-d for smartphones!). I thought I remembered reading an article from the Academy of Breastfeeding Medicine on whether formula supplementation for normal newborn jaundice was necessary or standard protocol, and I wanted to refresh my memory. I found exactly what I was looking for (PDF). In short, formula supplementation is not recommended for treatment of newborn jaundice unless there are other complicating factors. Short-term formula supplementation can have long-term risks. While it will help to clear the jaundice, it may interfere with establishing a good milk supply, may cause nipple confusion in a baby who is still learning to latch and breastfeed, and will cause the gut flora to be affected by introducing cow's milk proteins and non-breastmilk compounds into the developing digestive system. My Lactation Educator classes came back to me in a rush, and I remembered what we had learned about jaundice and supplementation. There are indications for short-term "interruption of breastfeeding" under certain conditions, but my baby and my situation did not call for such a drastic measure at this point.

And like that, I knew what I needed to do. I marched myself (figuratively) back to the NICU and found a different set of nurses sitting near my sleeping baby.

"Is the reason you'd want to supplement because you could feed him while he's still under the lights?" I asked.

"Yes," one of the nurses said.

"So, if I were able to pump some colostrum, you could feed him that instead of formula?"

"Sure. We do that all the time. Ask your nurse to get you set up with a pump. You can bring us whatever you pump."

I tracked down my nurse and explained what I wanted to do. She said no problem, and within the hour, I was set up with a pump and had started harvesting that precious, precious liquid gold. I felt if I could get at least 10mL (about a third of an ounce) in any given sitting, that should be enough to tide him over between the every-three-hour breastfeedings. I had a mild concern that giving him bottles might affect his desire and ability to latch, but I felt it was worth the risk. At least by pumping between at-breast feedings, I was giving myself the breast stimulation I'd need to establish a good milk supply, as well as giving Baby Y the colostrum he needed to keep him full and happy and able to pee and poop.

On my first go, I got 10mL from both breasts. Thrilled with my success, I happily delivered my first of what would be five 10mL bottles of colostrum that night. In between 30-minute feedings and 15-minute pumping sessions, I'd conk out, sleep for an hour or 90 minutes, to be awakened from a weird dream or a deep sleep by my nurse wheeling in a crying baby ready to breastfeed again. Tired but pleased, morning came and we eagerly awaited his latest blood test, to find out the result of our night's effort.

Liquid Gold

After 12 hours on the bili lights, at 51 hours of age, his bilirubin levels were down to 9.9, lower than they had been at the previous test, and down into the low intermediate risk range for his age. Yes!

We came home later that morning with instructions to have him seen by his regular pediatrician on Thursday. His doctor checked him over and decided that doing another blood test was not necessary. He told me to keep an eye out for more yellowing, lethargy, or not waking to feed, but as long as he was producing diapers, was waking up when he was hungry, and was feeding well, he was not concerned.

Thankfully, Baby Y's breastfeeding was not negatively affected by the use of a pacifier or by giving bottles. My mature milk appeared, on cue, at about 2.5 days postpartum, and he began gaining weight at an incredible rate. At hospital discharge, he was 7lbs., 14oz., about 8 ounces below his birth weight of 8lbs., 6oz. On Thursday, he was up to 8 pounds even, and on Friday, he had gained an additional 3 ounces in 24 hours, to reach a weight of 8lbs., 3oz. Though he has not been weighed since, I'm certain that he has surpassed his birth weight already, at eight days old.

In the next article, I'll discuss jaundice from a clinical angle. I am grateful that I had the experience and educational background to be able to effectively advocate for myself and my baby. Don't be afraid to do your own research and ask questions. When it comes to your baby's health and your breastfeeding relationship, it's important to speak up!