Bilirubin Levels In Newborns: What's Too High?

Jaundice, the yellowing of a newborn baby's skin and eyes, is a common condition that affects up to 60% of full-term babies and 80% of premature babies. It is caused by high levels of bilirubin in the blood, which occurs when a newborn's liver is not developed enough to remove it effectively. While jaundice usually resolves on its own within a couple of weeks, severe cases can lead to serious health issues such as brain damage if left untreated. Therefore, it is important to understand when bilirubin levels are too high and what treatments are available.

Jaundice symptoms

Jaundice is a common condition in newborns, characterised by a yellow discolouration of the skin and eyes. It is caused by a buildup of bilirubin in the blood when a newborn's liver isn't developed enough to remove it effectively. While jaundice usually clears up on its own within a couple of weeks, it is important to monitor bilirubin levels to ensure they do not reach harmful levels, which can cause serious health complications.

• Yellowing of the skin, particularly on the face, chest, stomach, abdomen, arms, legs, and the whites of the eyes. This may be more difficult to observe in babies with darker skin tones, but can be checked by gently pressing on the skin and observing if the skin appears yellow when the finger is lifted.
• Dark yellow urine (which should be colourless) and pale stools (which should be yellow or orange).
• Poor feeding or decreased appetite, leading to inadequate weight gain.
• Sleepiness or difficulty waking for feeds.
• Fussiness or irritability.
• Floppiness or difficulty moving.
• High-pitched cries.

If you notice any of these symptoms, it is important to consult a healthcare professional, especially if they persist or worsen over time. They can advise on appropriate treatments, such as phototherapy or, in rare cases, exchange transfusion to lower bilirubin levels.

Treatment options

The treatment for newborn jaundice depends on the cause of the jaundice, the bilirubin levels, and the baby's age. Mild jaundice often disappears on its own within one to three weeks as the baby's body gets rid of the extra bilirubin. However, for more severe cases of jaundice, treatment should be started as soon as possible. Here are some treatment options:

Enhanced nutrition

To prevent weight loss, your doctor may recommend more frequent feeding or supplementation to ensure your baby receives adequate nutrition. Breastfed infants should be fed eight to 12 times a day for the first several days of life. Formula-fed infants should have 1 to 2 ounces (30 to 60 milliliters) of formula every two to three hours for the first week. If your baby is having trouble breastfeeding, losing weight, or is dehydrated, your doctor may suggest giving your baby formula or expressed milk as a supplement.

Phototherapy

Phototherapy, also known as bili-lights, is a special type of light (not sunlight) used to treat newborn jaundice. It helps to lower bilirubin levels by making it easier for the baby's liver to break down and remove the bilirubin from the blood. During treatment, the baby will be placed under a special lamp that emits light in the blue-green spectrum, wearing only a diaper and protective eye patches. Light therapy may be supplemented with the use of a light-emitting pad or mattress. Phototherapy is generally very effective and has few side effects.

Exchange transfusion

In rare cases, when severe jaundice does not respond to other treatments, a complete blood transfusion, known as an exchange transfusion, may be necessary. This involves repeatedly withdrawing small amounts of the baby's blood and replacing it with donor blood, thereby diluting the bilirubin and maternal antibodies. This procedure is performed in a newborn intensive care unit and can take several hours to complete.

Intravenous immunoglobulin (IVIg)

If the jaundice is caused by blood type differences between the mother and baby, intravenous immunoglobulin (IVIg) may be used. IVIg is a blood protein that can reduce antibody levels, which contribute to the rapid breakdown of the baby's red blood cells. It may decrease jaundice and lessen the need for an exchange transfusion, although results are not conclusive.

Risk factors

Physiological Jaundice

This is the most common type of jaundice in newborns, affecting 50% of newborns and usually disappearing within 1-2 weeks. It typically appears 2-4 days after birth, with bilirubin levels peaking on days 4-5.

Breastfeeding or Malnutrition Jaundice

This type of jaundice affects 5-10% of newborns and is caused by inadequate intake of breast milk. It has a similar onset pattern to physiological jaundice and can cause poor weight gain.

Breast Milk Jaundice

Breast milk jaundice affects about 10% of newborns. It is caused by a substance in breast milk that blocks the removal of bilirubin. Onset usually occurs 4-7 days after birth, and weight gain remains normal.

Rh and ABO Blood Group Incompatibility (Serious but Rare)

This type of jaundice can be serious and reach harmful levels. It typically appears within the first 24 hours of life.

Liver Disease (Serious but Rare)

Liver disease can be indicated by light grey or pale yellow stools. Jaundice in this case does not go away. Causes include liver infection (hepatitis) and liver blockage (biliary atresia).

• Premature birth: Babies born before 38 weeks of gestation may not process bilirubin as efficiently as full-term babies. They may also feed less and have fewer bowel movements, resulting in higher bilirubin levels.
• Significant bruising during birth: Bruising can lead to higher bilirubin levels from the breakdown of more red blood cells.
• Blood type incompatibility: If the mother's blood type is different from the baby's, the baby may receive antibodies through the placenta that cause rapid red blood cell breakdown.
• Breastfeeding difficulties: Breastfed babies, especially those with nursing or adequate nutrition issues, are at higher risk. Dehydration or low caloric intake may contribute to jaundice.
• Race: Studies show that babies of East Asian ancestry are at an increased risk of developing jaundice.

Exclusive Breastfeeding

Exclusive breastfeeding has been identified as a risk factor for neonatal hyperbilirubinemia. While breast milk jaundice has a good prognosis, a significant percentage of infants with severe hyperbilirubinemia are exclusively or mainly breastfed.

Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency

G6PD deficiency is a confirmed risk factor for neonatal hyperbilirubinemia.

Maternal-Fetal ABO Blood Group Incompatibility

ABO blood group incompatibility is a risk factor for neonatal hyperbilirubinemia, as it can cause hemolysis.

Preterm Birth

Premature birth is a risk factor for neonatal hyperbilirubinemia. It may be related to the maturity of uridine diphosphate glucuronosyltransferase, with gestational age positively correlated with the activity of this enzyme.

Complications

High levels of bilirubin in newborns can lead to several complications, including:

• Jaundice: This is the most common complication, characterised by a yellow discolouration of the skin and eyes. Jaundice typically appears within the first few days after birth and usually resolves within 1-2 weeks. However, in some cases, it can last longer and require treatment.
• Kernicterus: This is a rare but serious complication caused by very high bilirubin levels. Kernicterus occurs when bilirubin reaches the brain, leading to permanent brain damage. Symptoms may include involuntary and uncontrolled movements (athetoid cerebral palsy), a permanent upward gaze, and improper development of tooth enamel.
• Acute bilirubin encephalopathy: This condition arises when bilirubin passes into the brain, posing a risk of permanent damage. Signs include poor sucking or feeding, and backward arching of the neck and body.
• Cerebral palsy: High bilirubin levels can lead to this neurological disorder, causing physical disabilities and difficulties with movement and coordination.
• Deafness: Untreated high bilirubin levels can result in hearing loss or deafness in newborns.
• Brain damage: If left untreated, severe jaundice can lead to brain damage. This can cause developmental delays and cognitive impairments.

It is important to closely monitor newborns for signs of jaundice and high bilirubin levels, as early diagnosis and treatment are crucial for preventing these complications. Treatment options may include phototherapy, exchange transfusion, and intravenous immunoglobulin administration.

Prevention

Preventing High Bilirubin Levels in Newborns

High bilirubin levels in newborns, known as hyperbilirubinemia, can be worrying for new parents. While this condition is common and usually harmless, it's important to take preventive measures to ensure the safety and health of your baby. Here are some detailed instructions on preventing high bilirubin levels and reducing the risk of severe jaundice:

Understand the Causes of High Bilirubin Levels:

Bilirubin is a yellow substance produced by the breakdown of red blood cells. During pregnancy, the placenta removes bilirubin from the baby's blood. After birth, the baby's immature liver takes over this task, but it may take some time to do so efficiently. High bilirubin levels can be caused by various factors, including:

• Premature birth: Premature babies are more likely to develop jaundice due to their underdeveloped livers.
• Breastfeeding issues: Inadequate intake of breast milk or difficulties in breastfeeding can lead to dehydration, reducing urine output and causing bilirubin buildup.
• Blood type incompatibility: If the mother's blood type differs from the baby's, it can result in the breakdown of red blood cells, increasing bilirubin levels.
• Bruising during birth: Significant bruising or bleeding under the scalp from a difficult delivery can contribute to higher bilirubin levels.
• Liver dysfunction: Jaundice can occur if the baby's liver isn't functioning properly due to infection or other factors.

Ensure Adequate Feeding:

One of the most important preventive measures is to ensure your baby is adequately fed. Breastfed infants should be fed frequently, with 8 to 12 feedings per day during the first few days of life. For formula-fed infants, offer 1 to 2 ounces (30 to 60 milliliters) of formula every 2 to 3 hours during the first week. This stimulates regular bowel movements, helping to eliminate bilirubin through stools.

Monitor Skin Colour and Jaundice:

Jaundice is characterized by a yellow discoloration of the skin and eyes. Examine your baby in good lighting conditions, preferably natural daylight. Gently press on your baby's forehead or nose, and if the skin appears yellow, it indicates mild jaundice. Keep a close eye on the progression of jaundice, as it typically starts on the face and then moves down the body. If you notice jaundice spreading beyond the chest, it's important to have your baby's bilirubin levels checked.

Seek Medical Attention:

It is crucial to have your baby examined for jaundice within the first 5 days of life. Schedule follow-up appointments, especially if your baby was discharged from the hospital within 72 hours of birth. Contact your healthcare provider if you notice any of the following:

• Jaundice persists or increases after the newborn visit or lasts longer than 2 weeks.
• Your baby's skin becomes more yellow, especially on the abdomen, arms, or legs.
• Your baby seems listless, sick, or difficult to awaken.
• Your baby isn't gaining weight or is feeding poorly.
• Your baby makes high-pitched cries.

Identify Risk Factors:

Be aware of risk factors that can increase the likelihood of severe jaundice. These include:

• Premature birth: Premature babies are at a higher risk of developing jaundice due to their underdeveloped livers.
• Maternal diabetes or Rh disease: Babies born to mothers with these conditions are more likely to have jaundice.
• Difficult birthing process: Significant bruising or bleeding under the scalp during a challenging delivery can increase the risk of hyperbilirubinemia.
• Race: Studies suggest that babies of East Asian ancestry have an increased risk of jaundice.

Early Diagnosis and Treatment:

Early diagnosis and treatment are crucial in preventing high bilirubin levels from rising to dangerous levels. If you notice any signs of jaundice or if your baby exhibits feeding difficulties, contact your healthcare provider immediately. Treatment options may include phototherapy, exchange transfusion, or intravenous immunoglobulin, depending on the severity of the condition.

Remember, while some degree of jaundice is normal in newborns, taking preventive measures and seeking timely medical attention can help ensure your baby's health and well-being.

Frequently asked questions