Pediatric hyperbilirubinemia (jaundice)

What are the signs and symptoms of pediatric hyperbilirubinemia (jaundice)?

The symptom seen most often is a yellow tint to the skin or eyes. Your child may also be sluggish, cranky and jittery, have a high-pitched cry and may not suck well if you are breastfeeding.

Many times, the yellow tint may not appear until you and your child are already home. Although it is usually not an emergency, you should make arrangements to see your baby’s primary care doctor quickly.

How is pediatric hyperbilirubinemia (jaundice) diagnosed?

The symptom seen most often is a yellow tint to the skin or eyes. Your child may also be sluggish, cranky and jittery, have a high-pitched cry and may not suck well if you are breastfeeding.

Many times, the yellow tint may not appear until you and your child are already home. Although it is usually not an emergency, you should make arrangements to see your baby’s primary care doctor quickly.

Tests and diagnosis

Testing for jaundice may occur while your baby is still in the hospital. Although there is some controversy over the effectiveness of in-hospital screening with no risk factors, many hospitals check total bilirubin levels on all babies about 24 hours after birth.

To avoid unnecessary pain and stress to the baby, hospitals use probes that estimate the bilirubin level just by touching the skin. High readings are confirmed with blood tests.

One of the tests routinely ordered measures total serum bilirubin (TSB). Although often used for follow-up testing following screening, it can also be used as a first-line test.

Because your baby’s veins are extremely small and damage easily, the sample will usually be obtained by sticking the heel. After processing in the laboratory, a report is issued telling the treatment team how much total bilirubin is circulating in the blood. Your baby’s doctor will look at these levels to see if there is any reason for concern.

If a diagnosis of hyperbilirubinemia is made, this test is likely to be repeated. It tracks whether the TSB level is going up or down. It helps tell the team if treatment is needed and if treatment is working.

Other tests that may be considered include:

• Complete blood cell (CBC) count that looks at most of the major components of blood such as white blood cells (fight infection), red blood cells (carry oxygen), and others
• Coombs test to find antibodies that cause early death of red blood cells, which releases extra bilirubin in the blood
• Reticulocyte count tests how fast the bone marrow is making new red blood cells. If they are being made very fast, then it may mean that red blood cells are also dying quicker and releasing too much bilirubin for the body to process.

Any additional testing that takes place will vary from one baby to another. What is done will depend on what the doctor suspects is causing the excess destruction of red blood cells. 

What are the causes of pediatric hyperbilirubinemia (jaundice)?

Jaundice occurs because your baby’s blood has more bilirubin than it can get rid of. This can happen because an infant’s red blood cells have a shorter lifespan and so are broken down at a higher rate. Bruising that occurs during the birth can lead to higher levels of bilirubin. Finally, the baby’s liver may just not be mature enough to filter bilirubin from the bloodstream to avoid the yellowish tint.

For the most part, jaundice is not a cause for concern. Physiologic jaundice is harmless and usually is seen at 2 to 4 days old. It goes away within 1 to 2 weeks.

Diseases that affect the liver and can lead to jaundice include:

• Cystic fibrosis (CF)
• Hepatitis

Other causes may include:

• Medication or infections can be a side effect of jaundice that maybe present at birth.
• Breastfeeding failure jaundice may occur in infants who are breastfed and is caused by not nursing well or when the mother’s milk is slow to start. Breastfeeding jaundice occurs most often in the first week of life. Late preterm infants (born at 34 to 36 weeks) are more susceptible because they don’t have the coordination or strength to breastfeed.
• Breast milk jaundice is a separate type that appears after day 5, peaks during weeks 2 and 3, and may last at low levels for a month or longer. This type is thought to be related substances in the milk that increase reabsorption of bilirubin back into the bloodstream.

How is pediatric hyperbilirubinemia (jaundice) treated?

For most babies with hyperbilirubinemia, the main treatment will be watching and waiting. The majority of the time, the problem will resolve as your baby gets used to living on its own outside of the womb.

When deciding if more active treatment is needed, the doctor and your baby’s treatment team will compare bilirubin levels to see if, and how fast, they are rising. Whether your baby was born early is considered because lower bilirubin levels are treated. Treatment will be started if the bilirubin level is too high or is rising too quickly.

• For low levels of bilirubin or when the level is steady or rising slowly, frequent feedings with breast milk or formula may be the main intervention.
  • Feeding your baby up 12 times a day helps keep him or her well hydrated and encourages frequent bowel movements. Bilirubin is removed from the body through the stool.
• For higher levels or levels that are increasing quickly, the use of specially colored lights (known as phototherapy) may be used. This particular color breaks down the bilirubin in the tiny blood vessels just below the skin and makes it easier for the body to remove.
  • Your baby will be placed under these lights in an enclosed bed. Because of the need to expose as much skin as possible, the baby usually wears only a diaper. The bed is warmed to maintain a constant temperature. A special eye mask is used to protect the eyes.
  • If the jaundice is diagnosed before discharge, it is likely that your baby will stay in the hospital until phototherapy is completed, which usually takes 1 or 2 days.

Other treatment options may include:

• Light-emitting blanket - Your doctor may prescribe a light-emitting blanket or neck ring as an alternative and/or additional treatment for your baby’s jaundice. This system uses fiber optics and represents advanced technology in phototherapy treatment given in the hospital or at home.
  • This covered fiberoptic pad is placed directly against your baby to bathe the skin in light. The blanket can be used 24 hours a day to provide continuous treatment if prescribed by your doctor. With this convenient form of phototherapy, your child can be diapered, clothed, held and nursed during treatment at home. A nurse will be available to help you set up the therapy, answer any questions you may have and do daily in-home follow-up visits.
  • While this will work much of the time, the bilirubin level might continue to rise. Your baby may need to be readmitted to the hospital for more intensive therapy.
• Transfusion - In the most severe (and fortunately relatively rare) cases, an exchange blood transfusion may be needed. This replaces the baby’s blood with fresh blood from a donor.
  • If the baby has a different blood type from the mother, the infant’s blood may be carrying antibodies from the mom that break down the baby’s red blood cells. A transfusion of immunoglobulin can reduce the level of antibodies. This, in turn, decreases the jaundice and may make an exchange transfusion unnecessary.