Neonatal Jaundice

Neonatal jaundice or hyperbilirubinemia is a common condition in newborns. It causes skin, tongue, or eye yellowing and usually occurs during the second or third day after birth. The yellowing results from too much of a naturally occurring substance called bilirubin in their blood.

Jaundice often resolves on its own. Moderate cases may need treatment, such as phototherapy (light therapy). Advanced treatment may be necessary for babies with severe jaundice to prevent serious complications or health conditions.

This article reviews symptoms of mild, moderate, and severe neonatal jaundice, its causes, treatment, complications, diagnosis, and when to see a healthcare provider.

Symptoms of Neonatal Jaundice

The main symptom of neonatal jaundice is the yellowing of skin, tongue, or whites of the eyes. Mild jaundice begins on the face. If the bilirubin continues to build up, yellowing can also occur on the belly, chest, arms, or legs. 

Symptoms of mild neonatal jaundice include:

• Yellowing of the face
• Yellowing on or under the tongue
• Yellowing in the whites of the eyes
• Clay-colored stools (poop)

If bilirubin levels continue to increase, symptoms become more concerning or moderate and require medical attention. Signs that indicate the jaundice is progressing include: 

• Yellowing of the chest, abdomen (belly), arms, and legs (as bilirubin levels increase)
• Not gaining weight or eating well
• Decreased wet and dirty diapers
• Listlessness or sluggishness, not easily woken up

The following symptoms may indicate severe jaundice that could lead to complications and require immediate medical attention:

• Continuous high-pitched cry
• Fever (rectal temperature over 100.4 degrees F for infants less than 3 months old)
• Limp or floppy body 
• Increased lethargy (sluggish, tired) and difficulty waking up 
• Baby looks sick and is not responding to their surroundings or your voice
• Arched body

Causes of Neonatal Jaundice

When the body makes new red blood cells (RBCs) and breaks down old RBCs, bilirubin is produced. It is a naturally occurring yellowish-orange substance. 

Bilirubin is filtered in the liver and wasted through bowel movements (poop). Jaundice or yellowing signifies that bilirubin is building up instead of moving out of the body. 

The buildup of excess bilirubin can occur for the following reasons:

• The liver is not fully developed
• Problems with the liver or digestive system
• Underlying health conditions
• Too many red blood cells breaking down
• Feeding difficulties

There are different types of neonatal jaundice, but physiological jaundice is the most common. During pregnancy, the pregnant parent processes bilirubin for the baby. When the baby is born, their immature liver has difficulty processing its own bilirubin. This type appears two or three days after delivery and often resolves on its own within a couple of weeks. 

What Medications Can Cause Neonatal Jaundice?

Research studies link the following antibiotics to jaundice or kernicterus (a complication of jaundice): 

• Rocephin (ceftriaxone) (evidence is conflicting)
• Rifampin (evidence is conflicting)
• Sulfonamides, such as Bactrim, Septra (sulfamethoxazole-trimethoprim)

A Tylenol (acetaminophen) overdose could also cause jaundice. Given in the proper dose, this is not a concern. However, an overdose can cause liver damage, leading to hyperbilirubinemia. 

How to Treat Neonatal Jaundice

Physiological jaundice is common and often mild. It frequently goes away in a couple of weeks as the baby’s liver develops. If bilirubin levels are too high or are rising too quickly, treatment may be necessary. 

Treatment for mild jaundice involves feeding babies often, about 10 to 12 times per day. This increases bowel movements and helps the liver get rid of excess bilirubin.

If jaundice progresses, treatment may include phototherapy. Phototherapy involves placing the baby under special lights or blankets. Depending on the severity of jaundice, this treatment may be done at home or in the hospital. Jaundice often resolves within a couple of days of phototherapy.

Rarely, when jaundice is severe, babies may need the following treatments in a hospital:

• Intravenous (IV) fluids
• Albumin 
• Immunoglobulin (IVIG) (in rare cases)
• Luminal (phenobarbital) (rare)
• Blood transfusion exchange (very rare)

Complications and Risk Factors Associated With Neonatal Jaundice

Most of the time, newborn jaundice does not cause long-term harm. It usually goes away on its own or within a couple of weeks with treatment. However, very high bilirubin levels can lead to the following complications:

• Kernicterus (brain or nervous system damage)
• Hearing loss
• Vision problems
• Cerebral palsy
• Dental problems
• Intellectual disabilities

Risk factors for severe jaundice include: 

• Health conditions that cause increased red blood cells or liver problems
• Liver conditions such as biliary atresia or hepatitis
• Small for gestational age (SGA)
• Severe infection 
• Bruising or bleeding under the scalp 
• Blood type incompatibility with mom
• Hypoxia (low oxygen levels)

Are There Tests to Diagnose Neonatal Jaundice?

Healthcare providers screen babies for jaundice and other risk factors after delivery. They will continue to monitor their skin color and bilirubin levels after birth and at a scheduled appointment three to five days after delivery.  

Your provider will use the following tools to diagnose neonatal jaundice:

• Transcutaneous bilirubin (TcB): TcB is a noninvasive screening test. The device is similar to a forehead thermometer. It directs light at the baby's head to check for high bilirubin levels. 
• Total bilirubin: Providers may order bilirubin blood tests if the TcB shows high bilirubin levels or the baby has symptoms. This involves a small needle stick on the baby's heel. 
• Other blood work: If your provider is concerned about risk factors for severe jaundice, they may order a complete blood count (CBC) or liver function tests. 

When to See a Healthcare Provider

All infants should see a healthcare provider within the first five days of birth to check for jaundice. It’s important to keep scheduled appointments and call your healthcare provider if your baby has the following symptoms:

• Yellowing of the face and eyes (and your healthcare provider is unaware)
• Yellowing worsens and moves to the chest, abdomen, arms, and legs 
• Yellowing becomes orange
• Jaundice lasts more than two weeks
• Not gaining weight or eating well
• Not easily waking up, especially if difficult to wake up for feeding
• Not peeing or pooping enough
• Overly fussy
• Anything else that may concern you

 If your baby has any of the additional following symptoms, call 911:

• High-pitched crying lasting over one hour
• Fever (rectal temperature over 100.4 degrees F for infants less than 3 months old)
• Limp or floppy body 
• Not responding
• Arched body

Summary

Neonatal jaundice is the yellowing of a baby’s skin due to excess bilirubin or hyperbilirubinemia. While there are multiple types, physiological jaundice is the most common and occurs due to normal newborn conditions. It usually appears on the second or third day after birth. 

Risk factors for severe jaundice include conditions that increase the baby’s red blood cells or cause liver or digestive tract issues. 

Jaundice often resolves on its own, but moderate cases may need treatment to prevent serious complications or health conditions. 

A Word From Verywell

Yellowing of your baby's skin, eyes, or tongue can be alarming. While jaundice is common and often resolves on its own, it's important to alert your healthcare team for new cases or if symptoms worsen. Early detection and treatment decrease the risk of rare, long-term damage.