Newborn jaundice: when it fades, how it is checked and when to see a doctor

Jaundice is a yellow colour of the skin, the whites of the eyes and the mucous membranes. It is caused by bilirubin, a yellow pigment made when red blood cells break down. Before birth, the mother's liver removes bilirubin from the baby's blood. After birth many red blood cells break down, and the newborn's liver is still immature and needs a few days to get good at removing bilirubin. That is why its level in the blood rises at first.

It is very common. According to the UK's NICE guideline, jaundice develops in the first week of life in about 60% of babies born at term and about 80% of preterm babies. The NHS stresses that in most babies it is not a sign of illness and gets better without treatment.

Less often jaundice has other causes, for example a blood group mismatch between mother and baby (haemolytic disease), an infection, or a liver or bile duct condition. The American Academy of Pediatrics (AAP) notes that very high bilirubin can, in rare cases, damage a baby's brain. That is why hospital staff watch every newborn, and why parents should know the signs that mean getting help quickly.

Sources differ on the details but agree on the general course. This is what NICE, the NHS, the WHO and Medycyna Praktyczna (a Polish medical publisher) say:

In breastfed babies the yellowing often lasts longer. NICE says about 10% of breastfed babies are still jaundiced at 1 month, and the AAP writes that in these babies it commonly lasts up to a month. Even so, show a doctor any jaundice that lasts longer than 2 weeks (3 weeks in a preterm baby), so that other causes can be ruled out.

NICE recommends that both parents and staff look out for jaundice. At home you can check your baby as NICE, the NHS and the AAP advise:

• Look at your undressed baby in bright, preferably natural light.
• Check the whites of the eyes, the gums and the inside of the cheeks or under the tongue.
• Press lightly on the skin of the nose or forehead and see whether it looks yellow when you let go.
• Notice how far the yellowing goes. According to the AAP, it starts on the face and, as bilirubin rises, moves down to the chest, tummy, arms and legs.
• Remember that yellowing is harder to see on darker skin, so the whites of the eyes and the gums are especially helpful.

Looking at the skin helps you notice jaundice, but NICE stresses that you cannot judge the bilirubin level by eye. Two tests are used for that:

• Transcutaneous measurement: a device is placed against the baby's skin, with no needle. NICE recommends it for babies born at 35 weeks of pregnancy or later who are more than 24 hours old. According to Medycyna Praktyczna experts citing the recommendations of the Polish Neonatal Society, in Poland this is the first test done in babies with visible jaundice.
• Blood bilirubin: NICE recommends it in the first 24 hours of life, in babies born before 35 weeks, when the skin measurement gives a high reading and when the level is close to the treatment threshold.

The WHO recommends transcutaneous screening for all newborns at discharge from hospital, and the AAP says every baby should have at least one bilirubin measurement, skin or blood, before leaving hospital.

There is no single normal bilirubin level for a newborn. NICE recommends interpreting the result according to the baby's age in hours, on special charts with treatment thresholds. The AAP adds that the week of pregnancy the baby was born in and other risk factors also matter. So the same result can mean something different in a baby who is a few hours old and one who is a few days old. Do not compare the result with tables online; ask the doctor what it means for your baby.

Most babies with jaundice do not need treatment. If bilirubin goes above the threshold for the baby's age, phototherapy is used, which means treatment with a special lamp. The baby lies undressed in a cot or incubator, and the light breaks down bilirubin in the skin, so its level in the blood falls. The NHS says most babies need about 48 hours of phototherapy. According to NICE, on the ward it looks like this:

• The baby's eyes are covered, and staff take care of them.
• The baby usually lies on their back, so the light reaches as much skin as possible.
• Staff check the baby's temperature, weigh them every day and check wet nappies.
• Short breaks of up to 30 minutes for breastfeeding, nappy changes and cuddles are encouraged. The exception is when bilirubin is very high or rising fast: then the light treatment is intensified and given without breaks, the baby is fed another way, for example through a tube or a drip, and the mother keeps getting breastfeeding support so she can go back to breastfeeding after treatment.
• Bilirubin is checked with blood tests during and after phototherapy.

Very rarely, when phototherapy is not enough, hospital treatment such as an exchange blood transfusion is needed.

Sunlight is not a treatment for jaundice. NICE explicitly recommends not using sunlight as treatment, and the AAP writes that putting your baby in sunlight is not a safe way to treat jaundice. Daylight is only useful for seeing the colour of the skin better. NICE also advises against, among others, charcoal, glycerin, homeopathy, acupuncture and traditional Chinese herbal medicine.

Usually not. NICE recommends reassuring parents that breastfeeding can usually continue, including during phototherapy. Medycyna Praktyczna experts write that a baby should not be taken off the breast during phototherapy, and that a break from breastfeeding is needed only exceptionally, with very severe jaundice, and is decided by a doctor.

According to the AAP, jaundice is more common in breastfed babies mainly when the baby is not yet getting enough milk, for example when milk comes in later or the baby does not latch well. Frequent feeding helps:

• The AAP and the NHS advise feeding 8-12 times a day in the first days.
• The Polish perinatal care standard says that early in breastfeeding a baby may be put to the breast a dozen or more times a day, and if the baby does not wake, they should be woken for a feed 3-4 hours after the start of the last feed, except on the first day of life.
• NICE recommends waking a sleepy jaundiced baby for feeds and giving the mother breastfeeding support.
• Giving water or glucose does not make bilirubin fall faster. Medycyna Praktyczna experts do not recommend it when breastfeeding is going well. If the baby needs extra feeds, NICE names the mother's expressed milk as the first choice.

Breast milk jaundice is a separate matter. Medycyna Praktyczna describes it as the most common form of prolonged jaundice in breastfed babies. It usually appears after day 3-4 and can last several weeks, even up to 3 months. The baby is well, and urine and stools are a normal colour. It usually needs no treatment, and the baby keeps breastfeeding. It is a doctor, though, who decides that this is the type of jaundice, after ruling out other causes.

Call 112 or go to the emergency department (SOR) if your baby has jaundice and:

• is less than 24 hours old,
• is sleepier than usual, hard to wake or not feeding,
• is floppy or stiff, has seizures, unusual movements or a piercing, high-pitched cry,
• has a temperature of 38°C or more, or 36°C or less,
• has no wet nappies,
• has difficulty breathing or is breathing very fast.

Contact your GP (lekarz POZ) the same day, or the out-of-hours service (nocna i świąteczna opieka zdrowotna) in the evening, at night and on public holidays, if:

• the jaundice is getting worse or not improving, or the yellowing spreads to the tummy, arms and legs,
• the palms and soles are yellow, because the WHO treats this as a danger sign at any age,
• stools are pale, creamy, greyish-white or chalky, and urine is dark yellow or brown and stains the nappy,
• the skin changes from yellow-orange to yellow-olive,
• the jaundice lasts longer than 14 days in a full-term baby or longer than 21 days in a preterm baby.

Pale stools and dark urine are not part of physiological jaundice or breast milk jaundice, so they always need a prompt medical check. The NHS advises keeping a nappy with poo in it to show the doctor or midwife. The lists above combine advice from the NHS, NICE, the WHO and Medycyna Praktyczna.

After you leave hospital, a primary care (POZ) midwife visits your baby at home. Under the perinatal care standard she makes at least 4 free postnatal home visits (wizyty patronażowe) funded by the NFZ, the first no later than 48 hours (excluding Saturdays, Sundays and public holidays) after she is notified of the birth or of the mother's discharge from hospital. The standard states explicitly that the midwife observes and assesses the newborn's skin, in particular the degree of yellowing. She also assesses and records:

• the baby's general condition, including temperature, weight, and passing urine and stools,
• feeding: how often and how long the baby feeds, whether they suck willingly and whether they seem satisfied,
• weight gain or loss,
• the baby's behaviour: sleep, alert periods and responsiveness.

The midwife also gives breastfeeding advice and helps when breastfeeding is not going well, which matters especially with jaundice. Before the visit, note how many times a day your baby feeds, how many wet and dirty nappies they have and since when you have noticed the yellowing. Also have your hospital documents ready, including any bilirubin results.

A postnatal visit does not replace urgent help. If between visits you notice any of the danger signs described above, do not wait for the midwife; contact a doctor straight away or call 112.