What is hyperbilirubinemia?

Hyperbilirubinemia is a condition in which there is too much bilirubin in the blood. When red
blood cells break down, a substance called bilirubin is formed. Babies are not easily able to get
rid of the bilirubin and it can build up in the blood and other tissues and fluids of the baby's body.
This is called hyperbilirubinemia. Because bilirubin has a pigment or coloring, it causes a
yellowing of the baby's skin and tissues. This is called jaundice.

Depending on the cause of the hyperbilirubinemia, jaundice may appear at birth or at any time
afterward.
What causes hyperbilirubinemia?
During pregnancy, the placenta excretes bilirubin. When the baby is born, the baby's liver must
take over this function. There are several causes of hyperbilirubinemia and jaundice, including
the following:
• physiologic jaundice
Physiologic jaundice occurs as a "normal" response to the baby's limited ability to excrete
bilirubin in the first days of life.

• breast milk jaundice

About 2 percent of breastfed babies develop jaundice after the first week. Some develop
breast milk jaundice in the first week due to low calorie intake or dehydration.

• jaundice from hemolysis

Jaundice may occur with the breakdown of red blood cells due to hemolytic disease of
the newborn (Rh disease), having too many red blood cells, or bleeding.

• jaundice related to inadequate liver function

Jaundice may be related to inadequate liver function due to infection or other factors.
Who is affected by hyperbilirubinemia?
About 60 percent of term newborns and 80 percent of premature babies develop jaundice. Infants
of diabetic mothers and of mothers with Rh disease are more likely to develop
hyperbilirubinemia and jaundice.
Why is hyperbilirubinemia a concern?
Although low levels of bilirubin are not usually a concern, large amounts can circulate to tissues
in the brain and may cause seizures and brain damage. This is a condition called kernicterus.
What are the symptoms of hyperbilirubinemia?
The following are the most common symptoms of hyperbilirubinemia. However, each baby may
experience symptoms differently. Symptoms may include:
• yellow coloring of the baby's skin (usually beginning on the face and moving down the
body)

• poor feeding or lethargy

The symptoms of hyperbilirubinemia may resemble other conditions or medical problems.
Always consult your baby's physician for a diagnosis.
How is hyperbilirubinemia diagnosed?
The timing of the appearance of jaundice helps with the diagnosis. Jaundice appearing in the first
24 hours is quite serious and usually requires immediate treatment. When jaundice appears on
the second or third day, it is usually "physiologic." However, it can be a more serious type of
jaundice. When jaundice appears on the third day to the first week, it may be due to an infection.
Later appearance of jaundice, in the second week, is often related to breast milk feedings, but
may have other causes.

Diagnostic procedures for hyperbilirubinemia may include:

• direct and indirect bilirubin levels
These reflect whether the bilirubin is bound with other substances by the liver so that it
can be excreted (direct), or is circulating in the blood circulation (indirect).

• red blood cell counts

• blood type and testing for Rh incompatibility (Coomb's test)

Treatment for hyperbilirubinemia:
Specific treatment for hyperbilirubinemia will be determined by your baby's physician based on:
• your baby's gestational age, overall health, and medical history
• extent of the disease
• your baby's tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference
Treatment depends on many factors, including the cause of the hyperbilirubinemia and the level
of bilirubin. The goal is to keep the level of bilirubin from increasing to dangerous levels.
Treatment may include:
• phototherapy
Since bilirubin absorbs light, jaundice and increased bilirubin levels usually decrease
when the baby is exposed to special blue spectrum lights. Phototherapy may take several
hours to begin working and it is used throughout the day and night. The baby's position is
changed to allow all of the skin to be exposed to the light. The baby's eyes must be
protected and the temperature monitored during phototherapy. Blood levels of bilirubin
are checked to monitor if the phototherapy is working.

• fiberoptic blanket
Another form of phototherapy is a fiberoptic blanket placed under the baby. This may be
used alone or in combination with regular phototherapy.

• exchange transfusion to replace the baby's damaged blood with fresh blood
Exchange transfusion helps increase the red blood cell count and lower the levels of
 bilirubin. An exchange transfusion is done by alternating giving and withdrawing blood
in small amounts through a vein or artery. Exchange transfusions may need to be repeated
if the bilirubin levels remain high.

• ceasing breastfeeding for one or two days

Treatment of breast milk jaundice often requires stopping the breastfeeding for one to two
days and giving the baby formula often helps lower the bilirubin levels. Breastfeeding
can then be resumed.

• treating any underlying cause of hyperbilirubinemia, such as infection

Prevention of hyperbilirubinemia:
While hyperbilirubinemia cannot be totally prevented, early recognition and treatment are
important in preventing bilirubin levels from rising to dangerous levels.

Hyperbilirubinemia

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Pronunciations

apnea

bilirubin

colitis

cutaneous

hemoglobin

hemolysis

hyperbilirubinemia

kernicterus

meconium

pneumothorax

polycythemia

retinopathy

sepsis

tachypnea

umbilical
Hyperbilirubinemia is an abnormally high level of bilirubin (a pigment produced
from the breakdown of red blood cells) in the blood.
• Severe hyperbilirubinemia is usually caused by illnesses that interfere
with feeding, serious disorders such as sepsis, or the rapid breakdown of
red blood cells.
• Bilirubin in the blood causes the skin and the whites of the eyes to appear
yellow (jaundice).
• The diagnosis is based on the presence of jaundice and high levels of
bilirubin measured in the blood.
• Newborns discharged from the hospital on the first day after birth should
have their bilirubin level checked at home by a visiting nurse or in the
doctor's office within a few days after discharge.
• When treatment is needed, newborns are treated with phototherapy and,
for very severe cases, exchange blood transfusion.
Aging red blood cells are normally removed by the spleen, and the hemoglobin
(the oxygen-carrying substance) from these red blood cells is broken down and
recycled. The heme portion of the hemoglobin molecule is converted into a
yellow pigment called bilirubin, which is carried in the blood to the liver where it
is chemically modified and then excreted in the bile into the digestive tract. It is
removed from the body when the newborn passes stools.
In most newborns, the level of bilirubin in the blood increases in the first days
after birth, and mild bilirubin elevations are considered normal. Bilirubin in the
blood can cause the newborn's skin and the whites of the eyes to appear yellow
(jaundice). If feedings are delayed for any reason, such as an illness or an
intestinal problem, blood levels of bilirubin can become high. Also, breastfed
newborns tend to have somewhat higher blood levels of bilirubin during the first
week, but this increase also is usually of no concern. After several days, as the
infant takes more in feedings, the bilirubin level decreases.

Did You Know...

• Mild hyperbilirubinemia is very
common in healthy newborns
and is not of concern.

Significant hyperbilirubinemia may occur when newborns have serious medical

disorders, such as infection in the blood (sepsis). It may also be caused by the
rapid breakdown of red blood cells (hemolysis), which occurs with Rh
incompatibility (see Pregnancy Complications: Rh Incompatibility) or ABO
incompatibility (see Problems in Newborns: What Is Hemolytic Disease of the
Newborn? ).
In the large majority of cases, elevated levels of bilirubin in the blood are not
serious. However, very high bilirubin levels can cause brain damage. Brain
damage caused by hyperbilirubinemia is termed kernicterus. Very premature and
critically ill newborns are at higher risk of developing kernicterus, but
kernicterus usually can be avoided with appropriate treatment. However,
newborns who are just a few weeks premature, who are breastfeeding, and who
are discharged early from the hospital must be monitored closely for
hyperbilirubinemia in the first few days after hospital discharge because they can
develop kernicterus if the bilirubin level becomes very high. Premature
newborns are at higher risk because they do not feed as vigorously as term
infants and their mother's milk has not yet come in well.
Symptoms and Diagnosis
Newborns with hyperbilirubinemia have jaundice. It may be more difficult to
recognize jaundice in dark-skinned newborns. Jaundice usually first appears on
the newborn's face and then, as the bilirubin level increases, progresses
downward to involve the chest, abdomen, and finally the legs and feet. But the
appearance of jaundice does not provide an accurate measure of the bilirubin
level.
The first symptoms of kernicterus are usually sluggishness (lethargy) and poor
feeding. Newborns who have hyperbilirubinemia and these symptoms should be
examined immediately by a doctor because they may need immediate treatment.
The later stages of kernicterus involve irritability, muscle stiffening, arching of
the back, seizures, and fever.
It is important that doctors assess the degree of jaundice in all newborns during
the first days of life. Most doctors measure a newborn's bilirubin level before
discharge from the hospital. Because bilirubin levels may take several days to
rise to a dangerous level, newborns discharged from the hospital on the first day
after birth should have their blood bilirubin levels checked at home by a visiting
nurse or in the doctor's office within a few days after discharge. This testing is
especially necessary for newborns born a few weeks prematurely who are
breastfeeding.
Doctors first examine newborns under good lighting and then measure the level
of bilirubin with a specialized piece of equipment held against the skin
(transcutaneous bilirubinometer) or test a sample of blood.
Treatment
Mild hyperbilirubinemia does not require special treatment. Frequent
breastfeedings accelerate the passage of stools, thus reducing the reabsorption of
bilirubin from the intestinal contents and lowering the bilirubin level.

Did You Know...

 • It is normal for breastfed
newborns to have slightly
elevated levels of bilirubin
during the first weeks after birth.

Moderate hyperbilirubinemia can be treated with phototherapy, in which

newborns are undressed and placed under bilirubin lights. The light exposure
alters the composition of the bilirubin in the newborn's skin, changing it to a
form that is more readily excreted by the liver and kidneys. The newborn's eyes
are shielded with a blindfold because the lights may damage the eyes. Newborns
can also be treated at home by having them lie on a fiber-optic bilirubin blanket,
which exposes their skin to bright light. Newborns being treated with bilirubin
lights need to have their blood levels of bilirubin tested repeatedly until the
levels decrease because jaundice may disappear even though the levels of
bilirubin in the blood remain elevated.
Very rarely, it may be necessary for a mother to change from breastfeeding to
formula feeding for 1 or 2 days to ensure that the newborn is receiving adequate
volumes with each feeding. The mother should resume breastfeeding as soon as
the bilirubin levels start to decrease. Moderate hyperbilirubinemia sometimes
continues for weeks in newborns who are breastfed, a normal phenomenon that
poses no problems for the newborn.
If the newborn's bilirubin approaches a dangerous level even while phototherapy
is used, the level can be lowered rapidly by doing an exchange blood transfusion.
In this procedure, a sterile catheter is placed into the umbilical vein located in the
cut surface of the umbilical cord. The newborn's bilirubin-containing blood is
removed one syringe-full at a time and replaced with an equal volume of non-
jaundiced blood provided by the blood bank.