Jaundice

Jaundice

What is jaundice?

The yellowing of the skin and the whites of the eyes are typical indications of jaundice, a condition that develops either shortly after birth or during adulthood as a symptom of a potentially harmful illness or disease. Mucous membranes in the mouth can also experience discolouration.

Jaundice (hyperbilirubinemia) is not a disease, but does signal that something in the body is not functioning as it should, indicating an underlying problem. The name of the condition is derived from the French word, ‘jaune’, meaning yellow.

The yellow discolouration is typically as a result of excess bilirubin (a yellow pigment / chemical compound that is regarded as a waste product) in the body’s system. Bilirubin forms as a result of red blood cells (RBCs) that are broken down in the liver. Red blood cells typically replenish themselves and travel through the bloodstream, carrying oxygen and nutrients that are essential for healthy bodily function. The liver normally rids the body of bilirubin by filtering it along with old RBCs no longer needed (these pass through the digestive tract and out of the body through stools and urine).

Jaundice occurs when this function does not happen efficiently (the liver does not metabolise bilirubin) and a build-up remains. This can indicate a serious illness whereby the impaired function of RBCs causes damage to the liver, pancreas or gallbladder.

What causes jaundice?

Jaundice is commonly seen in new-born babies, but can also occur as a symptom in adults signalling a more serious disease or health condition.

New-born (infant) jaundice

New-born baby with jaundice

It’s not uncommon for a new-born to be diagnosed with jaundice, also known as neonatal hyperbilirubinemia (and often termed ‘physiologic jaundice’), especially if they arrive a little earlier than expected (are born prematurely). Surplus bilirubin often occurs in a new-born due to their underdeveloped liver. Extra RBCs begin to breakdown soon after birth and an underdeveloped liver may be slow to process the chemical compound excess (basically, the body produces more bilirubin than the liver is capable of metabolising).

Signs of jaundice typically peak between the first 3 to 5 days of life. Usually, new-born or infant jaundice will resolve itself as the body’s functions stabilise and the liver matures (within the first 2 weeks following birth). A baby with jaundice will, however, still need to be cared for (placed under ‘bili lights’ in a neonatal incubator) and monitored in hospital.

‘Bili lights’ or phototherapy is used to help rid the blood of excess bilirubin. A new-born’s skin and blood absorb the light waves (emitted in the blue-green spectrum) of the therapy process which then stimulates the change of the chemical compound so that it can be easily passed through the digestive system. Essentially the light therapy stimulates the function in the body which would normally occur if the liver was fully developed and capable of metabolising bilirubin naturally. Phototherapy uses ultraviolet light which is protected with a plastic shield, filtering the light allowed through.

New-born baby with neonatal jaundice under blue UV light for phototheraphy

If jaundice is noted within the initial hours (within a 24-hour period) of life, it is not considered normal. A medical doctor will perform tests to either determine or rule out a potentially serious underlying cause (which can be due to illness).

Before being discharged, new-born babies will likely have their bilirubin levels measured. If the level is excessive, they will be placed under the ‘bili lights’ so as to prevent the development of a rare condition affecting the brain, called kernicterus (brain damage) as well as other potentially severe complications including cerebral palsy, spasticity, difficulties with vision or deafness.

If signs occur once a new-born is discharged and settling in at home, this is often diagnosed as ‘breastfeeding jaundice’ or ‘breast milk jaundice’.

  • Breastfeeding jaundice: This occurs when a new-born is receiving an inadequate amount of milk during its first 2 or 3 days (or up to 2 or 3 weeks) of life. A baby may have trouble latching to a mother’s breast or may be given supplement substitutes which can hinder normal breastfeeding.
  • Breast milk jaundice: This is jaundice that persists after physiologic jaundice clears in the days following birth (4 to 7 days). There may be substances in a mother’s breast milk that causes a baby’s developing liver difficulty in processing bilirubin sufficiently. There could also be the presence of an infection or a blood type mismatch between mom and baby.

A new mother need not be too alarmed by either occurrence and stop breastfeeding altogether. Her baby still needs to be fed sufficiently. She should keep her doctor or paediatrician in the loop and follow their care instructions if any discolouration is noted or breastfeeding problems occur. Typically, these forms of jaundice will not require treatment either. The first post-birth check-up (within the first week following birth) with your paediatrician will include a physical assessment for jaundice.

Jaundice that occurs beyond the first few weeks of life and in older children is regarded more as a red flag for a potential disease or illness. It is best to see a doctor as soon as possible (the same day you notice signs) to determine whether or not there are concerns or problems with the liver or if the underlying cause is as a result of an infection.

Jaundice is treatable, but if not effectively cared for, can develop more serious complications.

Jaundice in adults

Jaundice is less commonly seen in adults and young children than it is in new-born babies. It is usually symptomatic of a more serious underlying cause and indicates that normal metabolism and excretion functions of bilirubin in the body are compromised.

The liver, where bilirubin is usually combined with bile, is unable to make the chemical compound (bilirubin) more water soluble. This impairment has a domino effect in that the gallbladder is then unable to carry the compound into the intestines (digestive tract) and excrete the substance as waste in a person’s stool (faeces) or urine (in fact, it’s this bilirubin that gives these their brown and yellow colour respectively).

Illustration of pancreatic cancer and signs of jaundiceDysfunction in the normal metabolism and excretion process can occur at any point in the chain of function. Where the dysfunction occurs can help to determine the underlying cause of jaundice.

  • Pre-hepatic: If the problem is determined as ‘pre-hepatic’, it indicates to a medical professional that the dysfunction is likely taking place before the bilirubin is secreted to the liver. A combination of excessive RBC destruction and a rapid increase in bilirubin levels overwhelm the liver’s ability to metabolise the chemical compound. Unconjugated bilirubin levels increase and can lead to further breakdown of RBCs. Diseases and illnesses that may cause this type of jaundice include sickle cell anaemia and thalassaemia, Crigler-Najjar syndrome, hereditary spherocytosis and malaria. Conditions such as haemolytic anaemia can also lead to jaundice. The condition causes the rupture of RBCs, reducing the amount present in the bloodstream needed for sufficient bodily functions. A person can feel exceptionally weak and tired as a result.
  • Hepatic / Intra-hepatic: If ‘hepatic’ or ‘intra-hepatic’, the problem is occurring once the compound reaches the liver and is unable to be processed. Hepatic causing conditions can include viral infections such as glandular fever, Hepatitis A, B and C (This condition is typically caused by a virus and is generally diagnosed as either an acute (short-lived) or chronic infection (lasting at least 6 months). Certain medications or autoimmune disorders can also cause a hepatitis infection - a swelling of the liver. Liver damage experienced due to hepatitis can bring on jaundice), Gilbert’s syndrome, Dubin-Johnson syndrome, primary sclerosing cholangitis (a rare liver diseases resulting in chronic liver inflammation), primary biliary cirrhosis, liver cancer, glandular fever, leptospirosis (a bacterial infection spread by animals) and alcoholic liver disease (damage to the liver can also be caused by excessive alcohol consumption over a prolonged period of time (at least 8 to 10 years). Damage can be caused by the development of alcoholic hepatitis or alcoholic cirrhosis (scarring of the liver), as well as an infection). Drug abuse (whether illicit like ecstasy or over-the-counter like paracetamol) as well as exposure to harmful substances such as carbon tetrachloride and phenol may also cause hepatic jaundice. Some medications may result in damage to the liver, which in turn can cause liver disease. Medications which have been known to have such side-effects are penicillin, oral contraceptive pills (birth control), acetaminophen and steroids.
  • Post-hepatic: If ‘post-hepatic’, also known as obstructive jaundice, is identified, the dysfunction is occurring once the compound is excreted from the liver. Generally, this is an indication that the bile ducts are inflamed, blocked or damaged, preventing the gall bladder from moving the bile containing bilirubin into the digestive system. Increased levels of conjugated bilirubin can lead to cholangitis, pancreatitis, gallstones (hardened fat material or bilirubin pigment) or cancer of the pancreas, gallbladder or bile ducts.

Realistic illustration comparsion of healthy and sick (cirrhosis) human livers

How does jaundice affect babies?

Signs and symptoms

  • Yellowing of the skin: Mild cases of jaundice may make the discolouration more difficult to see. Sometimes lighting conditions can make it more difficult to see with the naked eyes as well. You can test for jaundice in these instances by gently pressing your baby’s nose and forehead. The skin will show discolouration more easily where pressed. If the skin appears slightly lighter when pressed, this is normal. Looking at your baby under natural light is best when trying to check for any discolouration. Discolouration of the skin will intensify and appear more yellow in severe cases of jaundice. Severe cases will also show yellowing of the skin in the arms, legs and abdomen area of the body too.
  • Yellowing of the whites of the eyes
  • The baby becomes passive and sluggish, refusing to be woken up
  • Poor weight gain
  • High-pitched cries

Any of the above-mentioned symptoms will need to be assessed by a medical doctor, especially if they persist for several weeks. Bilirubin levels will be checked periodically to determine whether the little one has a case of severe jaundice and excess levels of bilirubin which their little liver is finding overwhelming to metabolise.

Other underlying causes your paediatrician will want to check for in severe cases include:

  • The possibility of haemorrhage (internal bleeding)
  • Sepsis (an infection of the blood)
  • Viral or bacterial infections
  • Enzyme deficiency
  • Liver malfunction
  • RBC abnormalities
  • Blood type incompatibility between mother and baby

How does jaundice affect adults?

Common signs and symptoms

  • Yellowing of the skin, whites of the eyes and mucous membranes (especially in the mouth)
  • Dark-coloured urine or pale coloured stools
  • Rectal bleeding
  • Diarrhoea
  • Nausea and vomiting
  • Itching skin
  • Abdominal pain
  • Headache
  • Fever or chills
  • Weight loss and loss of appetite
  • Swelling in the legs, or distension of the abdomen
  • Body weakness

Risk factors and potential complications

Babies

Mother breastfeeding her new-born babyRisk factors and potential complications affecting infants are:

  • Premature birth: A baby that is born prematurely (before 38 weeks) may not be able metabolise bilirubin sufficiently and the amount produced in the system may be overwhelming for their little liver. A prem baby may also feed less and have fewer bowel movements. This means that little or no bilirubin is being excreted from the body.
  • Blood type mismatch: A new-born who has a different blood type to his or her mother may react to antibodies received through the placenta. The baby’s RBCs will break down a little quicker and result in jaundice.
  • Severe bruising during birth: A significantly difficult delivery can cause a little bruising for a new-born. This will typically result in the production of more bilirubin in the body and the early breakdown of more RBCs (before their usual lifespan is reached).
  • Breastfeeding problems: Dehydration and low calorie intake can lead to the development of jaundice. A nursing mother should not stop breastfeeding even when a baby is diagnosed as having jaundice. A baby may not need treatment but still requires enough to eat and must remain sufficiently hydrated as well.
  • Acute bilirubin encephalopathy: Severe cases of jaundice can occur when bilirubin becomes toxic to the cells of the brain. If this happens, immediate medical treatment is required. Signs of severe jaundice include a high-pitched cry (scream), poor feeding, a fever, vomiting, difficulty in waking the baby and a backward arching of the neck and body.
  • Kernicterus: If acute bilirubin encephalopathy worsens, permanent damage is caused to the brain. A baby will experience hearing loss, involuntary or uncontrolled movements (athetoid cerebral palsy), problems with the development of tooth enamel, and also develop a permanent upward gaze.

Adults

Adults are at risk of developing jaundice due to an underlying cause (as mentioned in the causes section). Other causes can include hereditary conditions (whereby RBCs are destroyed and excreted from the body before their normal lifespan is over) such as thalassemia or hereditary spherocytosis, or types of skin diseases such as Pyoderma gangrenosum (a condition that causes painful skin ulcers) and inflammation of the joints (Polyarthralgias).

Some individuals will make a full recovery, while others may experience long-term complications related to the underlying cause. Life-threatening complications include conditions such as anaemia, electrolyte abnormalities, internal bleeding, kidney failure, hepatic encephalopathy (brain function loss due to liver damage that prevents toxin removal from the blood), and in worst case scenarios, death.

Many of the complications which can occur in adults with jaundice relate to side-effects from medication used to treat the various underlying causes. Common side-effects include:

  • Digestive issues – gas, an upset stomach, diarrhoea, constipation, bloating
  • Stomach pain
  • Vomiting

Diagnosing jaundice

How is jaundice diagnosed in babies?

Babies will be examined within the initial 3 days of life when bilirubin levels typically peak. They may also be checked on several more occasions by the time they are 7 days old.

A doctor or paediatrician will assess:

  • The level of bilirubin in the blood
  • How well the new-born is feeding
  • Whether any bruising has occurred during delivery

A paediatrician will also take into account whether the baby was born prematurely, how old the baby is and if the little one has an older sibling who also experienced severe jaundice in infancy.

Follow-up visits will be recommended and your paediatrician will likely ask the mother, a series of questions to assess potential for jaundice in the first few weeks of life, these may include:

  • Is your baby feeding well?
  • How often are you feeding your baby?
  • Are you breastfeeding or using formula?
  • How frequently does your baby have a soiled nappy (diaper) – wet or stools?
  • Does your baby wake easily when it is time to feed?
  • Have you noticed any changes in your baby’s temperature?
  • Have you noticed any yellowing of your baby’s skin (including the arms, legs and abdomen) or eyes?

If moderate or severe jaundice is suspected, it is likely that your paediatrician may perform a blood test by taking a small sample via your baby’s toe (a small prick) to make a definite diagnosis. A skin test using a transcutaneous bilirubinometer can also be used to look at the condition of the skin. This device shines a special light on the surface of the skin making it easier for analysis.

During your follow-up, you may have questions too, and it is important that you ask them. Your paediatrician will guide you on the severity of your baby’s jaundice, if tests will be required, if treatment is necessary, if treatment will involve hospitalisation and whether or not your current schedule of feeding can still be maintained.

How is jaundice diagnosed in adults?

Your doctor will likely begin with a discussion about your medical history and what your symptoms are. Your doctor will also perform a physical exam to determine if there are any obvious signs which may point to a particular cause of jaundice.

If your doctor suspects liver dysfunction, he or she will begin checking for signs of liver disease. These signs may include:

  • Spider angiomas (an abnormal collection of blood vessels close to the surface of the skin)
  • Bruising on the skin
  • Palmar erythema (a red colouration of the fingertips and palms of the hands)

Blood sample for liver function testA diagnosis for jaundice in adults will be determined through tests. Recommended tests will relate to your overall symptoms. Common tests may involve:

  • Blood tests: The total amount of bilirubin in the body will be determined through a blood sample. Blood samples may also be used to diagnose various conditions causing jaundice, such as hepatitis. A doctor will also assess your CBC (complete blood count) and look for any signs of haemolytic anaemia (caused by abnormal degeneration of RBCs).
  • Liver function tests: Blood samples can also be used to measure levels of proteins and enzymes produced by the liver. The tests will show healthy function as well as damage caused by an impairment.
  • A liver biopsy: If any damage to the liver is suspected, small samples of liver tissue can be extracted for microscopic examination. This is done through the insertion of a needle between the lower ribs on the right-hand side to obtain a sample.
  • Imaging tests: Abdominal ultrasounds, MRI and CT scans can give your doctor detailed images of your internal organs – particularly the liver, pancreas and gallbladder. This will help to determine if there’s been any damage caused to your organs and also help to diagnose any underlying causes. If the liver is of concern, your doctor can determine its size and level of tenderness (which can indicate any abnormal function). In some cases, a HIDA scan (cholescintigraphy) may be recommended to check for any obstructions in the bile ducts (such as tumours and gallstones).
  • Urinalysis: The results of this test, which assesses the appearance, content and concentration of a sample of urine, is typically confirmed with a serum test (bilirubin levels and CBC).
  • Endoscopic retrograde cholangiopancreatography (ERCP): This invasive test will be used as necessary combining an endoscopy (a tube passed down the throat, into the stomach and duodenum, the first part of the small intestine) with a fluoroscopy (continuous X-ray image on a monitor) to determine abnormalities in the pancreatic or biliary ductal systems.

Treatment procedures

How will a baby with jaundice be handled?

Jaundice in infants is largely as a result of bilirubin production and under-developed liver function. Once this stabilises, jaundice typically resolves itself. A baby will still be monitored while displaying signs of jaundice though.

Moderate to severe cases of jaundice in infants may be treated with phototherapy (‘bili lights’). A baby will only be allowed to have on a nappy (diaper) and protective eye patches, and will be laid down on a light-emitting mattress or pad. A side-effect of this therapy may be that your baby will experience more frequent bowel movements (this is a good thing) and his or her stools may appear green in colour.

If a mismatch in blood type between a new mother and her baby is determined, the baby may also be given an intravenous immunoglobulin (IVIg) transfusion. The blood protein given will reduce the level of antibodies passed on from the mother and help alleviate the effects of jaundice.

It can happen, although rarely, that severe jaundice is unresponsive to the aforementioned treatments and an exchange transfusion of blood may be necessary.

Small amounts of blood will be drawn repeatedly. Each will be diluted with bilirubin and a mother’s antibodies before being transferred back into the new-born.

How will jaundice in an adult be handled?

Jaundice in adults is typically regarded as a symptom and not necessarily treated directly. The illness causing jaundice, however, will undergo a treatment plan. Once the underlying cause of jaundice is treated, it typically resolves itself and the discolouration experienced will return to normal.

Depending on the nature of the underlying cause, treatment may be managed at home, and in some instances, hospitalisation may be required.

Common treatments for underlying causes may include:

  • Home care: Underlying causes which may be mild can be managed without the need for hospitalisation, but may require consultation follow-ups to monitor a person’s condition.
  • Substance discontinuation / alcohol cessation: Where substances such as excessive alcohol are causing cirrhosis of the liver, acute pancreatitis or alcoholic hepatitis, treatment will include discontinued consumption in order for the body to begin healing. Medication use (intentional and unintentional overdose) will also need to be discontinued to alleviate aggravated symptoms, such as jaundice.
  • Medications and antibiotics: A doctor will carefully prescribe medications that will help to promote healing and clear up symptoms. These can include steroids for the treatment of autoimmune disorders, or diuretics and lactulose for those suffering cirrhosis complications. Bacterial infections will be treated with a course of antibiotics, killing off the cause and helping to promote healing in the body.
  • Blood transfusions: In some instances, the underlying cause could be anaemia from haemolysis (RBCs breakdown before their typical lifespan ends). Blood transfusions can help to replenish the body with RBCs and promote normal function.
  • Specialist treatment: Where a serious disease is the underlying cause, a person may be referred to an appropriate specialist. For instance, a cancer patient will be referred to an oncologist for treatment which will need to be carefully determined depending on the type and stage of the disease.
  • Surgery: Where necessary, the underlying cause may require invasive procedures in order to repair or correct an underlying problem. Liver failure or cirrhosis may require a liver transplant to restore the patient to health. Sometimes the underlying cause may be gallstones or a blocked bile duct which need surgical interventions to correct.

Mother breastfeeding her new-born baby at home

Home care – what can a mother do for her baby?

Where a new-born has a mild case of jaundice, you will be allowed to take your baby home. Your paediatrician will discuss any necessary adjustments in your feeding schedule beforehand so as to lower the levels of bilirubin in your baby’s system.

It can happen that in the days after being discharged from hospital, your healthy baby develops jaundice. Your paediatrician may diagnose ‘breast-feeding jaundice’ or ‘breast milk jaundice’ during your consultation discussion and assessment. It could merely mean that a substance in your breast milk is blocking proteins in the liver, and your baby’s system is unable to metabolise bilirubin or that your baby isn’t getting enough milk. If it is determined that your baby is latching well and getting enough milk, a blood test may still be recommended to make the diagnosis as to what is causing jaundice.

You may begin to worry when advised to stray from your planned feeding schedule, but you need not panic. Your paediatrician will guide you and address all your concerns so that you are completely comfortable with how much and how often your baby will need to be fed. Jaundice can make a little one a bit fussy or difficult to feed. Your paediatrician will guide you.

You will not be discouraged from breastfeeding (or formula feeds). Your paediatrician may advise:

  • More frequent feeds: With the increased levels of bilirubin in your baby’s system, you will need to encourage more frequent bowel movements. To do this, your paediatrician may advise more frequent feeds. More frequent bowel movements mean your baby will be excreting more of the chemical compound, alleviating symptoms of jaundice. If you are breastfeeding, your paediatrician will recommend 8 to 12 feeds a day during your baby’s first week or so of life. If you are opting to feed your baby formula, you will be encouraged to feed your baby every 2 to 3 hours.
  • Breastfeeding supplements: It is common for a jaundiced baby to have trouble being breastfed. A baby can easily become dehydrated and lose weight as well. In these instances, supplemental feeds will be encouraged. You can either try giving your baby formula or expressed breast milk. You may need to feed your baby formula for a few days before returning to breastfeeding.

What is the outlook for jaundice?

Jaundice typically resolves when the underlying cause is treated. In most instances, mild cases of the condition clear up on their own. Signs for severe underlying causes should always be monitored and appropriately treated by a medical professional to prevent serious complications.

Babies will typically come right within a week or two when their little livers mature and function more efficiently. It can happen, however, that jaundice persists. If a little one still has jaundice into his or her first 6 weeks of life, seek medical attention right away (don’t wait it out). A doctor will want to determine whether a possible illness is the cause and prescribe adequate treatment as soon as possible.

Is there a way to prevent jaundice?

In adults, it is possible to prevent jaundice. As a symptom of some conditions, as well as in the case of new-borns, however, it may not be possible to prevent.

As an adult, there are things you can do to reduce your risk. These include:

  • Avoiding high-risk behaviours: Intravenous drug use, unprotected sex or working with blood products and needles can place you at higher risk of infections such as hepatitis (B or C). You can also take care to avoid food products which are at high risk of contamination or unsanitary water. This will decrease your risk for hepatitis A. If you enjoy alcohol, it is best to take care to consume it responsibly and not develop excessive habits. Smoking also places you at higher risk for diseases such as pancreatic cancer, and a variety of other malignancies.
  • Getting necessary vaccinations: If you are at high risk, vaccinations for hepatitis A and B are available. 
  • Taking medications as instructed: Common side-effects of medication use can be attributed to unintentional overdose. This can cause damage to the liver. If you have a known issue with your liver, you should not take anything that isn’t directly prescribed by your doctor. If you intend to travel to a high-risk malaria area, it is advisable to get a prescription for antimalarial medications well ahead of time and take as directed.
  • Keep your diet and cholesterol levels in check: A healthy body is a healthy you. Ensure that your fitness levels are good and that your diet is nutritious.

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