Mild jaundice in newborns

Infant jaundice - Symptoms and causes

Overview

Infant jaundice is yellow discoloration of a newborn baby's skin and eyes. Infant jaundice occurs because the baby's blood contains an excess of bilirubin (bil-ih-ROO-bin), a yellow pigment of red blood cells.

Infant jaundice is a common condition, particularly in babies born before 38 weeks' gestation (preterm babies) and some breast-fed babies. Infant jaundice usually occurs because a baby's liver isn't mature enough to get rid of bilirubin in the bloodstream. In some babies, an underlying disease may cause infant jaundice.

Most infants born between 35 weeks' gestation and full term need no treatment for jaundice. Rarely, an unusually high blood level of bilirubin can place a newborn at risk of brain damage, particularly in the presence of certain risk factors for severe jaundice.

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Symptoms

Yellowing of the skin and the whites of the eyes — the main sign of infant jaundice — usually appears between the second and fourth day after birth.

To check for infant jaundice, press gently on your baby's forehead or nose. If the skin looks yellow where you pressed, it's likely your baby has mild jaundice. If your baby doesn't have jaundice, the skin color should simply look slightly lighter than its normal color for a moment.

Examine your baby in good lighting conditions, preferably in natural daylight.

When to see a doctor

Most hospitals have a policy of examining babies for jaundice before discharge. The American Academy of Pediatrics recommends that newborns be examined for jaundice during routine medical checks and at least every eight to 12 hours while in the hospital.

Your baby should be examined for jaundice between the third and seventh day after birth, when bilirubin levels usually peak. If your baby is discharged earlier than 72 hours after birth, make a follow-up appointment to look for jaundice within two days of discharge.

The following signs or symptoms may indicate severe jaundice or complications from excess bilirubin. Call your doctor if:

Your baby's skin becomes more yellow
The skin on your baby's the abdomen, arms or legs looks yellow
The whites of your baby's eyes look yellow
Your baby seems listless or sick or is difficult to awaken
Your baby isn't gaining weight or is feeding poorly
Your baby makes high-pitched cries
Your baby develops any other signs or symptoms that concern you

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Causes

Excess bilirubin (hyperbilirubinemia) is the main cause of jaundice. Bilirubin, which is responsible for the yellow color of jaundice, is a normal part of the pigment released from the breakdown of "used" red blood cells.

Newborns produce more bilirubin than adults do because of greater production and faster breakdown of red blood cells in the first few days of life. Normally, the liver filters bilirubin from the bloodstream and releases it into the intestinal tract. A newborn's immature liver often can't remove bilirubin quickly enough, causing an excess of bilirubin. Jaundice due to these normal newborn conditions is called physiologic jaundice, and it typically appears on the second or third day of life.

Other causes

An underlying disorder may cause infant jaundice. In these cases, jaundice often appears much earlier or much later than does the more common form of infant jaundice. Diseases or conditions that can cause jaundice include:

Internal bleeding (hemorrhage)
An infection in your baby's blood (sepsis)
Other viral or bacterial infections
An incompatibility between the mother's blood and the baby's blood
A liver malfunction
Biliary atresia, a condition in which the baby's bile ducts are blocked or scarred
An enzyme deficiency
An abnormality of your baby's red blood cells that causes them to break down rapidly

Risk factors

Major risk factors for jaundice, particularly severe jaundice that can cause complications, include:

Premature birth. A baby born before 38 weeks of gestation may not be able to process bilirubin as quickly as full-term babies do. Premature babies also may feed less and have fewer bowel movements, resulting in less bilirubin eliminated through stool.
Significant bruising during birth. Newborns who become bruised during delivery gets bruises from the delivery may have higher levels of bilirubin from the breakdown of more red blood cells.
Blood type. If the mother's blood type is different from her baby's, the baby may have received antibodies through the placenta that cause abnormally rapid breakdown of red blood cells.
Breast-feeding. Breast-fed babies, particularly those who have difficulty nursing or getting enough nutrition from breast-feeding, are at higher risk of jaundice. Dehydration or a low caloric intake may contribute to the onset of jaundice. However, because of the benefits of breast-feeding, experts still recommend it. It's important to make sure your baby gets enough to eat and is adequately hydrated.
Race. Studies show that babies of East Asian ancestry have an increased risk of developing jaundice.

Complications

High levels of bilirubin that cause severe jaundice can result in serious complications if not treated.

Acute bilirubin encephalopathy

Bilirubin is toxic to cells of the brain. If a baby has severe jaundice, there's a risk of bilirubin passing into the brain, a condition called acute bilirubin encephalopathy. Prompt treatment may prevent significant lasting damage.

Signs of acute bilirubin encephalopathy in a baby with jaundice include:

Listlessness
Difficulty waking
High-pitched crying
Poor sucking or feeding
Backward arching of the neck and body
Fever

Kernicterus

Kernicterus is the syndrome that occurs if acute bilirubin encephalopathy causes permanent damage to the brain. Kernicterus may result in:

Involuntary and uncontrolled movements (athetoid cerebral palsy)
Permanent upward gaze
Hearing loss
Improper development of tooth enamel

Prevention

The best preventive of infant jaundice is adequate feeding. Breast-fed infants should have eight to 12 feedings a day for the first several days of life. Formula-fed infants usually should have 1 to 2 ounces (about 30 to 60 milliliters) of formula every two to three hours for the first week.

By Mayo Clinic Staff

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Newborn jaundice - NHS

Jaundice in newborn babies is common and usually harmless. It causes yellowing of the skin and the whites of the eyes. The medical term for jaundice in babies is neonatal jaundice.

Yellowing of the skin can be more difficult to see in brown or black skin. It might be easier to see on the palms of the hands or the soles of the feet.

Other symptoms of newborn jaundice can include:

dark, yellow urine (a newborn baby's urine should be colourless)
pale-coloured poo (it should be yellow or orange)

The symptoms of newborn jaundice usually develop 2 days after the birth and tend to get better without treatment by the time the baby is about 2 weeks old.

Find out more about the symptoms of jaundice in babies

Your baby will be examined for signs of jaundice within 72 hours of being born as part of the newborn physical examination.

If your baby develops signs of jaundice after this time, speak to your midwife, health visitor or a GP as soon as possible for advice.

While jaundice is not usually a cause for concern, it's important to determine whether your baby needs treatment.

If you're monitoring your baby's jaundice at home, it's also important to contact your midwife straight away if your baby's symptoms quickly get worse or they become very reluctant to feed.

Find out more about diagnosing jaundice in babies

Why does my baby have jaundice?

Jaundice is caused by the build-up of bilirubin in the blood. Bilirubin is a yellow substance produced when red blood cells, which carry oxygen around the body, are broken down.

Jaundice is common in newborn babies because babies have a high number of red blood cells in their blood, which are broken down and replaced frequently.

Also, a newborn baby's liver is not fully developed, so it's less effective at removing the bilirubin from the blood.

By the time a baby is about 2 weeks old, their liver is more effective at processing bilirubin, so jaundice often corrects itself by this age without causing any harm.

In a small number of cases, jaundice can be the sign of an underlying health condition. This is often the case if jaundice develops shortly after birth (within the first 24 hours).

How common is newborn jaundice?

Jaundice is one of the most common conditions that can affect newborn babies.

It's estimated 6 out of every 10 babies develop jaundice, including 8 out of 10 babies born prematurely before the 37th week of pregnancy.

But only around 1 in 20 babies has a blood bilirubin level high enough to need treatment.

For reasons that are unclear, breastfeeding increases a baby's risk of developing jaundice, which can often persist for a month or longer.

But in most cases, the benefits of breastfeeding far outweigh any risks associated with jaundice.

Treating newborn jaundice

Treatment for newborn jaundice is not usually needed because the symptoms normally pass within 10 to 14 days, although they can occasionally last longer.

Treatment is usually only recommended if tests show very high levels of bilirubin in a baby's blood.

This is because there's a small risk the bilirubin could pass into the brain and cause brain damage.

There are 2 main treatments that can be carried out in hospital to quickly reduce your baby's bilirubin levels.

These are:

phototherapy – a special type of light shines on the skin, which alters the bilirubin into a form that can be more easily broken down by the liver
an exchange transfusion – where your baby's blood is removed using a thin tube (catheter) placed in their blood vessels and replaced with blood from a matching donor; most babies respond well to treatment and can leave hospital after a few days

Complications

If a baby with very high levels of bilirubin is not treated, there's a risk they could develop permanent brain damage. This is known as kernicterus.

Kernicterus is very rare in the UK.

Find out more about kernicterus in babies

You can also read the National Institute for Health and Care Excellence (NICE) guidance about jaundice in newborn babies under 28 days.

Page last reviewed: 03 February 2022
Next review due: 03 February 2025

Newborn jaundice: causes, treatment, consequences, prevention

Newborn jaundice is faced by many parents. This is especially true for premature babies, but in babies who were born at term, this is also a common occurrence.

Jaundice develops in the first few days after the birth of the baby, and the change in skin color usually becomes noticeable on the 3rd-4th day, just when the mother and baby return home from the hospital.

Why does this happen and what is the difference between physiological neonatal jaundice, which does not require treatment, and dangerous pathological neonatal jaundice? We deal with doctors.

What you need to know about jaundice in newborns

Bilirubin is formed from the breakdown of red blood cells (blood cells that are responsible for transporting oxygen) throughout life and is excreted from the body without problems with the help of the liver. All body systems in a newborn do not work well enough, for example, the liver may not have enough enzymes to break it down and excrete it. Because of this, bilirubin accumulates in the blood, and the skin color becomes yellow. It happens that the whites of the eyes acquire the same shade.

Physiological jaundice differs from pathological jaundice in that the former does not require treatment and resolves on its own. This usually happens after the first month of a baby's life. But the pathological condition is important and needs to be tracked in time. It affects the general well-being, has negative consequences, but with a competent approach, it is treated by a pediatrician or neonatologist.

Physiological jaundice - a variant of the norm	In the first days of life, many parents experience yellowing of the baby's skin. At the same time, nothing threatens the condition of children, and the shade of the skin is normalized after 7-10 days. The only thing that can overshadow the first days of a baby’s life is vomiting. Occurs against the background of a bunch of bilirubin with albumin to prevent the toxic effects of the first (1). But such a phenomenon is rare.
There are several types of pathological jaundice	Conjugative jaundice develops due to liver enzyme deficiency. Hemolytic jaundice is associated with a change in the structure of red blood cells. And the problem of obstructive jaundice is a violation of the outflow of bile.
Things to pay attention to when treating jaundice (in addition to the general condition)	The doctor first of all specifies whether the child has prematurity and other factors that can complicate the course of the disease, whether there is a hereditary predisposition to this disease. It is worth paying attention to the appetite of the baby, and his mother, the level of lactation is also important.
There is a "bilirubin encephalopathy"	In this condition, bilirubin enters the child's nervous system due to the fact that there is not enough albumin to neutralize it. The baby shows symptoms such as drowsiness, convulsions, and a weakened grasping reflex.
Jaundice is not contagious	It cannot be transmitted by airborne droplets. The cause of the disease is the increased breakdown of red blood cells and the insufficient functionality of the liver, which does not have time to process bilirubin secreted in large quantities.
When phototherapy is used for jaundice	At risk of hyperbilirubinemia, with physiological jaundice, with incompatibility of the baby's blood type with the mother's blood type, with an increase in bilirubin level above 5 µmol / l per hour.

How long does jaundice last in newborns

The duration of jaundice in a newborn depends on the characteristics of the organism. Physiological jaundice usually reaches its maximum on the 3-4th day of the baby's life. Gradual fading begins on days 4-5, and on days 7-14, the child's body completely copes with this condition.

- Parents are not always able to reliably determine whether the baby's jaundice is normal or not. Therefore, this condition is given maximum attention by the medical staff (first in the maternity hospital, then on patronage), - explains Albina Yusupova, pediatric neonatologist Lahta Clinic . - Before discharge in the maternity hospital, doctors examine the child, determine the presence of jaundice, evaluate the skin color in dynamics, whether the yellowness of the skin / sclera increases or not. Often they resort to using a percutaneous method for measuring the level of bilirubin (it is he who gives such staining of the skin) or take blood for analysis. With high numbers, phototherapy is prescribed (a special lamp or mattress). There are no exact numbers for this, it depends on many factors: gestational age (term baby or not), the presence of cephalohematoma or bruising at birth, the color of feces / urine, whether there are concomitant pathologies or not, the blood type of the mother and child, how the mother eats and gains weight baby.

In most cases, pathological jaundice develops on the first day of a newborn's life. The duration may vary depending on the reason why the child suffers from this disease: sometimes the treatment takes 2 months, and in complex cases where enhanced therapy is required, jaundice can last up to a month.

Higher bilirubin levels have been reported in breastfed neonates with large postpartum weight loss (≥8%), diabetic mothers, low gestational age, and drug induction of labor with oxytocin (2).

Causes of jaundice in newborns

Jaundice can appear in a baby for various reasons. Most often it is the accumulation of bilirubin in the blood. But there are other conditions that newborns face in the first weeks of life.

Bilirubin

Signs of pathology:

deviations from the normal course of physiological jaundice (earlier or later onset, prolonged persistence, undulating course),
appearance of pallor or a greenish hue of the skin,
increase in the concentration of total bilirubin in the blood serum,
relative increase in the level of the direct fraction of bilirubin (3).

Unlike physiological, pathological jaundice, as a rule, develops in the first hours after the baby is born. There may be dark urine and discoloration of feces, anemia, and pale skin. At the same time, the level of bilirubin is very high:

above 256 µmol/l in children born at term,
above 171 µmol/l in premature babies.

This condition is called hyperbilirubinemia. The most common cause of its development is hemolysis due to the incompatibility of the blood of the mother and child for erythrocyte antigens.

Other causes

“Pathological jaundice can be caused by several reasons,” says pediatrician Anna Levadnaya, PhD, author of the blog about pediatrics . - The most common is an increased breakdown of hemoglobin due to an Rhesus conflict or a blood type conflict between mother and child. Also, the cause of jaundice can be a pathology of the liver or a pathology of excretion of bile into the intestines. In addition, jaundice can be a sign of an infection, hypothyroidism (due to a decrease in thyroid function), polycythemia (an increased level of red blood cells in the blood), intestinal obstruction, or pyloric stenosis (this is a congenital narrowing of the stomach before entering the intestines, which makes it difficult for food to pass through). into it). It can occur with certain medications and for other reasons.

Hepatic jaundice occurs when a child's liver is exposed to viruses or bacteria. It can also develop with hepatitis B and hepatitis C, blood sepsis. At this time, the liver and spleen increase in size, the baby's urine acquires a more pronounced color. Hepatic jaundice is treated comprehensively, primarily by acting on the cause.

Violation of the outflow of bile can cause obstructive jaundice. This happens when the patency of the bile ducts worsens due to malformations, underdevelopment, or the appearance of neoplasms. Here, all attention should be paid to the place where bile accumulates and the reason why it accumulates. After all, it is because of her that the baby may show symptoms of jaundice.

Another cause is neonatal cholestasis. To confirm the diagnosis, it is necessary to make sure that the content of the direct fraction of bilirubin in the blood is more than 15-20% of the total level, an increase in the concentration of cholesterol, beta-lipoproteins, bile acids, as well as alkaline phosphatase and gamma-glutamyltransferase enzymes (3). This pathology occurs due to an increased level of bile acid synthesis, for which the newborn's liver is not ready. It happens that neonatal cholestasis occurs for reasons not related to the work of the liver. For example, against the background of hypoxia or the development of cardiovascular insufficiency.

There is also the so-called breastfeeding jaundice. There are studies that show that in healthy full-term infants who are bottle-fed, the level of bilirubin reaches a peak on the 5th day of life and becomes completely normal, on average, on the 13th day, while with natural feeding, two peaks of bilirubin rise are possible ( 3–5 and 10–15 days of life) with a gradual slow decrease (4). Jaundice from breast milk (from which certain hormones that increase bilirubin levels enter the baby's body) can last up to 6 weeks.

If the doctor makes this diagnosis, he must exclude the presence of hyperbilirubinemia. Because breastfeeding jaundice cannot cause it. If, when HB is canceled for 1-2 days, bilirubin begins to decrease, and yellowness disappears, the diagnosis is confirmed. But with positive dynamics, the abolition of breastfeeding is not required: it is resumed after 1-2 days. During the pause, the mother must definitely express herself in order to maintain lactation at the required level.

Treatment of neonatal jaundice

Physiological neonatal jaundice, as we have said, does not require treatment. Sometimes pediatricians recommend supplementing such children with water, but only if lactation is established and using a spoon, not a bottle.

As for the pathological jaundice of a newborn, it requires mandatory treatment, which is prescribed by a doctor.

The most effective treatment for this condition is phototherapy. For this, a special lamp with blue light is used: under the influence of ultraviolet radiation, bilirubin breaks down and is excreted from the body of the newborn with urine and feces. The intensity and duration of phototherapy depends on the baby's body weight at birth and the level of bilirubin, which is constantly monitored. As a rule, three-hour sessions under the lamp are prescribed with a break of 2-3 hours. The newborn must be undressed, but the eyes must be protected, the boys also have the genitals.

In severe cases of neonatal jaundice, when the life of the baby is at risk, a blood transfusion may be indicated.

Doctors have almost abandoned the use of drugs to treat neonatal jaundice. Some of them, for example, ascorbic acid and albumin, negatively affect the functioning of the nervous system, the effectiveness of allochol and B vitamins has not been proven, and Karsil and Essentiale have not been sufficiently tested specifically for newborns (3).

- It is important to note that most experts now agree that the appointment of sorbents, drugs such as phenobarbital, Essentiale, LIV-52, the abolition of breastfeeding, UV (ultraviolet blood enrichment), electrophoresis or excessive infusion therapy for jaundice is ineffective ( and it’s not safe for phenobarbital), says Anna Levadnaya.

Consequences of jaundice in newborns

Physiological jaundice in newborns, as we have already noted, passes by itself and does not bear negative consequences for the health of the baby. But the consequences of pathological jaundice in a newborn can be extremely serious, especially if treatment is not started on time.

— Too high blood levels of bilirubin can lead to brain damage, says Anna Levadnaya. - As a rule, this occurs in children with hemolytic disease according to the Rh factor, with an increase in the level of bilirubin above 298-342 µmol/l. And the higher the level of bilirubin, the higher the risk of encephalopathy.

Prevention of jaundice in newborns

The best prevention of jaundice in newborns is a healthy lifestyle for a mother during pregnancy, giving up bad habits, good nutrition.

In addition, the expectant mother must be tested to detect Rh-negative blood factor. Children born to mothers with Rh-negative blood are at risk for jaundice. After the birth of such babies, they carefully examine and monitor the content of bilirubin in the blood, and also determine the blood group.

- Women who may have a child with hemolytic jaundice are treated already during pregnancy. They are injected with anti-rhesus gamma globulin, and at birth, the child is immediately clamped on the umbilical cord and tested for bilirubin. If there are indications according to the tests, then the child is immediately put on phototherapy, - adds neonatologist Nadezhda Shurtakova . - The mother of the baby can also influence the fact that the child does not have jaundice. She needs to feed the baby more on the first day, try to get milk so that the baby does not lose weight. Jaundice often occurs with a large loss of initial weight. Bilirubin is a fat-soluble substance, and if the body of a newborn does not have enough fats, proteins and carbohydrates, then jaundice occurs at certain values of body weight loss.

Mother's milk is the best food for a newborn, it is easily digested, the intestines are stimulated faster, it is populated with beneficial microflora, the necessary enzymes are produced. All this helps the body of the newborn to cope with jaundice faster and more efficiently.

Frequently asked questions and answers

Nadezhda Shurtakova, neonatologist, head of the neonatal department at Maternity Hospital No. 4 (Moscow) answered frequently asked questions.

When is jaundice in newborns considered normal?

There are physiological and pathological jaundice. Physiological jaundice, which appears at the end of the second or third day of life, does not require treatment. Such jaundice is not pronounced and disappears on its own in 7-10 days. Physiological jaundice is present in 80% of children. Such children are discharged home without any additional examinations and treatment.

In what case is the child placed under the lamp and how long does the child need to stay there?

The child is placed under a lamp, for phototherapy, with pathological jaundice. The duration of therapy depends on what causes it.

Hemolytic jaundice of the newborn due to the Rh factor may appear already in the prenatal period, the child may be born with it and need an exchange transfusion. Such children are laid out under the lamp immediately at birth.

Jaundice caused by AB0 incompatibility (blood group incompatibility) appears at the age of 1.5 days. It is necessary to look at a biochemical blood test, and if there are indications, also put the child on phototherapy.

There is also conjugative jaundice, it, like physiological, also appears on the third day, but with it the amount of bilirubin (yellow substance) in the blood is significantly increased. Such children are also subject to phototherapy.

In different situations, phototherapy lasts from 1 to 4 days, usually 2-3 days, it is carried out under the control of biochemical and clinical blood tests. When the indicators are normal, the child is removed from phototherapy.

How long does it take to stay in the hospital if a newborn has jaundice?

Hemolytic jaundice lasts 5-7 days. We stabilize such children, wait for the end of the increase in bilirubin and then transfer them to another hospital. However, if treatment is started on time, the indicators return to normal faster, and the mother and child are already discharged from the hospital.

In case of conjugative jaundice, which may appear on the 4th day, already after discharge from the maternity hospital, children are admitted to hospitals from the districts.

Sources

E.I. Yulish. Jaundice syndrome in newborns: approaches to therapy // Health of the child. 2014. URL: https://cyberleninka.ru/article/n/sindrom-zheltuhi-u-novorozhdennyh-podhody-k-terapii
A.N. Goryainova. Jaundice in a healthy newborn: causes, course, prognosis // Medical Council. 2017. URL: https://cyberleninka.ru/article/n/zheltuhi-zdorovogo-novorozhdennogo-prichiny-techenie-prognoz
S. Ergieva. Jaundice of newborns // Vestnik VolGMU. 2007. URL: https://cyberleninka.ru/article/n/zheltuhi-novorozhdennyh/viewer
Gartner LM. Breastfeeding and Jaundice. J. Perinatol. 2001

Baby jaundice (jaundice) in newborns treatment

Why jaundice is common in newborns

Physiological jaundice in newborns (neonatal jaundice) is a medical term that describes the condition of children during the period of adaptation to environmental conditions. Popularly known as jaundice in newborns. It often manifests itself in the hospital. Mothers begin to be frightened when they see that the skin and whites of the baby's eyes acquire a yellowish tint. But this is one of the physiological processes that occur in the baby's body, allowing him to adapt to new living conditions. Statistics show that jaundice develops in 60% of full-term babies and 80% of premature babies.

Let's look at what jaundice is in a newborn, how long does jaundice in newborns last and how long does it take, whether it is worth fearing a reaction when resorting to treatment at home or in a hospital.

How is jaundice treated in newborns? They are much more than in the body of children and adults. When born, the baby no longer needs so many red blood cells that contribute to the oxidation of tissues. Therefore, they begin to break down, leading to an increase in bile pigment in the blood. During this period, infantile jaundice in newborns begins to appear. The norm of bilirubin at this moment exceeds 80 µmol / l or 5-12 mg / dl. It begins to be deposited in subcutaneous fat, giving it a yellow color. This leads to a change in the shade of the skin, mucous membranes.

By the second week of life, the infant's body begins to cope with excess bilirubin on its own, and the yellowness disappears. Many parents are worried about when the jaundice in the newborn will pass if the baby's skin remains yellowish after the first month. According to pediatricians, for uncertain reasons, breastfeeding can slow down the process of removing bilirubin. The rate of jaundice in newborns - 3-4 months

If the symptoms do not go away, it is worth checking whether the newborn is healthy - jaundice, which is prolonged in order, may indicate the development of diseases that must be urgently treated to avoid serious consequences. But in most cases, it is still associated with breastfeeding and is not a dangerous baby physiological jaundice in newborns. Treatment at home is in any case contraindicated, you should consult a pediatrician for advice.

Neonatal jaundice: causes and consequences

If your baby develops non-physiological neonatal jaundice that lasts more than 10 days, you should consult a doctor, as the consequences of neonatal jaundice can be very serious. Before reassuring the parents, the doctor must exclude the causes of the manifestation:

kernicterus. It develops if the norm of bilirubin is more than 400 μmol / l. Bile pigment affects the central nervous system, causing severe irreversible injury;
cholestasis. This syndrome occurs if the baby was born with an obstruction of the bile duct. In such a situation, immediate surgical intervention is required;
liver diseases.

How to cure jaundice in a newborn

For physiological jaundice, the main treatment that can be used is phototherapy (light therapy). This is a procedure during which a lamp with blue and green light at a wavelength of 400-500 nm is directed at the baby. In no case should the radiation contain ultraviolet rays. Under the influence of rays, the indirect bile pigment is converted into a safer, water-soluble form that the kidneys can filter.

If the mother does not have enough breast milk, the baby may develop what is called “hungry infant jaundice”.

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