Neonatal jaundice – the basics

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Cite this article as:
Kanagaratnam, S. Neonatal jaundice – the basics, Don't Forget the Bubbles, 2018. Available at:
http://doi.org/10.31440/DFTB.17047

Most newborns are jaundiced. Indeed, 60% of term infants, 80% of premies and 33% of breastfed babies are jaundiced in early life. Fortunately, the majority of these self-resolve and have no sinister underlying cause. But how do we identify those who require urgent management? How can we effectively and confidently reassure anxious patients whilst ensuring we don’t miss a significant diagnosis?

This step-by-step approach to neonatal jaundice will help those new to neonates to make an initial assessment:

 

Initial Assessment

 

Step 1: Is the baby yellow?

Visual inspection during a thorough neonatal examination

  • Jaundice often starts in the eyes, spreads to the face and then drops down to the trunk, legs and feet
  • Remember it is harder to rule out jaundice in babies with darker skin, premature infants and those less than 36 hours old.

 

Step 2: How long have they been yellow for?

<24 hours: jaundice within 24 hours should always be assumed to be pathological. Often these are picked up through screening programmes in the UK and so are unlikely to present to ED.

>24 hours but <14 days if term (or <21 days if prem): likely physiological

>14 days if term (or >21 days if prem): prolonged jaundice – requires further investigation

 

Step 3: How yellow are they?

Quantify ‘how yellow’ the baby is with a transcutaneous bilirubinometer

Use the NICE treatment threshold graph (ensure corrected for gestation) to determine if hyperbilirubinaemia is safe or requires treatment

  • Generally: if term baby, level <250 = reassure, safety-net and home
  • If level > 250 = consider admission

 

Step 4: Are they otherwise well?

Look for signs of underlying pathology (MAGGIE)

 

Step 5: Are they high risk?

When unconjugated bilirubin crosses the blood-brain barrier, acute neurotoxicity ensues and often presents with lethargy, irritability and hypotonia. In severe cases this leads to kernicterus which is characterised by yellow-staining of the basal ganglia on post mortem. At this time the baby may present as hypertonic, fitting or unconscious.

Aside from a high bilirubin level, other risk factors for encephalopathy include:

  • Jaundice within 24 hours
  • ABO/Rh incompatibility
  • Previous sibling requiring phototherapy
  • Cephalhaematoma or significant birth trauma
  • Family history of red blood cell defect
  • Sepsis or acidosis (secondary to displacement of bilirubin from albumin)
  • Prematurity (lower serum albumin concentrations)

 

Causes

Once you have assessed the child, you can start to think about possible diagnoses, some of which have been summarised in the table below:

 

Increased RBC Lysis Decreased Hepatic Uptake/Conjugation Physiological
ABO/Rh Incompatibilityconsider IVIG Metabolic Hypothyroidism Breast milkincreased reabsorption of bilirubin due to beta-glucoronidase in breast milk
Hypopituitarism
Crigler-Najjar Syndromebilirubin UGT enzyme deficiency
RBC defects e.g. hereditary spherocytosis, G6PD deficiency Structural Biliary atresiaaim for Kasai procedure before D45-60
Sepsis (esp. UTIs) Hepatitis e.g. infective, autoimmune Dehydrationcommon in D2-5 esp. in breast fed babies as milk coming in
Bowel obstruction/pyloric stenosis Physiological – higher number of RBCs with shorter lifespan = 2-3 x normal bilirubin production

 

Diagnoses may be pathological (first and second columns) or physiological (third column)

 

Investigations

If the child is either unwell or presents with prolonged jaundice, a neonatal screen is recommended in the form of:

  • Total and split bilirubin
  • FBC and blood film
  • Reticulocyte count
  • Mother and baby grouping
  • DAT test
  • TFTs
  • Genetic testing e.g. G6PD screening
  • Septic screen
  • +/- abdominal imaging if indicated

 

Management

Management should thereafter take on the following principles:

Correct dehydration

Treat hyperbilirubinaemia if indicated by the treatment threshold graph

  • Phototherapy:
    • Blue-green light photo-polymerises bilirubin
    • Bilirubin thus more water soluble and easier to excrete
  • Exchange blood transfusion:
    • Indicated if rapidly rising bilirubin, high bilirubin levels or signs of neurotoxicity
  • Treat underlying cause e.g. sepsis, obstruction

 

[Toggle title=”References”]

Don’t forget the bubbles (2016) And they were all yellow. Available on: https://dontforgetthebubbles.com/and-they-were-all-yellow/

EMDOCS (2018) Neonatal jaundice. Available on: http://www.emdocs.net/pem-playbook-neonatal-jaundice/

NICE (2010) Clinical Guideline: Neonatal jaundice. Available on: https://www.nice.org.uk/guidance/cg98/evidence/full-guideline-245411821

RCEM (2017) Maggie Simpson’s second audition. Available on: https://www.rcemlearning.co.uk/foamed/maggie-simpsons-second-audition-prolonged-jaundice/

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About 

Shal is an emergency medicine trainee at the Royal London Hospital currently working in paediatric ED. She is currently completing her MSc in Global Health and Infectious Diseases whilst working with other doctors to provide data-driven clinical transformation projects within the NHS through their company 33N. When not working, she can often be found trying to plan her next trip abroad.

Author: Shalome Kanagaratnam Shal is an emergency medicine trainee at the Royal London Hospital currently working in paediatric ED. She is currently completing her MSc in Global Health and Infectious Diseases whilst working with other doctors to provide data-driven clinical transformation projects within the NHS through their company 33N. When not working, she can often be found trying to plan her next trip abroad.

One Response to "Neonatal jaundice – the basics"

  1. Sawlar
    Sawlar 2 weeks ago .Reply

    Where is a good source for accessing a threshold graph, and how do I use it?

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