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:
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)
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 Incompatibility – consider IVIG||Metabolic||Hypothyroidism||Breast milk – increased reabsorption of bilirubin due to beta-glucoronidase in breast milk|
|Crigler-Najjar Syndrome – bilirubin UGT enzyme deficiency|
|RBC defects e.g. hereditary spherocytosis, G6PD deficiency||Structural||Biliary atresia – aim for Kasai procedure before D45-60|
|Sepsis (esp. UTIs)||Hepatitis e.g. infective, autoimmune||Dehydration – common 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)
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
- Genetic testing e.g. G6PD screening
- Septic screen
- +/- abdominal imaging if indicated
Management should thereafter take on the following principles:
Treat hyperbilirubinaemia if indicated by the treatment threshold graph
- 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
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/
Kanagaratnam, S. Neonatal jaundice – the basics, Don't Forget the Bubbles, 2018. Available at: