Jaundice (SBR >50 μmol
is one of the most common physical signs observed during the neonatal
Approximately 50-60% of
newborn infants will become jaundiced during the first week of life.
For many newborn infants the
jaundice may be regarded as a manifestation of their ongoing adaptation to
the extra uterine environment.
Although most jaundice is
mild and physiological in origin, it cannot safely be automatically assumed
to be either.
Jaundice may be a sign of
pathology and demands evaluation and rational management.
Atypical presentation of
jaundice (early onset, rapid rise in SBR, prolonged jaundice, and/or late
onset jaundice) is likely to reflect pathology.
Furthermore, it is important
to appreciate that an infant's symptoms may be attributed to its jaundice
when in fact they are due to other pathology.
The evaluation of the jaundiced newborn infant must include a thorough
history and physical examination, with particular emphasis on the state of
hydration and consideration of the possibility of an acute haemolytic process
The following approach to the evaluation of neonatal jaundice is
Review maternal blood group.
Request infant's blood group and Coomb’s test if mother's blood
group is O.
Check SBR (note that a direct SBR very rarely indicated within the
first 5 days of life).
Haemoglobin, WBC and differential, and reticulocytes if
suspicion/evidence of haemolysis.
Urine for microscopy and a culture only if clinical suspicion of a
urinary tract infection.
If galactosaemia is suspected, then discuss an urgent serum assay
through the National Testing Laboratory. Urine samples for reducing
substances are not reliable nor specific.
Other investigations may be necessary depending upon the specific
The significance of any SBR estimation depends upon the maturity and
postnatal age of the infant, the clinical status of the infant (hypoxaemia,
acidaemia, hypoalbuminaemia, and/or hypothermia) and the aetiology of the
Serial SBR estimations are an essential component of the continuing
assessment and management of the jaundiced newborn infant. Graphs are
available to aid the interpretation of SBR estimations.
Treatment Guidelines for Term Infants
Click on the picture on the right
Treatment Guidelines for Preterm
Infants or Infants with Haemolysis
Click on the picture on the right
It is important to maintain normal
hydration and nutrition of the jaundiced newborn infant. This may be
achieved by the encouragement of breastfeeding, the provision of additional
oral fluids or may require the intravenous administration of fluid. There is
no evidence to support the administration of excessive quantities of fluid
and most infants will not need extra fluids.
photodegradation of bilirubin in the infant's skin.
This form of physical
therapy has been shown to be an efficient method of lowering the SBR and
is usually effective.
phototherapy are generally mild and include increased insensible water losses, loose green
stools, skin rashes, overheating and/or chilling.
The levels of SBR at
which phototherapy is recommended in various situations are indicated in
the accompanying graphs.
An inadequate quantum of
phototherapy (<4 mcw/nm/cm2) is ineffective. Recommended
range for phototherapy is 5-10 mcw/nm/cm2. Increasing
phototherapy about 9-10 mcw/nm/cm2 is unlikely to provide any
phototherapy should be under paediatric supervision.
Administration of Immunoglobulin (see protocol)
Used when an infant has Isoimmune Haemolytic Jaundice.
Used when an infant is nearing the need for Exchange Transfusion, while
equipment is being set up for an exchange transfusion or if the bilirubin is
rising significantly despite maximal phototherapy.
An exchange transfusion is indicated for any infant in whom the
degree of hyperbilirubinaemia cannot be adequately controlled by
Discuss the indications for exchange transfusion with the
Note that infants with jaundice due to a haemolytic disorder
usually benefit from phototherapy but may also require an exchange
With appropriate management, exchange transfusion should rarely be