See also Neonatal Jaundice on the Postnatal Ward.

• Jaundice (SBR >50 μmol /L) is one of the most common physical signs observed during the neonatal period.
• 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.

Assessment

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 and/or infection.

• The following approach to the evaluation of neonatal jaundice is recommended:-

1. Review maternal blood group.
2. Request infant's blood group and Coomb’s test if mother's blood group is O.
3. Check SBR (note that a direct SBR very rarely indicated within the first 5 days of life).
4. Haemoglobin, WBC and differential, and reticulocytes if suspicion/evidence of haemolysis.
5. Urine for microscopy and a culture only if clinical suspicion of a urinary tract infection.
6. 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 clinical situation.
• 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 jaundice.
• 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.

Management

Treatment Guidelines for Term Infants without Haemolysis 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.

• Phototherapy causes 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.

  • Complications of 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 additional benefit.
• Infants receiving phototherapy should be under paediatric supervision.
• An exchange transfusion is indicated for any infant in whom the degree of hyperbilirubinaemia cannot be adequately controlled by phototherapy alone.
  • Discuss the indications for exchange transfusion with the appropriate specialist.
  • Note that infants with jaundice due to a haemolytic disorder usually benefit from phototherapy but may also require an exchange transfusion.

  • With appropriate management, exchange transfusion should rarely be required.

Atypical Jaundice

• Separate guidelines are available for the evaluation and management of late onset jaundice (7-10 days or later) and prolonged jaundice (SBR >200 μmol /L after 7-10 days of age).

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