Jaundice is the visible manifestation of
increased level of bilirubin in the body. It
is not a disease rather a symptom of
diseases.
 In adults sclera appears jaundiced when
serum bilirubin exceeds 2 mg/dl.
 However it is difficult to see sclera in
newborn due to difficulty in opening
eye. But in new born it is very easy to see
jaundice in skin.

Important problem in the 1st week of life
 Almost all neonates (60% Term and 80%
Preterm) will have bilirubin > 5 mg/dl in
the 1st week of life and become visibly
jaundiced, vast majority being benign
 Some of the term babies (8 to 9%) have
levels exceeding 15 mg/dl in 1st 7 days of
life.
 High bilirubin level is toxic to the
developing CNS

A women who delivered at home
presented on her 5th postpartum day at
pediatric OPD complaining that her baby
looked yellow.
Hyperbilirubinemia in the first week of life is
usually of the indirect variety.
1. Appearing at birth or within 24 hours of
age
› Hemolytic disease of newborn
› Infections: intrauterine viral, bacterial;
malaria
› G-6PD deficiency
2. Appearing between 24-72 hours of life
› Physiological
› Sepsis neonatorum
› Polycythemia
› Concealed hemorrhages:
cephalhematoma, subarachnoid
bleed, IVH.
› Increased enterohepatic circulation
3. Appearing after 72 hrs and within 1st
week
a) Sepsis neonatorum (4th - 7th days)
b) Syphilis
c) Toxoplasmosis
4. Jaundice appearing after1 week
a) Prolonged direct Jaundice
› Neonatal hepatitis (common)
› Extrahepatic biliary atresia
› Breast milk jaundice
› Metabolic disorders
› Intrahepatic biliary atresia
› Amino acid toxicity
› Inspissated bile syndrome (uncommon)
Jaundice appearing after1 week contd…
b) Prolonged Indirect Jaundice
› Criggler Najjar Syndrome
› Breast milk jaundice
› Hypothyroidism
› Pyloric stenosis
› Ongoing hemolysis, malaria
On history, the baby started turning yellow
on his 2nd day. The baby was a full term
male child delivered at home. Baby is
currently 120 hours old. There was no history
of any maternal illness during pregnancy.
Delivery was uneventful. Baby immediately
cried after birth and was immediately
breastfed.
Baby passed meconium on his first day.
Urine is normal with no staining of nappies.
Stool also is normal in colour.
On past history, there was no H/O history of
malaria during pregnancy.
On family history, there was no H/O of
jaundice, liver disease. Previous sibling had
no history of neonatal jaundice.
Baby was well looking, feeding well, vitals
were normal, temperature was normal.
There were no rashes and petechiae in the
body. Baby weighed 3 kg. Icterus was
present. Pallor was Absent. On abdominal
examination no organomegaly was
present. Chest was clear and CVS
examination was normal.
1.
2.
Dermal staining (By karmer) progresses
from head to toe
› Examined in good day light skin of
forehead, chest, abdomen, thigh, legs,
palms, and soles
› Blanched with digital pressure and the
underlying color of the skin and
subcutaneous tissue should be noted.
Transcutaneus bilirubinometer
In new born babies bilirubin metabolism is
immature which results in the occurrence
of hyperbilirubinemia in the first few days of
life. Also there is increased bilirubin load on
the hepatic cell due to physiological
polycythemia.
Immaturity could be at various steps of
bilirubin metabolism like:
 Defective uptake from plasma into liver
cell
 Defective conjugation
 Decreased excretion
 Increased entero-hepatic circulation
First appears between
hours of age
 Maximum intensity seen on 4-5th day in
term and 7th day in preterm neonates
 Does not exceed 15 mg/dl
 Clinically undetectable after 14 days.
 No treatment is required but baby should
be observed closely for signs of
worsening jaundice.

Presence of any of the following signs
denotes that the jaundice is pathological.
 Clinical jaundice detected before 24
hours of age
 Rise in serum total bilirubin by more than
5 mg/dl/ day (>5mg/dl on first day , 10
mg/dl on second day and 12- 13 mg/dl
thereafter in term babies)
Serum bilirubin more than 15 mg/dl
 Clinical jaundice persisting beyond 14
days of life
 Clay/white colored stool and/or dark
urine staining the nappy yellow
 Direct bilirubin >2 mg/dl at any time
Treatment is required in the form of
phototherapy or exchange blood
transfusion. One should investigate to find
the cause of pathological jaundice.

Clinical
Jaundice
Measure
Billirubin
> 12 mg/dl and
infant < 24 hr old
< 12 mg/dl and
infant > 24 hr old
Follow bilirubin
level
Coomb’s test
Positive
Identify antibody
Rh, ABO etc
Negative
Direct
bilirubin
Direct bilirubin
> 2 mg/dl
< 2 mg/dl
Consider
Hepatitis
Intrauterine,viral,or
Toxoplasmatic inf.
Hematocrit
Biliary obstr.
Sepsis
Galactosemia
Cholestasis
Normal or low
Hemochromatosis
High
(Polycythemia)
Normal or Low
RBC morphology
Reticulocyte Count
NORMAL
Enclosed hemorrhage
Increased enterohep. circ.
Breast milk, Hypothyroidism,
Crigler-Najjar syndrome
Infant of diabetic mother
RDS, Asphyxia
Infections, Drugs(eg
novobiocin), galactosemia
ABNORMAL
Spherocytosis
Elliptocytosis etc.
ABO Incompatibility
Red cell enzyme def
Alpha thallasemia
Drugs(eg penicillin
Investigations were done. Serum total
bilirubin was found to be 10 mg/dl. The
baby was diagnosed as a case of
physiological Jaundice. Parents were
counseled. The baby was discharge and
kept on follow up for serial analysis of
Bilirubin level.
1.
2.
3.
4.
Bhutani V.K., Johnson Lois H., Keren Ron Diagnosis and management
of hyperbilirubinemia in term neonates for a safer first week,
Pediatric clinic of North America, Common issues and concerns in
Newborn Nursery, Part II Aug 2004, vol 5, No. 4
Gowen CW Jr. Anemia and hyperbilirubinemia. In: Kliegman R.
Nelson Essentials of Pediatrics. 5th ed. Philadelphia, Pa.: Elsevier
Saunders; 2006:318.
Paul Vinod K, Deorari Ashok K, Agrawal Ramesh et all, Newborn
infants, Ghai Essential Pediatrics, 2009, 147-51
Internet