Doldol Hospital
Neonatal Jaundice Guideline
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Neonatal Hyperbilirubinaemia
(JAUNDICE)
Jaundice is the manifestation of hyperbilirubinaemia, where the skin and mucosae have a yellow discolouration
due to accumulation of excess bilirubin in the tissues. It affects almost 60% of terms and 80% of preterms.
Jaundice is notably visible at levels > 5-6 mg/dl (85-102 micromol/l) in neonates
Pathological .v. Physiological
Pathological
(a) Early - clinical jaundice detectable <24hours of age.
(b) Fast - rise in total serum bilirubin 5mg/dl/day (86micromol/l)
(c) High - total serum bilirubin of more than 15mg/dl (260 micromol/l)
(d) Long - clinical jaundice persisting more than 14 days.
(e) Obstructive - clay/white coloured stool or dark urine staining clothes yellow.
Physiological
(a) First appears between 24-72 hrs of life or age. Maximum level seen on 4-5th day in term babies and 8-9th day
in preterms.
(b) Does not exceed 15mg/dl (260micromol/l)
(c) Clinically disappears by 14 days of age.
(d) Baby remains clinically well
No treatment required but baby closely observed. It is due to immaturity of the hepatic bilirubin conjugation.
MAIN CAUSES
< 24 HOURS OF LIFE:
Haemolysis (ABO and Rh incompatibilities, Minor group incompatibilities), sepsis (viral, bacterial, malaria),
severe bruising, and G6DP deficiency
BETWEEN 24-72 HRS:
physiological jaundice, polycythaemia, concealed haemorrhages e.g cephalohematoma , haemolytic disease of
the newborn, ABO and Rh incompatibilities, Minor group incompatibilities, sepsis (viral, bacterial, malaria),
and G6DP deficiency
APPEARING > 72 HOURS OF LIFE;
Sepsis, neonatal hepatitis, TORCH infection, biliary tract obstruction eg biliary atresia, breastmilk jaundice and
metabolic causes e.g hypothyroidism.
1
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015
Doldol Hospital
Neonatal Jaundice Guideline
ASSESSMENT
History;
Time of onset, duration
Vomiting, weight loss, stool and urine colour
Feeding
Risk factors for infection (PROM, maternal fevers/ infection, HIV etc)
Past family history
Gestation
Clinical examination;
Check for jaundice in bright, natural light.
Severity of jaundice (sclera, trunk, limbs, soles of feet), Anaemia,
Organomegaly (liver and spleen), ascites
Encephalopathy (suck, tone, reduced activity etc)
Signs of sepsis
Observations
MANAGEMENT
Jaundice in preterm <37 weeks





If available, do urgent bilirubin with conjugated fraction if available, refer to bilirubin chart
for ?treatment
Phototherapy is usually required – if bilirubin not available, arrange transfer to an NBU for
admission, phototherapy, and investigations
Treat for sepsis
Ensure adequate hydration
Investigations needed; maternal and baby blood group, Coombs test, total blood count, CRP,
LFT with conjugated fraction, blood culture, peripheral blood film.
Specify on transfer letter which investigation results you have, and which
investigations are remaining.
Jaundice in less than 24 hours of age (any gestation);
PATHOLOGICAL. Consider as a medical emergency.
 Phototherapy is required – arrange transfer to an NBU for admission, phototherapy, and
investigations
 Treat for sepsis
 Ensure adequate hydration

Investigations needed; maternal and baby blood group, Coombs test, total blood count, CRP,
LFT with conjugated fraction, blood culture, peripheral blood film.
Specify on transfer letter which investigation results you have, and which
investigations are remaining.
Jaundice noted over 24 hours of age;
Assess for risk factors for infection, observations, feeding, and clinical examination
If the above assessment is normal, with tinge jaundice / only visible in sclera and upper body to the
umbilicus
 Observe for next 72 hours
2
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015
Doldol Hospital
Neonatal Jaundice Guideline
If the above are normal, but the jaundice visible to soles of the feet
 Do urgent bilirubin with conjugated fraction if available, refer to bilirubin chart for ?treatment
 If bilirubin unavailable, refer to an NBU for bilirubin levels and phototherapy
If the above assessment is abnormal/ baby is unwell;
PATHOLOGICAL. Consider as a medical emergency.
 Phototherapy is required – arrange transfer to an NBU for admission, phototherapy, and
investigations
 Treat for sepsis
 Ensure adequate hydration
 Investigations needed; maternal and baby blood group, Coombs test, total blood count, CRP,
LFT with conjugated fraction, UECs, blood culture, peripheral blood film.
Specify on transfer letter which investigation results you have, and which
investigations are remaining.
For babies under phototherapy, consider repeating bilirubin levels on alternate days, and aim to cease
phototherapy when levels are at least >50micromol/l below phototherapy threshold.
Feeding / Hydration;
If baby clinically well hydrated, feeding well, with good maternal milk supply  Promote frequent
breastfeeding. Baby can be removed from the lights for brief periods to breastfeed.
IV fluids and top-ups are not necessary.
If baby is dehydrated, poor feeding, biochemically signs of renal impairment or dehydration 
consider top ups, NG feeds, or iv fluids.
REFERENCES
1. Nelson textbook of paediatrics 17th edition.
2. Basic Paediatric Protocols: November 2013 Edition, Ministry of health
3
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015
Doldol Hospital
Neonatal Jaundice Guideline
Bilirubin measurement in micromol/L
Age
TREATMENT THRESHOLDS
Term > 37 weeks
(in hours - round age
up to nearest
threshold given)
Repeat
measureme
nt in 6
hours
0
-
Consider
phototerapy
Perform an
Initiate
phototherpy exchange
transfusion
- especially if risk
factors - and
repeat in 6 hours
unless the bilirubin level
falls below threshold
while the
treatment is being
prepared
-
>100
>100
6
> 100
> 112
> 125
> 150
12
> 100
> 125
> 150
> 200
18
> 100
> 137
> 175
> 250
24
> 100
> 150
> 200
> 300
30
> 112
> 162
> 212
> 350
36
> 125
> 175
> 225
> 400
42
> 137
> 187
> 237
> 450
48
> 150
> 200
> 250
> 450
54
> 162
> 212
> 262
> 450
60
> 175
> 225
> 275
> 450
66
> 187
> 237
> 287
> 450
72
> 200
> 250
> 300
> 450
78
-
> 262
> 312
> 450
84
-
> 275
> 325
> 450
90
-
> 287
> 337
> 450
96+
-
> 300
> 350
> 450
Estimated Gestational Age
Age in hours
28
weeks
30
weeks
32
weeks
34
weeks
36
weeks
All values in micromol/L
TREATMENT THRESHOLDS
Exchange Transfusion
Preterm
Start Phototherapy
12 hrs
4
Any value above normal range
24 hrs
80
90
100
110
110
36 hrs
110
120
130
140
150
48 hrs
140
150
160
170
180
60 hrs
160
170
190
200
220
72 hrs
+
180
200
220
240
260
12 hrs
120
120
120
120
120
24 hrs
150
150
160
160
170
36 hrs
180
180
200
210
220
48 hrs
210
220
240
250
260
60 hrs
240
260
280
290
310
72 hrs
+
280
300
320
340
360
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015
Doldol Hospital
Neonatal Jaundice Guideline
5
Dr J. Le Geyt, Dr S.M. Kilonzo
July 2015