Guidelines for management of Neonatal Jaundice
50% of newborn, 80% of preterm babies will develop jaundice. It can be abnormal or
normal. Jaundice is caused by excess production of bilirubin from red cell breakdown
in the newborn. This is converted to conjugated bilirubin (water-soluble), which can
be excreted in the urine, however the rate of production exceeds the conversion rate
because the neonatals’ liver is immature. This unconjugated (unconverted) bilirubin
(fat soluble) is what is deposited in the skin and visible as yellow. Fat-soluble
bilirubin easily crosses the blood brain barrier and can be damaging to the brain if not
identified and treated early. Most jaundice is normal and causes no harm but
abnormal jaundice should be treated promptly to avoid complications such as severe
anaemia, kernicterus (bilirubin neurotoxicity) and liver cirrhosis in cases of prolonged
jaundice (>14 days).
Abnormal Jaundice
 Jaundice within the first 24 hours
 Jaundice with fever
 Deep Jaundice affecting sole of the feet and palms
 Jaundice after 14 days of life in a term baby or after 21 days of life in
premature babies (see page 6)
Causes
 Onset less than 24 hours
o Always pathological
o Usually due to haemolysis: Rhesus or ABO incompatibility
o Exclude sepsis
o Rarer causes may include: G6PD
Onset 24 hours to 14 days










Sepsis
Haemolysis
Polycythemia
Cephalhaematoma Central nervous system haemorrhage
Poor feeding
Bruising or fractures.
Increased enterohepatic circulation, which may be due to gut obstruction.
Physiological jaundice
Breastfeeding jaundice: early breastfeeding jaundice. Develops within 2 to
4 days of birth and is most likely related to infrequent breastfeeding with a
limited fluid intake.
Onset greater than 14 days (>21 days in preterm) see page 6
Dr. Yetunde Odutolu (Paediatrician)
1





Conjugated Hyperbilirubinaemia due to:
o Congenital malformations (biliary atresia).
o Idiopathic neonatal hepatitis
or infections (Hepatitis B, TORCH
infections)
Sepsis
Hypothyroidism
Haemolysis
Breast milk jaundice: late breast milk jaundice is much less common and
develops 4 to 7 days after birth with a peak at 7 to 15 days of age
Investigations
All newborns should be monitored for the development of jaundice, which should be
confirmed by a bilirubin measurement, when possible, in all:




Especially in infants with jaundice on day 1
Preterm infants (< 35 weeks) if jaundice appears on day 2
Infants if palms and soles are yellow at any age.
Jaundice after 14 days in a term newborn or more than 21 days in preterm
The investigations depend on the probable diagnosis and what tests are available but
may include:






Haemoglobin estimate or packed cell volume
Full blood count to identify signs of serious bacterial infection (high or low
neutrophil count with > 20% band forms) and signs of haemolysis
Blood type of infant and mother and Coombs test
Syphilis serology, such as venereal disease research laboratory tests
Glucose 6-phosphate dehydrogenase screening, thyroid function tests, liver
ultrasound
Especially Bilirubin levels- the cut off value depends on the age of the baby,
the weight and the gestation ( > or < than 35weeks). See chart below.
Identifying Jaundice
In the absence of investigations, a rough guide is the Kramer’s cephalocaudal
(head to toe) progression of jaundice rules.
Always assess jaundice in a well-lit room or in daylight at a window by blanching the
baby’s skin with a finger and observing the underlying skin colour. Jaundice appears
first in the face and progresses caudally to the trunk and extremities
Although the use of this rule is limited in dark skin babies it is a rough guide and
evaluation of the mucosa areas is a good guide in dark skin babies. Always
examine the sclera, sole of the feet and palms.
Dr. Yetunde Odutolu (Paediatrician)
2
Zones
Definition
1
Head and
Neck
2
Upper
trunk
3
Lower
trunk and
thigh
Bilirubin
estimate in
mol/l
Bilirubin
estimate in
Mg/dl
100
150
5-7
8-10
Dr. Yetunde Odutolu (Paediatrician)
3
5
Deep yellow,
Palms and
soles
200
4
Arms and
Lower legs
Deep
yellow
250
12-15
15
> 15
>250
Treatment
In the absence of bilirubin levels use the estimate above.
Start phototherapy if
Any visible jaundice on day 1
Deep Jaundice affecting the sole of the feet and the palms
Prematurity and jaundice
Jaundice due to haemolysis – known incompatibilities
Always remember to treat other causes such as sepsis, congenital syphilis and
ensure adequate hydration.
Start phototherapy using the table below to identify babies requiring
phototherapy. Continue until baby is well and there is no longer any jaundice of
the sclera, palms and soles.
Transfer the high-risk groups to Mulago for exchange transfusion if needed
To use the table, ascertain the gestation and weight of the baby as well as how
old they are. Using the laboratory result see if the values are above the
Phototherapy
Exchange transfusion
Age
Health baby
Unwell or
Health baby
Unwell or
≥35wks
Preterm ≤ 35 ≥35wks
Preterm ≤
wks or ≤
35wks or ≤
2.5kg
2.5kg
Day 1
Any visible Jaundice
>250mol/l
200mol/l
15mg/dl
10mg/dl
Zone 5
Zone 3
Day 2
>250mol/l
15mg/dl
Zone 5
170mol/l
10mg/dl
>Zone 2
Day ≥3
310mol/l
20mg/dl
Zone 5
>250mol/l
15mg/dl
Zone 5
425mol/l
25mg/dl
> Zone
5(severe)
425mol/l
25mg/dl
> Zone 5
(severe)
>250mol/l
15mg/dl
Zone 5
310mol/l
20mg/dl
Zone 5
phototherapy threshold and treat accordingly. If no values are available, use the
Kramer estimate diagram to determine what zones are affected and if the zones
meet the threshold for treatment.
Care during phototherapy.
Sepsis
 Unwell babies or babies with signs of sepsis must be commenced on
antibiotics (using the neonatal sepsis guidelines)
Temperature
 Monitor temperature every 3 hours to avoid getting baby cold or too
warm.
Dr. Yetunde Odutolu (Paediatrician)
4
Feeding
 Whilst on phototherapy give babies an extra 10ml/kg of fluids to avoid
dehydration.
 Encourage all mothers to breastfeed their babies 8 - 12 times a day in the first
2 - 3 days of life.
 IV fluids should be used in the red feeding regime or on day one of the yellow
feeding regime (see feeding regimen)
 NG fed babies should be feed 2 hourly
 Weigh daily and monitor that the baby is passing urine.
Clothing during phototherapy Remove all clothing except nappy. No lotions/lubricants on skin.
Eye patches
 Must be worn during phototherapy to avoid retina damage.
Stopping Phototherapy
When baby is well and there is no longer any jaundice of the sclera, palms and
soles.
Identifying and Preventing Kernicterus
Sunlight Phototherapy
When phototherapy is unavailable, sunlight has been found to be effective in
treating jaundice. When using sunlight, undress the baby except for the nappy. Keep
the baby in a room that has a lot of sunlight. Do not place the baby directly in the
sun, preferably always through the window. Since the baby is uncovered, monitor
temperature. If the baby becomes cold re-warm the baby by performing Kangaroo
mother care. Once the baby becomes warm, wait 1-2 hours, undress the baby and try
again.
Kernicterus is a complication of neonatal jaundice. The word kern-icterus means
yellow kern, kern being the structures of the brain that are most commonly affected.
Affecting the basal ganglia mostly as well as other parts such as cochlear, vestibular
and other cranial nerves nuclei.
The following are at risk of bilirubin neurotoxicity,
Preterm infants
small for gestational age
Sepsis
Asphyxia
Hypoalbuminaemia and
Jaundice < 24 hours of age
 Early features within the first few days include severe jaundice, hypotonia,
poor sucking and feeding, and absent startle reflex.
 The affected baby may then develop a high-pitched cry, hypertonia of
extensor muscles with arched back and hyperextended neck, bulging
Dr. Yetunde Odutolu (Paediatrician)
5

fontanelle and seizures.
Later neurological features include sensory hearing loss, intellectual disability,
muscle rigidity, speech difficulties, seizures and movement disorder.
Babies who are thought to have neurological damage should be referred early for
paediatric follow up neurodevelopmental assessment and remedial help.
Management of kernicterus will include management of neurological complications,
including seizures and sensory nerve deafness.
Prolonged Jaundice
Babies with prolonged jaundice (obvious persisting clinical jaundice at greater than 2
weeks in term babies and greater than 3 weeks in preterm babies) require:
•
•
Clinical review including examination/enquiry regarding stool colour
Total serum bilirubin and conjugated bilirubin level: conjugated
hyperbilirubinaemia or a jaundiced baby with pale stools and dark
urine requires urgent discussion with a senior paediatrician
immediately
• Thyroid function tests (TFT)
• FBC to check for anaemia or signs of haemolysis
• Total serum bilirubin and conjugated bilirubin levels
• LFT (including: AST, ALT, GGT, ALP and albumin)
• Coagulation screen
• Blood group and DAT/Coombs test
• Liver ultrasound
• Urine: CMV congenital infection serology o micro culture and sensitivity
It is important to identify persistent pale stools and dark urine
(conjugated Hyperbilirubinaemia) urgently as these patients
might require urgent surgery.
Reference
1. The Pocket book of Hospital Care for Children: Guideline for the
management of common childhood illnesses. Second edition 2013
2. Clinical assessments of neonatal jaundice in developing countries- a
multicenter study. The young infants clinical sign study group. Abstract
333.
3. Neonatal Jaundice: Prevention, Assessment and Management.
Queensland Maternal and Neonatal Clinical guidelines 2009
4. http://www.kairos2.com/18_Neonatal%20jaundice.pdf
Dr. Yetunde Odutolu (Paediatrician)
6