II. Epidemiology
- Jaundice Incidence in full term infants: 60%
- Jaundice Incidence in Preterm Infants: 80%
III. Physiology: Physiologic Jaundice
- See Breast Feeding Jaundice
- Neonatal Bilirubin starts to increase days 2 to 5 and returns to normal by 3 weeks of life
- Mechanisms of physiologic Neonatal Jaundice
- Increased Bilirubin production (2-3 fold over older infants)
- High fetal Hemoglobin turn-over (short Half-Life)
- Impaired Bilirubin conjugation
- Immature hepatic glucuronosyl transferase
- Decreased Bilirubin excretion
- Bilirubin requires conjugation to become water soluble and able to be excreted in the urine and stool
- Most Neonatal Jaundice is due to accumulation of unconjuigated Bilirubin (indirect Hyperbilirubinemia)
- Decreased excretion of Conjugated Bilirubin (direct Hyperbilirubinemia) is much less common
- Increased Bilirubin production (2-3 fold over older infants)
- Physiologic Jaundice
- Transient limitation of Bilirubin conjugation (immature hepatic glucuronosyl transferase)
- Increased Hemolysis
- Hemoglobin drops from 20 to 12 in first week
- Exaggerated Physiologic Jaundice
- Low glucuronyl transferase (Hepatic immaturity)
- Risk factors
- Breast Feeding Jaundice
- Prematurity
- Asian ethnicity
- Weight loss
IV. Signs: Jaundice
-
General
- Visual Jaundice indicates Total Bilirubin >4 mg/dl
- Physiologic Jaundice is not present on Day 1
- Visual inspection is not an accurate screening tool
- Misses cases of severe Hyperbilirubinemia (esp. in darker skin tones)
- Visual estimated Bilirubin can differ from actual Serum Bilirubin by as much as 15 mg/dl
- Observe for signs of Jaundice beyond the skin exam
- Scleral Icterus
- Mucous membranes (e.g. beneath the Tongue)
- Level of Jaundice correlates with Bilirubin level (inexact)
V. Differential Diagnosis
VI. Labs: Bilirubin
- See Neonatal Bilirubin
- Transcutaneous Bilirubin (TcB) Meter
- Do not use to monitor infants on Phototherapy
- Correlates well with lower total Serum Bilirubin levels in most infants regardless of ethnicity
- Confirm with total Serum Bilirubin at >15 mg/dl (or when within 3 mg/dl of Phototherapy threshold)
- May overestimate Neonatal Bilirubin in black infants
- Holland (2009) Am J Clin Pathol 132(4): 555-61 [PubMed]
- Bhutani (2000) Pediatrics 106(2): E17 [PubMed]
- Campbell (2011) Paediatr Child Health 16(3): 141-5 [PubMed]
- Transcutaneous Bilirubin (TcB) level at >=12 hours of life (typical first universal screening time)
- Hour specific threshold for Phototherapy is based on age and Severe Neonatal Hyperbilirubinemia Risk Factors
- Obtain total Serum Bilirubin if TcB >15 mg/dl (or when within 3 mg/dl of Phototherapy threshold)
- Transcutaneous Bilirubin (TcB) level at 6 hours of life (Transcutaneous Bilirubin or TcB)
- Bilirubin <3 mg/dl): Unlikely to require Phototherapy in first 24 hours of life
- Bilirubin >5.3 mg/dl (90.6 umol/L): Likely to require Phototherapy in first 24 hours of life (and close monitoring)
VII. Labs: Secondary Cause
- See Nonphysiologic Neonatal Jaundice for additional evaluation
VIII. Evaluation: Jaudice Monitoring BEFORE Hospital Discharge
- Visually inspect skin with Vital Signs (at least every 8 hours)
- Visual inspection alone has low Test Sensitivity (misses cases of severe Hyperbilirubinemia)
- Confirming observation with transcutaneous or Serum Bilirubin is preferred
- Moyer (2000) Arch Pediatr Adolesc Med 154:391-4 [PubMed]
- Obtain Transcutaneous Bilirubin or Serum Bilirubin
- Obtain Neonatal Bilirubin based on risk (preferred method)
- See Risk Score for Neonatal Hyperbilirubinemia (score of 8 or more indicates testing)
- Often part of hospital directed universal screening (e.g. all newborns at 24 hours)
- Universal screening is controversial, but recommended at 24 to 48 hours of life and before hospital discharge
- Estimated to cost >$5 million in U.S. annually to prevent a single case of Kernicterus
- Increases Phototherapy rates without evidence that it decreases the risk of Bilirubin Encephalopathy
- Trikalinos (2009) Pediatrics 124(4): 1162-71 [PubMed]
- Obtain for Jaundice
- Neonatal Jaundice in the first 24 hours
- Neonatal Jaundice that appears excessive (e.g. below nipple line)
- Neonatal Jaundice that is difficult to assess on exam
- Do not rely solely on appearance of Jaundice as a screening indication (misses cases of severe Hyperbilirubinemia)
- Obtain Neonatal Bilirubin based on risk (preferred method)
IX. Evaluation: Jaundice Monitoring AFTER Hospital Discharge
- Monitoring in newborns who received Phototherapy during hospitalization
- Phototherapy before 48 hours or Hemolysis history or risk (e.g. Direct Antiglobulin Test positive)
- See Severe Neonatal Hyperbilirubinemia Risk Factors
- Recheck total Serum Bilirubin in 12 to 24 hours
- Other infants who received Phototherapy during hospitalization
- Recheck total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) in 1 to 2 days
- Phototherapy before 48 hours or Hemolysis history or risk (e.g. Direct Antiglobulin Test positive)
- Monitoring in newborns who have NOT received Phototherapy
- Phototherapy Threshold minus TSB or TcB <1.9 mg/dl
- Age <24 hours
- Delay discharge, consider Phototherapy and recheck TSB in 4 to 8 hours
- Age >24 hours
- Recheck total Serum Bilirubin (TSB) in 4 to 24 hours
- Consider home Phototherapy or delayed discharge for inpatient Phototherapy
- Age <24 hours
- Phototherapy Threshold minus TSB or TcB 2.0 to 3.4 mg/dl
- Recheck total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) in 4 to 24 hours
- Phototherapy Threshold minus TSB or TcB 3.5 to 5.4 mg/dl
- Recheck total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) in 1 to 2 days
- Phototherapy Threshold minus TSB or TcB 5.5 to 6.9 mg/dl
- Discharge <72 hours of age
- Follow-up in 2 days
- Consider total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) at follow-up based on evaluation
- Discharge >72 hours of age
- Apply clinical judgment based on exam, Severe Neonatal Hyperbilirubinemia Risk Factors
- Discharge <72 hours of age
- Phototherapy Threshold minus TSB or TcB >7.0 mg/dl
- Discharge <72 hours of age
- Follow-up in 3 days
- Consider total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) at follow-up based on evaluation
- Discharge >72 hours of age
- Apply clinical judgment based on exam, Severe Neonatal Hyperbilirubinemia Risk Factors
- Discharge <72 hours of age
- Phototherapy Threshold minus TSB or TcB <1.9 mg/dl
- References
X. Management
- See Phototherapy Indications
- See Breast Feeding Jaundice
XI. Prevention
- Adequate early nutrition and hydration
- See Breast Feeding Technique
- See Infant Feeding
- See Formula Feeding
- Do not supplement with dextrose water or plain water
- Monitoring
- See Evaluation above
XII. Complications
- Kernicterus is most linked to nonphysiologic causes
-
Kernicterus has been associated with physiologic causes
- Physiologic Jaundice
- Exaggerated Jaundice
- Breast Feeding Jaundice
XIII. References
- (2004) Pediatrics 114(1): 297-316 [PubMed]
- (2001) Pediatrics 108(3):763-5 [PubMed]
- (2023) Am Fam Physician 107(6): 661-4 [PubMed]
- Dennery (2001) N Engl J Med 344:581-90 [PubMed]
- Moerschel (2008) Am Fam Physician 77:1255-62 [PubMed]
- Muchowski (2014) Am Fam Physician 89(11): 873-8 [PubMed]
- Kemper (2022) Pediatrics 150(3): e2022058859 [PubMed]
- Par (2023) Am Fam Physician 107(5): 525-34 [PubMed]
- Porter (2002) Am Fam Physician 65(4):599-614 [PubMed]