Jaundice in Newborns

Aka: Jaundice in Newborns, Neonatal Jaundice, Neonatal Hyperbilirubinemia, Newborn Jaundice

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II. Epidemiology

  1. Jaundice Incidence in full term infants: 60%
  2. Jaundice Incidence in Preterm Infants: 80%

III. Physiology: Physiologic Jaundice

  1. See Breast Feeding Jaundice
  2. Neonatal Bilirubin starts to increase days 2 to 5 and returns to normal by 3 weeks of life
  3. Mechanisms of physiologic Neonatal Jaundice
    1. Increased Bilirubin production (2-3 fold over older infants)
      1. High fetal Hemoglobin turn-over (short Half-Life)
    2. Impaired Bilirubin conjugation
      1. Immature hepatic glucuronosyl transferase
    3. Decreased Bilirubin excretion
      1. Bilirubin requires conjugation to become water soluble and able to be excreted in the urine and stool
      2. Most Neonatal Jaundice is due to accumulation of unconjuigated Bilirubin (indirect Hyperbilirubinemia)
      3. Decreased excretion of Conjugated Bilirubin (direct Hyperbilirubinemia) is much less common
  4. Physiologic Jaundice
    1. Transient limitation of Bilirubin conjugation (immature hepatic glucuronosyl transferase)
    2. Increased Hemolysis
      1. Hemoglobin drops from 20 to 12 in first week
  5. Exaggerated Physiologic Jaundice
    1. Low glucuronyl transferase (Hepatic immaturity)
    2. Risk factors
      1. Breast Feeding Jaundice
      2. Prematurity
      3. Asian ethnicity
      4. Weight loss

IV. Signs: Jaundice

  1. General
    1. Visual Jaundice indicates Total Bilirubin >4 mg/dl
    2. Physiologic Jaundice is not present on Day 1
      1. Jaundice on the first day of life suggests Hemolysis
    3. Visual inspection is not an accurate screening tool
      1. Misses cases of severe Hyperbilirubinemia (esp. in darker skin tones)
      2. Visual estimated Bilirubin can differ from actual Serum Bilirubin by as much as 15 mg/dl
    4. Observe for signs of Jaundice beyond the skin exam
      1. Scleral Icterus
      2. Mucous membranes (e.g. beneath the Tongue)
  2. Level of Jaundice correlates with Bilirubin level (inexact)
    1. Jaundice above nipple line
      1. Reliably predicts Bilirubin <12 mg/dl
    2. Less accurate landmarks for estimation of Bilirubin
      1. Head and neck Jaundice: 6 mg/dl Bilirubin
      2. Trunk to Umbilicus: 9 mg/dl Bilirubin
      3. Trunk to knees: 12 mg/dl Bilirubin
      4. Wrists and Ankles: 15 mg/dl Bilirubin
      5. Hands and Feet: >15 mg/dl Bilirubin

V. Differential Diagnosis

  1. See Neonatal Jaundice Causes

VI. Labs: Bilirubin

  1. See Neonatal Bilirubin
  2. Transcutaneous Bilirubin (TcB) Meter
    1. Do not use to monitor infants on Phototherapy
    2. Correlates well with lower total Serum Bilirubin levels in most infants regardless of ethnicity
      1. Confirm with total Serum Bilirubin at >15 mg/dl (or when within 3 mg/dl of Phototherapy threshold)
      2. May overestimate Neonatal Bilirubin in black infants
      3. Holland (2009) Am J Clin Pathol 132(4): 555-61 [PubMed]
      4. Bhutani (2000) Pediatrics 106(2): E17 [PubMed]
      5. Campbell (2011) Paediatr Child Health 16(3): 141-5 [PubMed]
  3. Transcutaneous Bilirubin (TcB) level at >=12 hours of life (typical first universal screening time)
    1. Hour specific threshold for Phototherapy is based on age and Severe Neonatal Hyperbilirubinemia Risk Factors
    2. Obtain total Serum Bilirubin if TcB >15 mg/dl (or when within 3 mg/dl of Phototherapy threshold)
  4. Transcutaneous Bilirubin (TcB) level at 6 hours of life (Transcutaneous Bilirubin or TcB)
    1. Bilirubin <3 mg/dl): Unlikely to require Phototherapy in first 24 hours of life
    2. 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

  1. See Nonphysiologic Neonatal Jaundice for additional evaluation

VIII. Evaluation: Jaudice Monitoring BEFORE Hospital Discharge

  1. Visually inspect skin with Vital Signs (at least every 8 hours)
    1. Visual inspection alone has low Test Sensitivity (misses cases of severe Hyperbilirubinemia)
    2. Confirming observation with transcutaneous or Serum Bilirubin is preferred
    3. Moyer (2000) Arch Pediatr Adolesc Med 154:391-4 [PubMed]
  2. Obtain Transcutaneous Bilirubin or Serum Bilirubin
    1. Obtain Neonatal Bilirubin based on risk (preferred method)
      1. See Risk Score for Neonatal Hyperbilirubinemia (score of 8 or more indicates testing)
    2. Often part of hospital directed universal screening (e.g. all newborns at 24 hours)
      1. Universal screening is controversial, but recommended at 24 to 48 hours of life and before hospital discharge
      2. Estimated to cost >$5 million in U.S. annually to prevent a single case of Kernicterus
      3. Increases Phototherapy rates without evidence that it decreases the risk of Bilirubin Encephalopathy
      4. Trikalinos (2009) Pediatrics 124(4): 1162-71 [PubMed]
    3. Obtain for Jaundice
      1. Neonatal Jaundice in the first 24 hours
      2. Neonatal Jaundice that appears excessive (e.g. below nipple line)
      3. Neonatal Jaundice that is difficult to assess on exam
      4. Do not rely solely on appearance of Jaundice as a screening indication (misses cases of severe Hyperbilirubinemia)

IX. Evaluation: Jaundice Monitoring AFTER Hospital Discharge

  1. Monitoring in newborns who received Phototherapy during hospitalization
    1. Phototherapy before 48 hours or Hemolysis history or risk (e.g. Direct Antiglobulin Test positive)
      1. See Severe Neonatal Hyperbilirubinemia Risk Factors
      2. Recheck total Serum Bilirubin in 12 to 24 hours
    2. Other infants who received Phototherapy during hospitalization
      1. Recheck total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) in 1 to 2 days
  2. Monitoring in newborns who have NOT received Phototherapy
    1. Phototherapy Threshold minus TSB or TcB <1.9 mg/dl
      1. Age <24 hours
        1. Delay discharge, consider Phototherapy and recheck TSB in 4 to 8 hours
      2. Age >24 hours
        1. Recheck total Serum Bilirubin (TSB) in 4 to 24 hours
        2. Consider home Phototherapy or delayed discharge for inpatient Phototherapy
    2. Phototherapy Threshold minus TSB or TcB 2.0 to 3.4 mg/dl
      1. Recheck total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) in 4 to 24 hours
    3. Phototherapy Threshold minus TSB or TcB 3.5 to 5.4 mg/dl
      1. Recheck total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) in 1 to 2 days
    4. Phototherapy Threshold minus TSB or TcB 5.5 to 6.9 mg/dl
      1. Discharge <72 hours of age
        1. Follow-up in 2 days
        2. Consider total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) at follow-up based on evaluation
      2. Discharge >72 hours of age
        1. Apply clinical judgment based on exam, Severe Neonatal Hyperbilirubinemia Risk Factors
    5. Phototherapy Threshold minus TSB or TcB >7.0 mg/dl
      1. Discharge <72 hours of age
        1. Follow-up in 3 days
        2. Consider total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) at follow-up based on evaluation
      2. Discharge >72 hours of age
        1. Apply clinical judgment based on exam, Severe Neonatal Hyperbilirubinemia Risk Factors
  3. References
    1. Kemper (2022) Pediatrics 150(3): e2022058859 [PubMed]

X. Management

  1. See Phototherapy Indications
  2. See Breast Feeding Jaundice

XI. Prevention

  1. Adequate early nutrition and hydration
    1. See Breast Feeding Technique
    2. See Infant Feeding
    3. See Formula Feeding
    4. Do not supplement with dextrose water or plain water
  2. Monitoring
    1. See Evaluation above

XII. Complications

  1. Kernicterus is most linked to nonphysiologic causes
  2. Kernicterus has been associated with physiologic causes
    1. Physiologic Jaundice
    2. Exaggerated Jaundice
    3. Breast Feeding Jaundice

XIII. References

  1. (2004) Pediatrics 114(1): 297-316 [PubMed]
  2. (2001) Pediatrics 108(3):763-5 [PubMed]
  3. (2023) Am Fam Physician 107(6): 661-4 [PubMed]
  4. Dennery (2001) N Engl J Med 344:581-90 [PubMed]
  5. Moerschel (2008) Am Fam Physician 77:1255-62 [PubMed]
  6. Muchowski (2014) Am Fam Physician 89(11): 873-8 [PubMed]
  7. Kemper (2022) Pediatrics 150(3): e2022058859 [PubMed]
  8. Par (2023) Am Fam Physician 107(5): 525-34 [PubMed]
  9. Porter (2002) Am Fam Physician 65(4):599-614 [PubMed]

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