Jaundice in Newborns

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

1. See also
   1. Nonphysiologic Neonatal Jaundice
   2. Risk Score for Neonatal Hyperbilirubinemia
   3. Breast Feeding Problems for the Infant
   4. Acute Bilirubin Encephalopathy
   5. Chronic Bilirubin Encephalopathy (Kernicterus)
   6. Neonatal Bilirubin
   7. Phototherapy
   8. Exchange Transfusion in Newborns
2. Epidemiology
   1. Jaundice Incidence in full term infants: 60%
   2. Jaundice Incidence in Preterm Infants: 80%
3. Pathophysiology: Physiologic Jaundice
   1. See Breast Feeding Jaundice
   2. 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
   3. 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
   4. Exaggerated Physiologic Jaundice
      1. Low glucuronyl transferase (Hepatic immaturity)
      2. Risk factors
         1. Breast Feeding Jaundice
         2. Prematurity
         3. Asian ethnicity
         4. Weight loss
4. Signs: Jaundice
   1. General
      1. Visual Jaundice indicates Total Bilirubin >4 mg/dl
      2. Physiologic Jaundice is not present on Day 1
      3. Visual inspection is not an accurate screening tool (misses cases of severe Hyperbilirubinemia)
   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
5. Differential Diagnosis
   1. See Neonatal Jaundice Causes
6. Labs: Bilirubin
   1. See Neonatal Bilirubin
   2. Transcutaneous Bili Meter
      1. Accurate in white infants
      2. Overestimates Bilirubin in black infants
      3. Do not use to monitor infants on Phototherapy
7. Labs: Secondary Cause
   1. See Nonphysiologic Neonatal Jaundice for additional evaluation
8. 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
         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)
9. Evaluation: Jaundice Monitoring after hospital discharge
   1. Based on age
      1. Discharge before 24 hours old: Reevaluate by 72 hours old
      2. Discharge before 48 hours old: Reevaluate by 96 hours old
      3. Discharge before 72 hours old: Reevaluate by 120 hours old
   2. Based on risk factors
      1. See Severe Neonatal Hyperbilirubinemia Risk Factors
      2. Number of risk factors dictates timing of follow-up (typically within 24-48 hours)
10. Management
    1. See Phototherapy Indications
    2. See Breast Feeding Jaundice
11. 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
12. 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
13. References
    1. (2004) Pediatrics 114(1): 297-316 [PubMed]
    2. (2001) Pediatrics 108(3):763-5 [PubMed]
    3. Dennery (2001) N Engl J Med 344:581-90 [PubMed]
    4. Moerschel (2008) Am Fam Physician 77:1255-62 [PubMed]
    5. Muchowski (2014) Am Fam Physician 89(11): 873-8 [PubMed]
    6. Porter (2002) Am Fam Physician 65(4):599-614 [PubMed]