Summary

Neonatal jaundice is yellowing of the skin and sclera caused by elevated bilirubin levels. It is extremely common, affecting 60% of term and 80% of preterm infants. Most cases are physiological and benign. However, pathological jaundice (early onset, rapidly rising, or prolonged) requires urgent investigation. Severe unconjugated hyperbilirubinaemia can cause kernicterus — irreversible bilirubin encephalopathy with permanent neurological damage.

Key Facts

• Incidence: 60% term infants, 80% preterm infants visible jaundice
• Physiological: Appears after 24 hours, peaks day 3-5, resolves by 2 weeks (term)
• Pathological: Before 24 hours, rapidly rising, over 14 days (term), over 21 days (preterm)
• Kernicterus: Irreversible brain damage from very high unconjugated bilirubin — PREVENTABLE
• Treatment: Phototherapy (vast majority), exchange transfusion (severe cases)
• Conjugated hyperbilirubinaemia: URGENT — biliary atresia is time-critical surgical emergency

Clinical Pearls

Jaundice in the first 24 hours of life is ALWAYS pathological — investigate and treat urgently

Pale stools + dark urine = conjugated hyperbilirubinaemia → urgent referral to exclude biliary atresia (Kasai procedure has best outcomes if performed before 6 weeks)

Always plot bilirubin on the gestation-appropriate NICE treatment threshold chart — don't rely on clinical inspection alone

Why This Matters Clinically

Neonatal jaundice is one of the most common conditions encountered in paediatrics. While usually benign, delayed recognition or treatment of severe hyperbilirubinaemia causes preventable brain damage. Every clinician working with newborns must be able to identify red flags, use treatment threshold charts correctly, and recognise conjugated hyperbilirubinaemia requiring urgent referral.

General Approach

1. Assess jaundice extent (cephalocaudal progression)
2. Check vital signs and growth parameters
3. Look for signs of underlying cause
4. Assess hydration and feeding
5. Neurological assessment

Specific Examination Findings

Clinical Assessment of Jaundice

• Visual inspection unreliable, especially in dark-skinned infants
• Always measure bilirubin — do not rely on clinical judgement alone
• Use transcutaneous bilirubinometer (TcB) as screening
• Confirm with serum bilirubin (SBR) if above threshold or TcB unavailable

Causes by Timing

Unconjugated vs Conjugated

NICE Treatment Thresholds

• Use gestation-appropriate treatment threshold graphs
• Different thresholds for phototherapy vs exchange transfusion
• Lower thresholds in preterm infants
• Plot actual bilirubin on chart at baby's age in hours

Natural History

• Physiological jaundice: Resolves by 2 weeks, no sequelae
• Breast milk jaundice: May persist 3-4 weeks, benign, no treatment needed
• Haemolytic disease: May have prolonged anaemia requiring monitoring

With Treatment

• Phototherapy: Highly effective; most infants respond within 24-48 hours
• Exchange transfusion: Effective at reducing bilirubin rapidly; rare complications

Prognostic Factors

Biliary Atresia Prognosis

• Kasai procedure before 60 days: 60-80% successful bile drainage
• After 90 days: Success rate drops significantly
• Without treatment: Death from liver failure by 2 years

Key Guidelines

1. NICE CG98: Neonatal Jaundice (2010, updated 2023) — UK guideline for screening and management
2. AAP Clinical Practice Guideline: Management of Hyperbilirubinaemia (2022) — US guideline with updated thresholds
3. BAPM Framework for Newborn Jaundice — UK practical guidance

Key Evidence

Phototherapy Efficacy

• Multiple RCTs show phototherapy effectively reduces bilirubin
• LED phototherapy as effective as conventional
• Intensive phototherapy reduces need for exchange transfusion

Exchange Transfusion

• Historically standard; now rare due to effective phototherapy and screening
• Still indicated for severe cases and acute encephalopathy

Biliary Atresia Screening

• Stool colour cards in Taiwan reduced delayed diagnosis
• UK considering national screening programme

What is Neonatal Jaundice?

Jaundice is yellowing of the skin and eyes caused by a substance called bilirubin. It is very common in newborn babies — more than half of all babies develop some jaundice in the first week of life.

Most jaundice is normal and goes away on its own. However, if bilirubin levels get too high, it can sometimes be harmful. That's why we may need to measure your baby's bilirubin level with a blood test or special device on the skin.

When to Seek Help

Contact your midwife, health visitor, or GP urgently if:

• Your baby is jaundiced in the first 24 hours of life
• Jaundice is getting worse or spreading down the body
• Your baby is not feeding well or seems very sleepy
• Your baby has pale poo (chalky white/grey) or dark wee
• Jaundice is still present after 14 days (term baby) or 21 days (premature baby)

What Does Treatment Involve?

Phototherapy (light treatment):

• Your baby lies under special blue lights
• This helps break down bilirubin in the skin
• Your baby will wear eye protection
• You can still feed and cuddle your baby

How Can I Help My Baby?

• Feed frequently (at least 8-12 times in 24 hours)
• Wake your baby for feeds if they're very sleepy
• Keep them warm during phototherapy
• Watch for warning signs listed above

Resources

• NHS: Jaundice in Newborns
• NICE Patient Information on Neonatal Jaundice
• CLDF (Children's Liver Disease Foundation)