PassFinals
Paediatrics

Neonatal jaundice

Jaundice is common in newborns, but its timing, bilirubin fraction, rate of rise and effect on the baby distinguish physiological jaundice from haemolysis, sepsis, cholestatic liver disease and bilirubin neurotoxicity.

In a nutshell

Neonatal jaundice is common, but jaundice in the first 24 hours, rapid bilirubin rise, neurological change, poor feeding or pale stools/dark urine are emergencies. Measure bilirubin and plot total serum bilirubin against the current postnatal-age and gestational-age threshold graph. Phototherapy treats significant hyperbilirubinaemia; exchange transfusion treats threshold-level or encephalopathic disease; prolonged conjugated jaundice needs urgent expert liver assessment.

Classic presentation

A well newborn develops jaundice after 24 hours, often around days 2–3, with bilirubin below the age- and gestation-specific treatment threshold and adequate feeding. This pattern is common, but measurement is still required when jaundice is suspected.

Key points

  • Jaundice within the first 24 hours: serum bilirubin within 2 hours, repeat 6-hourly until below threshold and stable/falling, and urgent medical review within 6 hours.
  • Do not rely on visual inspection alone, especially when jaundice is harder to see in darker skin; measure bilirubin and interpret it by age in hours and gestational age.
  • Treatment decisions use total serum bilirubin on the current NICE/local chart; do not subtract conjugated bilirubin from the total.
  • Phototherapy is intensified for a rapid rise, proximity to the exchange threshold or failure to respond; check rebound bilirubin 12–18 hours after stopping.
  • Exchange transfusion is a neonatal intensive-care emergency for threshold-level bilirubin or acute bilirubin encephalopathy.
  • Pale chalky stools, dark urine or conjugated bilirubin above 25 micromol/litre require expert liver advice; think cholestasis and biliary atresia.
  • Support frequent breastfeeding and lactation; do not routinely give additional fluids to breastfed babies, and use expressed milk if an additional feed is indicated.

First-line investigation

Prompt bilirubin measurement: serum in the first 24 hours or below 35 weeks’ gestation, otherwise transcutaneous screening where appropriate with serum confirmation when indicated; plot total bilirubin on the current threshold graph.

Management

Treat first-24-hour jaundice urgently

  • Obtain serum bilirubin within 2 hours, repeat every 6 hours until below threshold and stable/falling, and arrange urgent medical review within 6 hours.1

Measure and plot bilirubin

  • Use the correct serum or transcutaneous method and plot total bilirubin against the current gestational-age and postnatal-age chart; consult the local laboratory about assay interpretation.1,4

Give phototherapy when indicated

  • Start artificial phototherapy when total bilirubin crosses the current threshold, intensify for rapid rise or poor response, and check rebound bilirubin after stopping.1

Escalate to neonatal intensive care

  • Arrange double-volume exchange transfusion for threshold-level bilirubin or acute bilirubin encephalopathy, maintaining continuous intensified phototherapy and measuring bilirubin within 2 hours afterwards.1,3

Protect feeding and hydration

  • Encourage frequent breastfeeding and lactation support; monitor weight and wet nappies, and use maternal expressed milk if an additional feed is clinically indicated.1,3

Recognise haemolysis and cholestasis

  • Use IVIG only in the specified rhesus or ABO haemolytic-disease pathway with rapidly rising bilirubin, and obtain expert liver advice for prolonged jaundice with conjugated elevation, pale stools or dark urine.1,2,5

Safety-net after treatment or discharge

  • Give carers clear return advice for poor feeding, lethargy, abnormal tone, seizures, worsening jaundice, pale stools, dark urine or reduced wet nappies, and ensure rebound or specialist follow-up tests are completed.1,3

Exam traps

  • Day-one jaundice is not physiological: obtain serum bilirubin urgently and arrange medical review.
  • A single fixed bilirubin cut-off is unsafe; thresholds vary with postnatal age and gestational age, and local assays may vary.
  • Do not subtract conjugated bilirubin from total serum bilirubin when deciding on phototherapy or exchange transfusion.
  • A well appearance does not exclude haemolysis, sepsis or evolving hyperbilirubinaemia.
  • Stop phototherapy only when the level is at least 50 micromol/litre below the phototherapy threshold, then check for rebound 12–18 hours later.
  • Prolonged breastfed jaundice is a diagnosis of exclusion: check conjugated bilirubin and inspect stools and urine.

Illustrations

Bilirubin metabolism pathwayDiagram of red-cell breakdown to unconjugated bilirubin, hepatic conjugation and biliary excretion, showing where increased production, immature conjugation, haemolysis and cholestasis act.PassFinals · original
Treatment threshold graphExample age-in-hours and gestational-age-specific bilirubin graph showing separate phototherapy and exchange-transfusion thresholds; label it as an educational schematic and direct learners to the current NICE/local chart for clinical decisions.PassFinals · original
Cephalocaudal progression of jaundiceIllustration of visible jaundice progressing from the face down the body, with a note that visual inspection cannot quantify bilirubin and jaundice may be harder to see in darker skin.PassFinals · original

Key sources

  1. NICE CG98: Jaundice in newborn babies under 28 days (Current recommendations on recognition, bilirubin measurement, threshold graphs, phototherapy, IVIG, exchange transfusion, feeding and prolonged jaundice; last updated 31 October 2023.)
  2. Norfolk and Norwich University Hospitals: Trust Guideline for Management of Neonatal Jaundice in the NICU, approved August 2024 (UK neonatal pathway aligned to NICE, covering haemolysis, phototherapy, prolonged/conjugated jaundice, feeding, rebound monitoring and escalation.)
  3. Great Ormond Street Hospital: Neonatal jaundice (Specialist paediatric information on assessment, feeding, phototherapy, neurological risk and pale stools/dark urine as signs of liver disease.)
  4. NICE 2023 exceptional surveillance of CG98 (Surveillance update noting assay variability and the planned review of total serum bilirubin thresholds; consult the local laboratory when interpreting threshold tables.)
  5. BNFc: current paediatric prescribing information for IVIG (Use the current monograph and local neonatal IVIG policy for patient-specific prescribing, contraindications, monitoring and infusion requirements.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.