Hyperbilirubinaemia, or jaundice, is seen in around 60% of all newborns. In many cases there is no pathological cause if it appears after 24 hours of life and is lessening by 14 days of life.
Jaundice in older children will not be covered here, although is generally always a pathological process that requires further investigation and referral to an Emergency Department or paediatric outpatient services, depending on the level of clinical concern.
For the management of jaundice, please refer to the Neonatal Handbook.
Jaundice should be initially assessed visually using Kramer's rule (see Neonatal Handbook).
If concern arises as to the level of jaundice, or jaundice appears during the first 24 hours of life, a blood test for a serum bilirubin (SBR) should be ordered. Note that dark-skinned newborns are difficult to assess clinically.
- The UK based NICE guidelines have an excellent downloadable treatment threshold graphs for the evaluation of jaundice.
- Base further tests on the clinical situation:
- need for phototherapy: repeat SBR, add FBE, blood group and direct Coombs
- ask for fractionated SBR, if level >15% conjugated this is concerning for conjugated hyperbilirubinaemia
- prolonged jaundice - see Neonatal Handbook.
Babies more at risk of jaundice include those with:
- prematurity
- cephalhaematoma or other bruising
- blood group incompatability (esp. Rhesus or ABO)
- sepsis
- family history of significant jaundice
- significant weight loss
- Although jaundice can be initially assessed clinically, a blood test for a serum bilrubin (SBR) should be ordered if concern arises as to the level of jaundice, or jaundice appears during the first 24 hours of life.
- The UK based NICE guidelines have an excellent downloadable treatment threshold graphs for the evaluation of jaundice.
- Prolonged jaundice warrants further investigation and consideration of discussion with and/or transfer to paediatric services.
- Consideration of phototherapy if SBR is within range (treatment threshold graphs).
- Escalation of treatment should be done in a Special Care Nursery or Neonatal Intensive Care experienced in managing higher level neonatal care:
- Exchange transfusion and/or IVIG can be considered if phototherapy is insufficient.
- Treat any underyling problems e.g. sepsis
- Paediatrician
- Although phototherapy for simple cases of jaundice can be undertaken in peripheral centres, poor response to treatment, unwell babies, prolonged jaundice, severe jaundice (exchange transfusion range) or management of babies with any signs of bilirubin encephalopathy should be managed in consultation with paediatric services.
- Prolonged jaundice or elevated conjugated fraction (> 15%) warrants further investigation and timely discussion with and/or transfer to paediatric services.