Clinical Practice Guidelines

Jaundice in early infancy

  •  See also:

     Neonatal guideline

    NICE Guidelines & Charts


    • Jaundice (or hyperbilirubinaemia) occurs in approximately 60% of full term babies (80% of pre-term babies) within the first week of life
    • Visual assessment of bilirubin level is unreliable
    • Kernicterus is a rare complication of unconjugated hyperbilirubinaemia that can lead to major long-term neurological sequelae


    History & Examination- features particularly relevent to jaundice:

    • Is the infant unwell? (sepsis & GIT obstruction can cause jaundice)
    • Is there dehydration or poor wt-gain? (both exacerbate jaundice)
    • Jaundice before 48 hrs of age (suggests haemolysis)
    • Onset of jaundice after 3 days of age (more likely to be pathological)F
    • Birth trauma such as cephalhaematoma, significant bruising (breakdown of heme)
    • Maternal history (blood group, viral serology)
    • Family history of haemolytic disease (ABO/G6PD, spherocytosis)
    • Dark urine or pale stools (suggest biliary obstruction)
    • Level of icterus in terms of cephalocaudal progression (but often unreliable)
    • Plethora (may suggest polycythaemia)
    • Hepatosplenomegaly (viral hepatitis, metabolic problems)


    1. Serum Bilirubin, 'split' into:

    • Unconjugated Bilirubin ('indirect')
    • Conjugated Bilirubin ( 'direct')

    Use total Bilirubin when making decisions about management of unconjugated hyperbilirubinaemia (unconjugated fraction >85% of total)

    2. Other Investigations:

    ( see flowchart)

    Juandice flowchart pic
    View flowchart

    Unconjugated Hyperbilirubinaemia


    Physiological Jaundice

    • Is an exaggerated physiological response
    • Should resolve within 2 weeks in a term baby (3 weeks in a pre-term baby).

    Breast Milk Jaundice

    • Common
    • jaundice may continue for many weeks
    • Cessation of breast feeding is NOT indicated

    Other Causes

    • Sepsis- rarely presents with jaundice alone (occasional for UTI); usually unwell
    • Haemolysis from Bl grp incompatibility and red cell defects - early onset for ABO, Rhesus
    • Excessive, non-haemolytic red cell destruction (such as polycythaemia, bruising or cephalhaematoma)
    • GIT obstruction or ileus (eg. pyloric stenosis)
    • Prematurity
    • Hypothyroidism (TSH included in newborn screening tests, results available by ph: 8341 6272)

    Management of unconjugated hyperbilirubinaemia:

    • Treat underlying sepsis
    • Prolonged jaundice (>2wks term, > 3 wks pre-term) rarely requires treatment
    • Jaundiced neonates requiring admission to RCH should be discussed with NNU fellow/ consultant
    • Suspected haemolysis should be discussed with haematologist on call.
    • See NETS handbooktables for treatment ranges

    a. Discharge instructions

    • Sunlight exposure is not recommended as a treatment for jaundice
    • Arrange early follow-up with MCHN and/or GP to ensure adequate oral intake, especially if:
      • < 3 days old
      • Exclusively breastfeeding or still establishing adequate oral feeds
      • bilirubin level is borderline for requiring treatment
    • Recheck bilirubin in 24-48 hours if borderline level or still rising
    • Parents should be advised to represent if:
      • Stools become pale or urine becomes dark
      • Baby unwell or feeding poorly
      • Jaundice prolonged beyond 2 wks, for term, or 3 wks, for preterm babies

    b. Phototherapy

    • Particular attention should be paid to fluid intake and hydration status, with monitoring of weights and electrolytes at least daily.
    • Correct dehydration over at least 24 hours
    • Bilirubin should be rechecked 6 hours after initial test

    NB. If rate of rise of bilirubin is >10 micromol/L/hour - Contact NNU fellow/  NETS for further advice

    c. Exchange Transfusion

    • This should only be carried out in a Tertiary Neonatal Intensive Care Unit
    • Obtain advice from NNU fellow or  NETS

    Conjugated Hyperbilirubinaemia

    • Pale stools/ dark urine, raised conjugated bilirubin (>15% total or >15umol/l)
    • The causes of conjugated hyperbilirubinaemia are potentially serious
    • All cases warrant further investigation and discussion with Paediatric Gastroenterology


    Biliary atresia:

    • Needs to be detected early to improve chances of success of surgical repair (Kasai)
    • Kasai best operated on before 45-60 days of life.
    Other causes:
    • Choledochal cyst
    • Neonatal hepatitis (congenital infection, alpha-1 antitrypsin deficiency; often idiopathic)
    • Metabolic (galactosaemia, fructose intolerance - ask about sucrose/fructose in food/medication)
    • Complication of TPN


    NETS Guideline - Jaundice in the first two weeks of life