See also

Recognition of the seriously unwell neonate and young infant

Key points

1. If significant jaundice is clinically suspected, a transcutaneous bilirubinometer (TcB) and/or serum bilirubin level should be performed. Visual assessment alone is unreliable for estimating bilirubin level
2. Most jaundice in otherwise well infants is physiological and self-limiting, however severe unconjugated hyperbilirubinaemia may cause acute bilirubin encephalopathy and kernicterus
3. Features suggestive of pathological jaundice include onset <24 hours of age, rapidly rising bilirubin, unwell appearance, prolonged jaundice, conjugated hyperbilirubinaemia, or evidence of haemolysis
4. Pale or acholic stools at any age require urgent evaluation for cholestatic liver disease, including biliary atresia

Background

• Jaundice (hyperbilirubinaemia) occurs in approximately 60% of term and 80% of preterm infants within the first week of life
• Hyperbilirubinaemia results from an imbalance between bilirubin production, conjugation and elimination
• Most jaundice is physiological and benign, however severe unconjugated hyperbilirubinaemia may lead to acute bilirubin encephalopathy and kernicterus, which can cause permanent neurological injury
• Risk factors for severe hyperbilirubinaemia include prematurity, poor feeding, dehydration, excessive weight loss, haemolysis, bruising/cephalhaematoma
• Clinical assessment aims to
  • identify infants requiring phototherapy or further treatment
  • identify pathological jaundice requiring further investigation and management
• Early community follow-up and feeding support, including by GPs and maternal child health nurses, are important to reduce the risk of severe hyperbilirubinaemia

Assessment

History

Examination

• General tone
• Neurological exam
• Hydration status: capillary refill time, heart rate, mucous membranes
• Plethora
• Bruising/cephalohaematoma
• Hepatosplenomegaly
• Stool/urine colour
• Pattern and degree of jaundice (may be less obvious in infants with darker skin)

Management

Investigations

1. Investigation of jaundice

Transcutaneous bilirubinometer (TcB) and/or serum bilirubin (SBR) measurements should be performed in any infant with clinically suspected jaundice.

TcB

• may be used as a screening tool in well infants
• ≥35 weeks gestation
• ≥24 hours old
• should be confirmed with SBR if:
  • within 50 micromol/L of treatment threshold
  • ≥250 micromol/L
  • Rapidly rising
  • Phototherapy is being considered or has commenced
• reliability decreases following phototherapy

SBR

• Gold standard for diagnosis and treatment decisions
• Levels should be interpreted according to gestation, postnatal age and clinical risk factors using an appropriate gestation-specific nomogram
• Fractionated bilirubin (unconjugated/conjugated) should be performed in prolonged jaundice, unwell infants, suspected pathological jaundice, pale stools or dark urine

2. Investigation for a cause

The majority of well infants with unconjugated hyperbilirubinemia do not require further investigation or management

Causes of neonatal jaundice and relevant investigations

Treatment

1. Treatment of unconjugated hyperbilirubinaemia

• Severity of jaundice should be assessed according to gestation, postnatal age, bilirubin level, clinical condition, hydration status and risk factors
• TcB/SBR should be plotted on an appropriate gestation-specific nomogram. Refer to local bilirubin treatment thresholds (see additional notes – section below)
• Ensure adequate hydration and feeding support, particularly in breast-fed infants and those with excessive weight loss or poor intake. Consider lactation consultant and maternal and child health nurse involvement

Phototherapy

• Refer to local protocol regarding phototherapy intensity, biliblanket use and monitoring
• Ongoing close monitoring of weight, hydration, and bilirubin levels should be performed during treatment as per local protocol, with serial checks of SBR to ensure resolution of hyperbilirubinaemia

Exchange transfusion

• Should only be performed in, or in conjunction with, a Neonatal Intensive Care Unit
• Contact local paediatric retrieval service for support

2. Treatment of cause

Consider consultation with local paediatric team when

• Child is unwell
• Cause of jaundice is unclear
• Conjugated bilirubin is >20% of total level

Consider transfer when

• Jaundice level rising despite adequate treatment offered at local centre
• Child needs exchange transfusion

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• SBR/TcB below the treatment threshold and plan in place for follow-up
• Causes requiring further treatment or investigation have been excluded
• Clinically well and feeding well

Discharge advice

• Sunlight exposure is not recommended as a treatment for jaundice
• Arrange early follow-up with maternal and child health nurse and/or GP to ensure adequate oral intake, especially if
  • <7 days old
  • exclusively breastfeeding or still establishing adequate oral feeds
  • bilirubin level is borderline for requiring treatment
• Re-check bilirubin in 24-48 hours if borderline level or still rising
• Parents should be advised to seek medical review if
  • jaundice is present for 2-3 weeks and cause has not previously been established
  • parents believe jaundice is worsening or there is any other cause for clinical concern

Parent information

• Jaundice in Newborns – Children's Health Queensland
• Jaundice and Your Newborn Baby – The Royal Women's Hospital
• What is jaundice and phototherapy – The Royal Women's Hospital

Additional notes

Established treatment nomograms

NICE treatment threshold graphs

Bilitool - an online tool to assess the risk of developing hyperbilirubinaemia (American Academy of Paediatrics)

Local guidelines with nomograms

New South Wales
Jaundice Identification and Management in Neonates >32 Weeks Gestation

Jaundice In Neonatal Care Practice Guideline

Queensland

Neonatal Jaundice
Nomograms for jaundice management for all weight/gestations
Assessment for jaundice flowchart

South Australia

Neonatal Jaundice

Western Australia

Jaundice Guideline

Updated June 2026