Jaundice neonatal


These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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To guide staff with the assessment and management of neonatal jaundice in patients who present to Emergency Department (ED).


  • Up to 60% of term and 80% of preterm neonates will become clinically jaundiced in the first week of life1, 2
  • Usually, the total serum bilirubin (TSB) rises during days 3-5 of life, begins to decline from then, and usually resolves within 10-14 days.4
  • Very high bilirubin levels can cause neurological damage, a condition known as kernicterus.
  • Early recognition of jaundice is vital for treatment of any underlying cause and for appropriate use of phototherapy to control bilirubin levels.2

Key points

  • Most well newborns with jaundice have physiological jaundice with unconjugated bilirubin and usually do not require specific treatment.1,2
  • Kernicterus was rarely seen in the decades following the introduction of phototherapy and exchange transfusion; however, recent reports suggest it is re-emerging. This has been partly attributed to earlier hospital discharge (within 48 hours of birth) before the natural peak of bilirubin in the neonate, as well as a result of relaxation of the treatment criteria.4
  • Assume a sick neonate who presents with jaundice is septic.
  • Conjugated hyperbilirubinaemia requires urgent discussion with a paediatric gastroenterologist.3
  • Measure bilirubin concentrations in all babies with jaundice- visual inspection alone is not reliable to estimate the bilirubin concentration.2

Risk factors1,2

 Maternal Neonatal
  • Blood group O
  • RhD negative
  • Red cell antibodies
  • Genetic: family history, East Asian, Mediterrean
  • Diabetes
  • Previous baby requiring phototherapy
  • Feeding - breastfeeding, reducing intake
  • Haematoma, bruising
  • Polycythaemia
  • Haemolysis
  • Bowel obstruction
  • Infection
  • Pre-term, male
  • Sub optimal intake jaundice or breastfeeding associated jaundice usually appears between 48-72 hours of life, peaks at day 3-5, and is associated with poor intake, poor weight gain and delayed or reduced bowel motions.
  • Increasing oral intake +/- phototherapy is the treatment.
  • If there are concerns for a breastfed baby regarding milk supply or poor oral attachment, refer to a lactation consultant for assessment at the Breastfeeding Centre of WA (King Edward Memorial Hospital (KEMH), Community Health breastfeeding support or a private lactation consultant.


Red flags for pathological jaundice

  • Jaundice that occurs in the first 24 hours of life
  • Associated anaemia and hepatomegaly
  • Rapidly rising total serum bilirubin (> 85 micromol/L per day)1
  • Elevated conjugated bilirubin level > 10% total serum bilirubin, or >20micromol/L – neonatal cholestasis (e.g. biliary atresia)2
  • Prolonged jaundice > 14 days in term, >21 days in preterm infants.1,2 Notably, 10% of breastfed babies are still jaundiced at 1 month, but breastmilk jaundice remains a diagnosis of exclusion.2


Clinical history should include:

  • Birth history: Instrumental delivery/birth trauma, gestational age, birth weight
  • Timing of jaundice: Onset and progression of jaundice, <24 hours pathological, >2 weeks prolonged (>3 weeks in preterm)
  • Feeding: Breast or formula, intake, weight loss, vomiting
  • Output: Hydration status, dark urine and pale stools (cholestasis), delayed passage of meconium
  • Behaviour: lethargy, cries becoming shrill, arching of the body (bilirubin encephalopathy)
  • Family history: ABO/rhesus incompatibility, glucose-6-phosphate-dehydrogenase (G6PD) deficiency, hereditary spherocytosis, prolonged jaundice, thyroid dysfunction
  • History of temperature instability.


  • General tone and neurological examination
  • Pallor, petechiae, cephalohaematoma, excessive bruising, hepatosplenomegaly.
  • Hydration and weight status (calculate percentage weight loss).
  • Plethora due to polycythaemia.

Initial ED investigations


  • Transcutaneous biliometry (TcB) (if available) for immediate estimate of bilirubin. Very difficult to assess level of jaundice by eye alone. Refer to Jaundice – Neonatology Guideline
  • Serum Bilirubin (SBR) conjugated and unconjugated
  • Blood group and Direct Coombs if not previously done
  • Full Blood Count (FBC) (add reticulocyte count if anaemic)
  • Liver Function Tests (LFTs) + albumin
  • Urine culture
  • + / - Thyroid Function Test (TFT) (check if infant has had normal neonatal screening)
  • +/- Glucose-6-phosphate-dehydrogenase deficiency (G6PD)
  • +/- Urine for reducing substances

Table 1: Overview of initial investigations and management of neonatal jaundice

 Unwell neonate Well neonate   Conjugated hyperbilirubinaemia
   <24 hours old 2 to 14 days old  >14 days old  

Septic screen:

  • FBC, CRP, blood cultures, urine
  • +/- LP
  • SBR (direct and indirect)
  • Consider TORCH and metabolic screen

SBR (direct and indirect)

Direct Coombs test (DCT) + blood group

FBC + retics

DTC + blood group - if not done

TcB (if available)

SBR (direct and indirect)

FBC + retics

DCT + blood group - if not done

SBR (direct and indirect)

FBC + retics

DCT + blood group if not done

LFTs + albumin


Red cell enzynes (G6PD)

Urine culture

 LFTs and albumin

FBC + retucs


Blood sugar

Consider sepsis if unwell

Further investigations guided by Gastro

Empiric antibiotics and admission 

Admission and early consult with neonates

Phototherapy if SBR above treatment line

Consider discharge if well and bloods normal. F/up GP in 1 to 2 days

Phototherapy if SBR above treatment line

Feeding support/fluid replacement. Consider d/c if well and bloods normal

Phototherapy if SBR above treatment line

Early consult with paediatric gastroenterologist

Management - Phototherapy

  • Plot SBR level on graph below.
  • Admit for phototherapy if bilirubin level is over the line as per the graph. (Refer to Phototherapy – Neonatal Guidelines).
  • If significantly above the treatment line consider possibility of requiring exchange transfusion. Plot on exchange graph and consult early with neonatology/intensive care.(Refer to Phototherapy – Neonatal Guidelines).
  • Phototherapy should be commenced in the Emergency Department if there is a delay in transfer to an inpatient ward

Graph 1: Guidelines for phototherapy in hospitalised Infants of greater than 35 weeks gestation11

Guidelines for phototherapy in hospitalised infants of 35 or more weeks gestation 

Breast milk jaundice12

  • Breast milk jaundice is common and is a diagnosis of exclusion.
  • Breast milk jaundice usually appears between day 5-10, the infant is generally thriving, and no intervention is required.
  • Breast feeding should continue to be encouraged and supported. Breast milk jaundice may last 3-12 weeks.


  • Unwell babies should have a septic screen, antibiotics and admission +/- phototherapy. Refer to Sepsis Recognition and Management.
  • Babies requiring phototherapy should be admitted under general paediatrics or neonatology
  • Babies requiring exchange transfusion should be admitted under neonatology
  • Conjugated hyperbilirubinaemia requires gastroenterology admission or follow up
  • Full term, well appearing and afebrile neonates without significant risk factors and bilirubin level less than treatment level indicated in the graph can be discharged with GP follow-up in 1-2 days for review of intake/results check +/- repeat SBR.
  • Sunlight exposure is not recommended for the management of hyperbilirubinaemia since it is an uncontrolled source of multiple wavelengths of light. Sunburn is a risk and parents should be discouraged from using this approach. 


  1. Management of hyperbilirubinaemia in the Newborn 35 or more weeks gestation, Pediatrics 114:297-316, July 2004
  2. Neonatal Jaundice: summary of NICE guidance. BMJ 2010;340:c2409 doi: 10.1136/bmj.c2409 (Published 19 May 2010)
  3. McKiernan P. Neonatal Jaundice. Clinics and Research in Hepatology and Gastroenterology, 2012-06-01, Volume 36, Issue 3, Pages 253-256
  4. Managing the jaundiced newborn: a persistent challenge. CMAJ 2015. DOI:10.1503 /cmaj.122117
  5. Maisels MJ, McDonagh AF.Phototherapy for neonatal jaundice.N Engl J Med. 2008 Feb 28;358(9):920-8. Review. PubMed PMID: 18305267
  6. Chou S-C et al. Management of hyperbilirubinaemia in newborns: measuring performance by using a benchmarking model. Pediatrics 2003; 112(6):1264-73
  7.  Johnson, L, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatrics 2002;140(4):396-403
  8. Bhutani VK, Johnson LH, Maisels MJ, et al. Kernicterus: epidemiological strategies for its prevention through systems based approaches. J Perinatal 2004;24:650-62
  9. Hamilton P, Schwartz, Beth E, Haberman RM. Hyperbilirubinaemia. Paediatric Emergency Care, 2001;27(9):884-9
  10. Colletti JE, Kathari S, Jackson D, Kagore K, Berringer K. An emergency Medicine Approach to neonatal hyperbilirubinaemia. Emerg Med Clin N AM 2007;25:1117-1135
  11. Jaundice Threshold Graphs – CAHS document. Last Modified 28 August 2020. Available from: https://cahs-healthpoint.hdwa.health.wa.gov.au/Neonatology/Documents/CAHS.NEO.Jaundice_ThresholdGraphs.xlsx
  12. International Lactation Consultant Association. Core Curriculum for Lactation Consultant Practice. 3rd Ed. 2012

Endorsed by: Nurse Co-director, Surgical Services  Date: Apr 2022

 Review date:  Apr 2024

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