Neonatal Jaundice
NICE Clinical guideline [CG98] Jaundice in newborn babies under 28 days. Last updated: Oct 2023.
Background Information
Physiological neonatal jaundice:
Prolonged neonatal jaundice:
Pathological neonatal jaundice:
- >24 hours after birth
- Always unconjugated (indirect) hyperbilirubinaemia
Prolonged neonatal jaundice:
- Lasting >2 weeks
Pathological neonatal jaundice:
- Onset <24 hours after birth
- Can be either unconjugated (indirect) or conjugated (direct) hyperbilirubinaemia
Note that only unconjugated hyperbilirubinaemia can cross the blood-brain barrier:
Conjugated hyperbilirubinemia cannot cross the blood-brain barrier:
- Main complication: bilirubin encephalopathy and kernicterus (chronic bilirubin encephalopathy)
Conjugated hyperbilirubinemia cannot cross the blood-brain barrier:
- Negligible neurotoxicity
- Main complication results from the underlying cause
Diagnosis Guidelines
Measure serum bilirubin directly if:
Otherwise, use a transcutaneous bilirubinometer as 1st line:
- Onset <24 hours (i.e. pathological jaundice), or
- Gestational age <35 weeks
Otherwise, use a transcutaneous bilirubinometer as 1st line:
- If the measurement is elevated → measure the serum bilirubin
Management Guidelines
Reassure that breastfeeding, nappy‑changing and cuddles can usually continue
If on / above treatment line → offer corresponding treatment accordingly (i.e. phototherapy or exchange transfusion)
Note that total bilirubin level is used to guide management.
Example of a treatment threshold graph (exam questions always provide this table, and the thresholds depend on gestational age):
If on / above treatment line → offer corresponding treatment accordingly (i.e. phototherapy or exchange transfusion)
- If the bilirubin level is within 50 mmol/L below the phototherapy threshold → repeat bilirubin measurement
- Otherwise, no routine repeat measurement is required
Note that total bilirubin level is used to guide management.
Example of a treatment threshold graph (exam questions always provide this table, and the thresholds depend on gestational age):
Phototherapy should be given using an artificial light source (not natural sunlight).
Educate about phototherapy:
- Eye protection required
- Increased risk of dehydration
- Short breaks for feeding, nappy changes, and cuddling are encouraged
- Bronze baby syndrome is rare but benign
Monitoring during phototherapy:
- Repeat 4-6 hours after initiating phototherapy
- Repeat every 6-12 hours when the serum bilirubin level is stable / falling
Only stop phototherapy when:
- Serum bilirubin level is at least 50 mmol/L below the phototherapy threshold
- Repeat 12-18 hours after stopping phototherapy
Phototherapy can be intensified by adding another light source or increasing irradiance of the initial light source.
Consider if:
Consider if:
- Serum bilirubin level is rising rapidly (>8.5 mmol/L per hour), or
- Poor response (bilirubin continues to rise / does not fall within 6 hours of initiating), or
- Serum bilirubin is still within 50 mmol/L below the threshold for exchange transfusion after 72 hours since birth
Exchange transfusion should be performed in an intensive care bed
Use a double-volume exchange transfusion:
Use a double-volume exchange transfusion:
- Do not stop the ongoing phototherapy