---
title: Neonatal Jaundice Assessment
description: A clinical reference on the evaluation and management of neonatal hyperbilirubinemia.
keywords: [neonatal jaundice, hyperbilirubinemia, kernicterus, bilirubin, phototherapy]
category: clinical
---

## Introduction

Neonatal jaundice, caused by hyperbilirubinemia, is a common condition affecting up to 60% of term and 80% of preterm infants. While typically benign, severe or prolonged hyperbilirubinemia can lead to bilirubin encephalopathy (kernicterus), a devastating neurological complication. Careful assessment and management of neonatal jaundice is crucial to prevent adverse outcomes.

## Diagnostic Criteria

The diagnosis of neonatal jaundice is based on the clinical observation of yellow discoloration of the skin and mucous membranes, confirmed by measurement of serum bilirubin levels. The American Academy of Pediatrics (AAP) recommends obtaining a total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) measurement in all newborns before discharge and in any infant with suspected jaundice.

Significant hyperbilirubinemia is defined as a TSB level above the 95th percentile for the infant's age in hours, as outlined in the Bhutani nomogram. Factors that increase the risk of severe hyperbilirubinemia include preterm birth, blood group incompatibilities, maternal diabetes, and bruising or cephalhematoma.

## Evaluation

The initial evaluation of neonatal jaundice should include a detailed history and physical examination. Relevant factors to assess include:
- Onset and progression of jaundice
- Feeding patterns and stool/urine output
- Family history of jaundice or hemolytic disorders
- Physical examination for signs of hemolysis, infection, or underlying medical conditions

Diagnostic testing may include the following:
- Complete blood count (CBC) with differential
- Blood type and direct Coombs test
- Reticulocyte count
- Liver function tests (AST, ALT, alkaline phosphatase)
- Thyroid function tests
- Glucose-6-phosphate dehydrogenase (G6PD) screening

Additional tests, such as direct and indirect bilirubin levels, may be ordered based on the clinical presentation and initial laboratory findings.

## Treatment

The management of neonatal jaundice is guided by the infant's age, bilirubin levels, and risk factors. The primary interventions include:

1. Phototherapy:
   - Indicated for TSB levels above the treatment threshold on the Bhutani nomogram
   - Utilizes blue-green light to convert unconjugated bilirubin into water-soluble forms for excretion
   - Administered using overhead, fiberoptic, or combination phototherapy devices
   - Monitoring includes TSB levels every 6-12 hours and temperature, hydration, and stool/urine output

2. Exchange transfusion:
   - Indicated for TSB levels approaching or exceeding the exchange transfusion threshold on the Bhutani nomogram
   - Involves the removal and replacement of the infant's blood with donor blood to rapidly lower bilirubin levels
   - Performed in a neonatal intensive care unit (NICU) setting with close monitoring

3. Pharmacological interventions:
   - Intravenous immunoglobulin (IVIG): Used in the setting of Rh or ABO incompatibility to inhibit hemolysis
   - Phenobarbital: Can be considered in cases of prolonged or severe hyperbilirubinemia to enhance bilirubin conjugation

Contraindications to phototherapy include porphyria, erythropoietic protoporphyria, and certain skin conditions. Exchange transfusion is contraindicated in the presence of active bleeding, coagulopathy, or severe thrombocytopenia.

## Monitoring and Discharge

Infants receiving phototherapy should be monitored closely for signs of complications, such as dehydration, electrolyte imbalances, and skin changes. Frequent TSB or TcB measurements are essential to guide treatment and ensure bilirubin levels are decreasing as expected.

Prior to discharge, the following should be assessed:
- Bilirubin levels have declined to a safe range
- Infant is feeding well and maintaining adequate hydration
- Parents/caregivers have received education on the signs and symptoms of jaundice, the importance of follow-up, and when to seek medical attention

Discharge criteria may vary based on institutional guidelines, but generally include a TSB level below the phototherapy threshold and a plan for timely follow-up within 24-48 hours.

## Complications and Long-Term Outcomes

Severe or prolonged hyperbilirubinemia can lead to bilirubin encephalopathy, also known as kernicterus. This condition is characterized by the deposition of unconjugated bilirubin in the basal ganglia and brainstem, resulting in neurological sequelae such as athetoid cerebral palsy, hearing loss, and developmental delays.

Risk factors for kernicterus include prematurity, hemolytic disease, G6PD deficiency, and delayed or inadequate treatment of hyperbilirubinemia. Early recognition and management of neonatal jaundice is crucial to prevent this devastating complication.

In the majority of cases, neonatal jaundice resolves without long-term consequences. However, close follow-up is recommended to monitor for potential developmental or neurological issues that may arise, even in infants who have received appropriate treatment.

## Conclusion

Neonatal jaundice is a common condition that requires careful assessment and management to prevent the development of bilirubin encephalopathy. Clinicians should be familiar with the diagnostic criteria, evaluation, and treatment options, as well as the importance of close monitoring and timely follow-up. By adhering to evidence-based guidelines and utilizing appropriate interventions, healthcare providers can optimize the care of infants with neonatal jaundice and minimize the risk of adverse outcomes.