QuestionSBA
QuestionChoice
Hypothyroidism can result in  an unconjugated hyperbilirubinaemia, however heel-prick testing would detect congenital hypothyroidism. Further TFTs may be undertaken, but this is not the most important next step given that the baby is febrile.
10017340
e
Thyroid function tests
QuestionChoice
Neonatal jaundice can be precipitated by an infection. In this case, the baby is febrile, tachypnoeic, and has features of a respiratory infection. Their bilirubin level is under the treatment line for phototherapy or exchange transfusion. A full septic screen should be undertaken (including a lumbar puncture) to identify any infections that require treatment.
10017336
a
Perform a septic screen
QuestionChoice
A DIRECT (not indirect) DAT (Coomb's) test will be required in the work-up of this patient, however it is not the most important next step given that the baby is febrile. This will help to determine if there is a haemolytic component.
10017339
d
Perform an indirect antiglobulin (Coomb's) test
QuestionChoice
IVIG is considered for babies undergoing phototherapy in cases of ABO or rhesus haemolytic disease, when bilirubin levels rise by more than 8.5 micromol/litre/hour. This is not the case.
10017338
c
Administer IV immunoglobulin
QuestionChoice
At present, the baby's bilirubin level does not warrant phototherapy. This should be monitored in case it rises above the threshold.
10017337
b
Initiate phototherapy
Concept
Chapter
# Summary
 

Neonatal jaundice, a common condition characterized by a yellowing of the skin and eyes due to bilirubin accumulation, typically presents as physiological but may also indicate serious underlying pathologies. Key signs and symptoms include yellow discoloration of the skin and eyes, poor feeding, lethargy, and in severe cases, kernicterus. Important investigations involve bilirubin levels, gestational age assessment, and potential additional tests for underlying causes. Management strategies can range from watchful waiting to phototherapy and exchange transfusion.
 

# Definition
 

Neonatal jaundice is a clinical condition that presents as a yellowing of a newborn's skin and eyes. It results from the accumulation of bilirubin, a by-product of the breakdown of red blood cells, in the body.
 

# Epidemiology
 

Neonatal jaundice is a common condition affecting a significant proportion of newborns. While most cases are physiological and self-limiting, a subset may be pathological, representing serious conditions requiring prompt identification and management.

Neonatal jaundice is more commonly seen in male and East Asian infants. 
 

# Aetiology
 

The causes of neonatal jaundice can be classified based on the age of onset:
 

 **Causes <24 hours**
 

 -  Haemolytic disorders (Rhesus incompatibility, ABO incompatibility, G6PD deficiency, spherocytosis)
 -  Congenital infections (TORCH screen indicated)
 -  Sepsis
 

**Causes 24 hours - 14 days**
 

 -  Physiological jaundice
 -  Breast milk jaundice
 -  Dehydration
 -  Infection, including sepsis
 -  Haemolysis
 -  Bruising
 -  Polycythaemia
 -  Crigler-Najjar Syndrome
 

**Causes >14 days (>21 if preterm)**
 

 -  Physiologic jaundice
 -  Breast milk jaundice
 -  Infection
 -  Hypothyroidism
 -  Biliary obstruction (including biliary atresia)
 -  Neonatal hepatitis
 
#  Classification

Physiological jaundice is largely attributable to:
 

 -  Relative polycythaemia in newborns
 -  Shorter red blood cell lifespan compared to adults
 -  Less efficient hepatic bilirubin metabolism in the first few days of life

Breast milk jaundice is seen in an otherwise well baby (and can suggest mild, but not clinical dehydration) and usually resolves within 6 weeks. 
 

# Signs and Symptoms
 

 -  Yellowing of the skin and eyes
 -  Poor feeding
 -  Lethargy
 -  In severe cases, kernicterus, a rare but serious complication of untreated jaundice, can occur. This results from excess bilirubin damaging the brain, particularly the basal ganglia.
      -  Symptoms include irritability, vomiting, hypotonia followed by hypertonia) 

If the neonatal jaundice is due to hepatitis or biliary atresia, there will be pale stools and dark urine seen. 

# Investigations
 

Investigations should include:
 

 -  Measuring transcutaneous bilirubin levels. If elevated, confirm with serum bilirubin level, and plot on the nomograms produced by BNF/NICE, taking into account the patient's gestation and age.
     -  Serum bilirubin should always be used if jaundice occurs in the first 24 hours of life or if the neonate is less than 35 weeks gestational age. 
-  Depending on the clinical history, further investigations may also be warranted to elucidate a cause.
     -  Consider FBC, blood film, Coombs' test, LFTs, G6PD levels
     -  Ultrasound or liver biopsy may be required to investigate for hepatitis and biliary atresia 
 

# Management
 
 -  Admit to neonatal or paediatric unit urgently if < 24 hours old, >7 days old, if the neonate is unwell, gestational age < 35 weeks. 
 -  If the neonate is well, the cause is likely physiological or breastmilk jaundice, and the bilirubin is below the treatment threshold, no treatment is indicated. Parents should be educated to monitor the jaundice and to return if the neonate becomes unwell or if the jaundice is not resolving. 
 -  Increase fluid intake (ideally orally, but IV may be required) 
 -  If intervention is required due to elevated bilirubin levels, patients may need:
     -  Phototherapy 
           -  Ensure adequate fluid intake and eye care 
     -  An exchange transfusion
-  Monitoring of bilirubin levels:
     -  Patients with bilirubin levels nearing the phototherapy line should have a repeat measurement in 24 hours.
 -  Further management based on clinical history may also be necessary to uncover the underlying cause.

# Complications
 
The complications of neonatal jaundice depend on the underlying cause. Complications are rare for breastmilk or physiological jaundice.
 
Complications may include:
 
 - Related to phototherapy
       - Loose stools and dehydration
 - Kernicterus 
       - Prolonged exposure to excess bilirubin causes neurologic damage

#  Prognosis 

Neonatal jaundice is usually short-lived and benign. Breastfeeding can continue during the jaundice. For more serious causes (ie biliary atresia, sepsis), the prognosis will depend on how quickly treatment is initiated and the underlying cause. 
 

# NICE Guidelines
 
 [NICE Clinical Knowledge Summary on Neonatal Jaundice](https://cks.nice.org.uk/topics/jaundice-in-the-newborn/)
 
#  References 

 [NHS page about Jaundice in Newborns](https://www.nhs.uk/conditions/jaundice-newborn/)
 
 [Patient Info - Neonatal Jaundice](https://patient.info/doctor/neonatal-jaundice-pro#)
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Neonatal Jaundice
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Paediatrics
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Neonatal Jaundice
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Haemolytic disease of the newborn
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Neonatal Jaundice
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Quesmed Tutorial: Haemolytic Anaemia
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In neonates with jaundice, a septic screen is crucial if there are signs of infection, such as fever or respiratory distress.
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Haematology
A 10-day-old baby is referred to the paediatric emergency department by her GP as her skin and sclerae look yellow. She was born at full term. There were no complications during pregnancy or birth. She is exclusively breastfed. Her parents report that she is feeding slightly less than normal and has a runny nose, but is wetting nappies as usual.


Blood results show:


 * Total bilirubin 120 micromoles/litre (refer to image of treatment graph)


Observations:


 * Heart rate 152 beats/minute (normal 140-160 beats/minute)


 * Blood pressure 63/42 mmHg (normal 50-70 / 25-45 mmHg)


 * Respiratory rate 72 breaths/minute (normal <60 breaths/minute)


 * Temperature 38.0 degrees Celcius


Jaundice treatment graphs:


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Which of the following is the most important next step?
a