Neonatal Jaundice (Hyperbilirubinaemia)

Neonatal jaundice affects 60% of term and 80% of preterm neonates. Physiological jaundice peaks at day 3–4 in term infants. Jaundice <24h is always pathological. Treatment is phototherapy or exchange transfusion, guided by gestation-specific…

NICE CG98 Neonatal Jaundice

The pathway

1 · When to worry

<24h: always pathological (haemolytic)
>2 weeks (>3 weeks if breastfed): conjugated jaundice workup needed — biliary atresia must be excluded.

2 · Measure bilirubin

Transcutaneous bilirubinometer (TcB) for screening. If TcB high or age <24h — serum bilirubin (SBR) always. Plot on NICE hour-specific threshold chart for gestation.

3 · Phototherapy

Start if SBR ≥ phototherapy threshold on NICE chart. Overhead LED phototherapy. Remove eye shields every 4h to allow feeding. Continue until SBR falls below treatment line.

4 · Investigate haemolysis

Blood group
DAT (Coombs)
FBC

Haemolysis: ABO incompatibility, Rh disease, G6PD, spherocytosis.

5 · Exchange transfusion threshold

If SBR within 50 μmol/L of exchange line, or rising rapidly (>8.5 μmol/L/hr), or not responding to phototherapy — urgent haematology + neonatal registrar.

6 · Prolonged jaundice

>2 weeks (term) or >3 weeks (breastfed/preterm): split bilirubin. Conjugated >20% of total — urgent surgical referral (biliary atresia must be excluded by 6 weeks for Kasai procedure).

Drugs

Drug	Dose	Route	Notes
Phototherapy	Continuous	Overhead LED	Remove eye protection every 4h. Maintain temperature. Increase feeds to prevent dehydration.
Intravenous immunoglobulin (IVIG)	500mg/kg	IV over 4h	For immune haemolytic disease unresponsive to phototherapy. Consult haematology.

When to escalate

SBR at or above exchange transfusion threshold — neonatal registrar + haematology immediately,Bilirubin encephalopathy (hypertonia, opisthotonus, high-pitched cry) — emergency exchange transfusion,Conjugated jaundice — urgent surgical referral (biliary atresia),Rapidly rising SBR (>8.5 μmol/L/hr) — intensify phototherapy, prepare for exchange

Reference: NICE CG98 Neonatal Jaundice 2010 (updated 2016) / BNFc

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