Neonatal jaundiceMANAGEMENT

PEDIATRIC-SPECIFIC PRESENTATIONS · 12 SECTIONS

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504 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Bronchiolitis Croup Emergency delivery Febrile seizure Intussusception Kawasaki disease Neonatal jaundice Neonatal sepsis Nursemaid's elbow Pediatric fever 0 to 28 days Pediatric fever 29 to 60 days Pediatric fever 61 to 90 days Pyloric stenosis

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp51

Immediate priorities

›Stabilization priorities

›Airway and breathing

›Apnea

›Respiratory distress

›Circulation

›Shock

›Poor perfusion

›Neurologic risk

›Acute bilirubin encephalopathy concern

›Lethargy

›Hypotonia or hypertonia

›High pitched cry

›Poor feeding

›Fever

›Arching or retrocollis

›Seizure

›Hyperbilirubinemia severity

›Age in hours

›Gestational age category

›Neurotoxicity risk factors

›TSB trajectory

›Rapid rise consistent with hemolysis

›Near exchange threshold

High risk triggers

›Escalation triggers

›Jaundice in first 24 hours

›Hemolysis evaluation priority

›Early phototherapy threshold assessment

›Any neuro signs

›NICU consult

›Exchange transfusion pathway activation

›TSB at or above exchange threshold

›Immediate exchange preparation

›Intensive phototherapy while preparing

›Conjugated hyperbilirubinemia

›Cholestasis workup pathway

›Urgent evaluation for biliary obstruction or infection

Bedside essentials

›Rapid bedside actions

›Confirm bilirubin type

›Total serum bilirubin preferred for decisions

›Direct or conjugated fraction if prolonged or ill

›Identify feeding status

›Breastfeeding adequacy

›Intake and output

›Temperature and glucose

›Hypothermia

›Hyperthermia

›Hypoglycemia

›Phototherapy readiness

›Intensive phototherapy capability

›Eye protection availability

›Irradiance measurement availability

02History/hx54

Core history elements

›Key history

›Age in hours at onset

›Jaundice before 24 hours

›Peak timing

›Gestational age and birth weight

›Late preterm 35 to 37 weeks

›Small for gestational age

›Feeding history

›Latch quality

›Frequency

›Milk transfer concern

›Supplementation

›Output history

›Wet diapers count

›Stool frequency and color

›Weight change

›Percent weight loss from birth

›Dehydration concern

›Maternal and infant blood groups

›ABO incompatibility risk

›Rh status

›Maternal antibodies history

›Family history

›G6PD deficiency

›Prior sibling requiring phototherapy

›Prior sibling exchange transfusion

›Birth trauma

›Cephalohematoma

›Significant bruising

›Infection risk

›Maternal fever

›Prolonged rupture of membranes

›Poor feeding with lethargy

›Medication and exposure history

›Maternal sulfonamides near delivery

›Naphthalene exposure

›Traditional remedies

Classic patterns and pitfalls

›Pattern recognition

›Physiologic jaundice pattern

›Onset after 24 hours

›Peak day 3 to 5 term

›Breastfeeding associated jaundice pattern

›Early onset with suboptimal intake

›Weight loss and low output

›Breast milk jaundice pattern

›Persistent unconjugated bilirubin after first week

›Well appearing infant

›Pathologic red flags

›Onset under 24 hours

›Rapid rise

›Ill appearance

›Pale stools

›Dark urine

›Hepatosplenomegaly

03Physical Exam/exam40

Focused exam

›Exam targets

›General appearance

›Toxic appearance

›Lethargy

›Irritability

›Vital signs

›Fever

›Hypothermia

›Tachycardia

›Hypotension

›Hydration status

›Mucous membranes

›Skin turgor

›Fontanelle

›Skin findings

›Jaundice extent

›Bruising

›Cephalohematoma

›Petechiae

›Neurologic tone and behavior

›Hypotonia

›Hypertonia

›Arching

›High pitched cry

›Suck quality

›Abdominal exam

›Hepatomegaly

›Splenomegaly

›Stool and urine cues

›Acholic stool history corroboration

›Dark urine concern

PITFALLS

›Common pitfalls

›Visual assessment alone

›Poor correlation with TSB

›Reduced accuracy in darker skin tones

›Under-recognition in early discharge

›Peak bilirubin after discharge common

›Missing conjugated hyperbilirubinemia

›Jaundice beyond 2 weeks

›Pale stools or dark urine

04Differential Diagnosis/ddx36

Unconjugated hyperbilirubinemia

›Causes of unconjugated hyperbilirubinemia

›Physiologic jaundice

›Increased bilirubin production

›Immature conjugation

›Hemolysis

›ABO incompatibility ICD-10 P55.1

›Rh isoimmunization ICD-10 P56.0

›Other red cell antibodies ICD-10 P55.8

›G6PD deficiency

›Hereditary spherocytosis

›Increased bilirubin load

›Cephalohematoma ICD-10 P12.0

›Extensive bruising ICD-10 P58.0

›Polycythemia ICD-10 P61.1

›Decreased intake

›Breastfeeding jaundice

›Dehydration and weight loss

›Endocrine or metabolic

›Congenital hypothyroidism

›Crigler Najjar syndrome

›Gilbert syndrome

›Infection

›Sepsis ICD-10 P36.x

›Urinary tract infection

Conjugated hyperbilirubinemia

›Causes of conjugated hyperbilirubinemia

›Biliary obstruction

›Biliary atresia ICD-10 Q44.2

›Choledochal cyst

›Hepatitis and infection

›Neonatal hepatitis

›TORCH infections

›Metabolic

›Alpha-1 antitrypsin deficiency

›Galactosemia

›Tyrosinemia

›Total parenteral nutrition associated cholestasis

05Laboratory Tests/lt56

Bilirubin and hemolysis panel

›Core labs

›Total serum bilirubin

›Decision standard for treatment thresholds

›Repeat interval based on proximity to threshold

›Direct or conjugated bilirubin

›Indications

›Prolonged jaundice

›Ill appearance

›Pale stools

›Dark urine

›Infant blood type and DAT

›Isoimmune hemolysis detection

›DAT negative hemolysis possibility

›Maternal blood type and antibody screen

›Rh and minor antigen risk

›Hemoglobin or hematocrit

›Hemolysis severity assessment

›Anemia detection

›Reticulocyte count

›Hemolysis marker

›Bone marrow response

›Peripheral smear

›Spherocytes

›Fragmentation

Additional labs by scenario

›Targeted labs

›G6PD level

›High risk ancestry or family history

›Unexplained rapid rise

›Poor response to phototherapy

›Serum albumin

›Lower binding capacity risk

›Neurotoxicity risk factor assessment

›Glucose

›Lethargy

›Poor feeding

›Sepsis evaluation labs

›Blood culture

›CBC with differential

›C reactive protein

›Thyroid screening review

›Persistent jaundice

›Liver panel for conjugated bilirubin

›ALT

›AST

›GGT

›INR

Interpretation pearls

›Interpretation

›Rapid bilirubin rise

›Hemolysis likelihood higher

›Shorter recheck intervals

›Direct bilirubin elevation

›Cholestasis workup required

›Phototherapy non-therapeutic for conjugated fraction

›DAT positive

›Increased risk of severe hyperbilirubinemia

›IVIG consideration when near exchange threshold

06Diagnostic Tests/dt41

Scoring Systems

›Risk stratification tools

›Hour specific bilirubin nomograms

›Predischarge TSB or TcB plotted by age in hours

›Risk zones for subsequent significant hyperbilirubinemia

›Delta to treatment threshold approach

›TSB difference from phototherapy threshold

›Follow-up timing based on proximity

›Neurotoxicity risk factor assessment

›Gestational age under 38 weeks

›Isoimmune hemolysis

›G6PD deficiency

›Sepsis

›Clinical instability

›Low albumin

MRI

›Neuroimaging

›Indications

›Suspected chronic bilirubin encephalopathy

›Persistent abnormal tone or movement disorder after neonatal period

›Typical findings

›Bilateral globus pallidus signal abnormalities

›Subthalamic nucleus involvement

›Limitations

›Early MRI false positives possible

›Imaging not required for acute treatment decisions

›CT role

›Routine use not indicated

›No role in bilirubin threshold decisions

›Alternative diagnosis pathways

›Intracranial hemorrhage concern

›Trauma concern

›Risks

›Ionizing radiation in neonate

Ultrasound

›Ultrasound applications

›Hepatobiliary ultrasound

›Conjugated hyperbilirubinemia evaluation

›Biliary tree abnormalities

›Cranial ultrasound

›Preterm with neurologic symptoms

›Hemorrhage screening pathway support

›Limitations

›Does not assess unconjugated bilirubin neurotoxicity risk directly

07Disposition/dispo23

Site of care

›Disposition decisions

›NICU level care

›Exchange transfusion indicated

›Acute bilirubin encephalopathy signs

›Rapid rise with hemolysis and near exchange threshold

›Inpatient ward

›Phototherapy requirement

›Significant feeding support needs

›Sepsis evaluation pending

›Outpatient management

›Below phototherapy threshold

›Well appearing

›Reliable follow-up within recommended interval

Follow-up timing

›Follow-up planning

›Timing based on age and bilirubin proximity to threshold

›Closer follow-up when TSB near phototherapy threshold

›Earlier repeat bilirubin when rapid rise suspected

›Feeding follow-up

›Lactation support appointment

›Weight check within 24 to 48 hours when weight loss concern

›Prolonged jaundice follow-up

›Direct bilirubin testing pathway

›Stool color monitoring pathway

08Treatment/t66

Phototherapy

›Phototherapy strategy

›Intensive phototherapy criteria

›TSB at or above treatment threshold for age and risk category

›Hemolysis with rapid rise

›Delivery optimization

›Maximal skin exposure

›High irradiance device

›Minimized time off lights

›Monitoring and response

›TSB reassessment interval

›Short intervals when near exchange threshold

›Longer intervals when falling and far from threshold

›Expected decline pattern

›Early decline within hours suggests adequate irradiance

›Poor response suggests hemolysis or inadequate intensity

›Supportive care during phototherapy

›Maintain normothermia

›Hydration and feeding support

›Eye protection and positioning

Exchange transfusion

›Exchange transfusion pathway

›Indications

›TSB at or above exchange threshold for age and risk category

›Acute bilirubin encephalopathy signs regardless of level

›Bridge measures while preparing

›Intensive phototherapy continued

›IV access readiness

›Glucose monitoring

›Procedure essentials

›Double volume exchange typical approach

›Blood product selection and crossmatch with maternal antibodies

›Calcium monitoring during exchange

›Complications monitoring

›Hypocalcemia

›Hypoglycemia

›Thrombocytopenia

›Arrhythmia

›Catheter complications

IVIG

›IVIG for isoimmune hemolysis

›Candidate profile

›DAT positive hemolysis

›Rising TSB despite intensive phototherapy

›Approaching exchange threshold

›Dosing

›IVIG 0.5 to 1 g per kg

›Infusion per institutional protocol

›Repeat dosing based on response and guideline pathway

›Risks and monitoring

›Volume overload

›Necrotizing enterocolitis signal concern in some reports

›Anaphylaxis rare

Feeding and supplementation

›Nutrition management

›Optimize breastfeeding

›Lactation consultation

›Feeding frequency support

›Supplementation indications

›Excessive weight loss

›Dehydration signs

›Inadequate intake with rising TSB

›IV fluids considerations

›Reserved for significant dehydration or inability to feed

›Not a substitute for phototherapy or exchange when indicated

Medication cautions

›Avoidance and safety

›Drugs that displace bilirubin from albumin

›Higher concern in preterm or ill neonate

›Ceftriaxone avoidance in hyperbilirubinemic neonate

›Bilirubin displacement risk

09Special Populations/sp29

Pregnancy

›Maternal factors affecting neonatal risk

›Maternal blood group and antibodies

›Rh negative with sensitization risk

›ABO incompatibility risk when mother O

›Diabetes in pregnancy

›Polycythemia risk

›Prematurity risk

›Delivery factors

›Assisted delivery with bruising risk

›Delayed cord clamping and bilirubin load context

Geriatric

›Applicability

›Not applicable

›Neonatal specific condition

›No geriatric modifications

›Systems note

›Ensure neonatal pathway selection in order sets

›Avoid adult jaundice protocols

Pediatrics

›Neonatal specific considerations

›Gestational age groups

›35 to 37 weeks higher neurotoxicity risk

›Under 35 weeks separate thresholds and NICU protocols

›Neurotoxicity risk factors

›Sepsis

›Hemolysis

›Clinical instability

›Low albumin

›Home phototherapy

›Selected low risk infants only

›Reliable follow-up and device quality assurance

10Background/b37

Epidemiology

›Frequency and burden

›Common neonatal condition

›Physiologic jaundice in many newborns

›Subset requiring phototherapy

›Peak timing

›Term peak commonly day 3 to 5

›Later peak in breast milk jaundice

›Major risk contributors

›Prematurity

›Hemolysis

›Exclusive breastfeeding with suboptimal intake

›Bruising and cephalohematoma

Pathophysiology

›Mechanisms

›Unconjugated bilirubin production

›High neonatal red cell turnover

›Shorter red cell lifespan

›Hepatic uptake and conjugation limits

›Immature UGT1A1 activity

›Reduced clearance early life

›Enterohepatic circulation

›Increased beta glucuronidase activity

›Delayed stooling increases reabsorption

›Neurotoxicity pathway

›Unbound bilirubin crossing blood brain barrier

›Basal ganglia and brainstem nuclei vulnerability

Therapeutic Considerations

›Rationale for therapies

›Phototherapy mechanism

›Converts bilirubin to water soluble isomers

›Enhances excretion without conjugation

›Exchange transfusion mechanism

›Removes bilirubin and sensitized red cells

›Provides albumin binding capacity

›IVIG mechanism in isoimmune disease

›Reduces hemolysis by blocking Fc receptors

›Guideline based thresholds

›Age in hours thresholding reduces overtreatment

›Lower thresholds with neurotoxicity risk factors

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions

›Feeding and hydration

›Feed at least 8 to 12 times per 24 hours if breastfeeding

›Monitor wet diapers

›Monitor stool frequency and color

›Follow-up plan

›Repeat bilirubin test at scheduled time

›Weight check appointment

›Lactation support contact

›Home safety with jaundice

›Avoid sun exposure as treatment substitute

›Maintain normal room temperature

›Return now warning signs

›Poor feeding

›Hard to wake or unusual sleepiness

›High pitched cry

›Stiffness or arching

›Fever

›Breathing problems

›Fewer wet diapers

›Pale or white stools

›Dark urine

›Jaundice spreading to legs or deepening quickly

12References/r48

Clinical guidelines and key sources

›Core references

›AAP Clinical Practice Guideline Revision 2022

›Title

›Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation

›Journal

›Pediatrics 2022;150(3):e2022058859

›DOI

›10.1542/peds.2022-058859

›Link

›https://publications.aap.org/pediatrics/article/150/3/e2022058859/

›Canadian Paediatric Society position statement 2025

›Title

›Guidelines for detection and management of hyperbilirubinemia in term and late preterm newborns 35 or more weeks gestation

›Date

›March 18, 2025

›Link

›https://cps.ca/en/documents/position/hyperbilirubinemia-newborns

›NICE Clinical Guideline CG98

›Title

›Jaundice in newborn babies under 28 days

›Link

›https://www.nice.org.uk/guidance/cg98

›Bhutani et al 1999 predischarge nomogram study

›Journal

›Pediatrics 1999

›PubMed

›9917432

›Link

›https://pubmed.ncbi.nlm.nih.gov/9917432/

›MRI of bilirubin encephalopathy review 2014

›Source

›Wisnowski et al

›Link

›https://pmc.ncbi.nlm.nih.gov/articles/PMC4250342/

Coding references

›Coding map

›ICD-10

›P59.9 Neonatal jaundice unspecified

›P55.1 ABO isoimmunization of newborn

›P56.0 Rh isoimmunization of newborn

›P57 Kernicterus

›Q44.2 Atresia of bile ducts

›SNOMED CT concepts

›Neonatal jaundice

›Hyperbilirubinemia

›Acute bilirubin encephalopathy

›Kernicterus

›Phototherapy

›Exchange transfusion

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