Originally published at Pediatric EM Morsels on July 1, 2011. Reposted with permission.

Follow Dr. Sean M. Fox on twitter @PedEMMorsels

Jaundice can be a normal part of the neonatal period (certainly both of my kids looked like the Yellow M&M for a short period in their beginnings); however, hyperbilirubinemia also generates the concern for the development of kernicterus (abnormal accumulation of unconjugated bilirubin in the brain).

Some Important Points to Keep in Mind:

  • Physiologic jaundice in healthy, full-term newborns typically develops during the 2nd – 3rd day of life.
  • Physiologic jaundice in healthy, full-term newborns typically resolves by the 5th or 6th day.
  • Premature neonates are at greater risk! Also, the nomogram only pertains to those greater than 35 weeks gestational age.
  • The nomogram is based on TOTAL bilirubin (not fractionated bilirubin).
  • Consider DDx:
    a. Conjugated – biliary atresia, hepatitis (HSV?), biliary cholestasis, alpha-1-antitrypsin deficiency
    b. Unconjugated – SEPSIS, ABO incompatibility, hereditary spherocytosis, Gilbert’s syndrome, Crigler-Najjar syndrome, glucose-6-phosphate deficiency, breastfeeding vs. breast-milk.

Evaluation (after you’ve determined there is hyperbilirubinemia):

  • Total and Fractionated Bilirubin
  • Blood Type with Rh factor
  • Coomb’s test
  • CBC w/ Diff
  • Reticulocyte count
  • Consider sepsis work-up as well. Remember that these neonates don’t do many things to show you that they are sick… hyperbilirubinemia may be the one red flag that they are able to raise.


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