Neonatal jaundice

Red Flags

Acute bilirubin encephalopathy (lethargy, hypotonia, poor feeding, high-pitched cry, opisthotonos, seizure) — emergency exchange transfusion; intensive phototherapy concurrently^[1]
Jaundice <24 h of life or persisting >2 weeks (term) or >3 weeks (preterm) — investigate sepsis, haemolysis, hypothyroidism, biliary atresia (split bilirubin)^[1]
Direct bilirubin >20% of total or >2 mg/dL — investigate cholestasis (biliary atresia within 6 weeks for Kasai operability), TORCH, metabolic^[1]
Severe haemolysis (rising bilirubin >0.5 mg/dL/h or G6PD/Rh isoimmunisation) — escalate phototherapy and consider exchange transfusion^[1]

First-line treatment

Interventions

Promote exclusive breastfeeding with frequency support^[1]
8–12 feeds/day; weight loss <7%; avoid water and formula supplementation unless medical indication; lactation support; assess latch and hydration; jaundice often improves with adequate feeds
Phototherapy thresholds by hours of life and risk^[1]
Use AAP 2022 or NICE nomogram; LED phototherapy preferred over fluorescent; intensive (multiple devices, biliblanket) for rapidly rising or severe levels; eye protection, hydration, monitoring
Exchange transfusion thresholds^[1]
Above exchange line on nomogram, signs of bilirubin encephalopathy, or rapidly rising despite intensive phototherapy; perform at NICU; double-volume exchange; complications (catheter, electrolytes, NEC, infection)
Identify and treat underlying cause^[1]
Sepsis: antibiotic per neonatal infection pathway. Haemolysis: aetiology-specific. Hypothyroidism: levothyroxine. Biliary atresia: Kasai operation within 60 days for best outcome

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Intensive phototherapy (LED units)^[1]	Phototherapy	Not applicable	Wavelength 460–490 nm at irradiance ≥30 µW/cm²/nm; multiple devices for severe disease; eye protection and hydration	First-line treatment; lowers bilirubin via configurational and structural isomerisation; LED units cooler and more efficient than fluorescent; do not interrupt for routine cares unless feeding
Intravenous immunoglobulin (Rh or ABO incompatibility)^[1]	Polyclonal IgG	Not applicable	0.5–1 g/kg IV over 2 h; may repeat at 12 h	Rh or ABO isoimmunisation rising despite intensive phototherapy and approaching exchange threshold; reduces need for exchange transfusion
Exchange transfusion blood product^[1]	Reconstituted whole blood	Not applicable	Double-volume exchange (160 mL/kg) using O Rh-negative leukoreduced packed cells reconstituted with AB plasma to haematocrit ~50%	Performed at NICU via umbilical vein; aliquot exchanges over 1.5–2 h; calcium and electrolyte monitoring; post-procedure phototherapy
Phenobarbitone (selected familial)^[1]	Liver enzyme inducer	Not applicable	5 mg/kg PO/IV daily	Crigler-Najjar type II; rarely used in routine neonatal jaundice; under specialist supervision

Intensive phototherapy (LED units)^[1]

Phototherapy

Adult: Not applicable
Paediatric: Wavelength 460–490 nm at irradiance ≥30 µW/cm²/nm; multiple devices for severe disease; eye protection and hydration

First-line treatment; lowers bilirubin via configurational and structural isomerisation; LED units cooler and more efficient than fluorescent; do not interrupt for routine cares unless feeding

Intravenous immunoglobulin (Rh or ABO incompatibility)^[1]

Polyclonal IgG

Adult: Not applicable
Paediatric: 0.5–1 g/kg IV over 2 h; may repeat at 12 h

Rh or ABO isoimmunisation rising despite intensive phototherapy and approaching exchange threshold; reduces need for exchange transfusion

Exchange transfusion blood product^[1]

Reconstituted whole blood

Adult: Not applicable
Paediatric: Double-volume exchange (160 mL/kg) using O Rh-negative leukoreduced packed cells reconstituted with AB plasma to haematocrit ~50%

Performed at NICU via umbilical vein; aliquot exchanges over 1.5–2 h; calcium and electrolyte monitoring; post-procedure phototherapy

Phenobarbitone (selected familial)^[1]

Liver enzyme inducer

Adult: Not applicable
Paediatric: 5 mg/kg PO/IV daily

Crigler-Najjar type II; rarely used in routine neonatal jaundice; under specialist supervision

Safety-net

All babies should be checked for jaundice in the first 72 h of life — visual assessment in good light, with transcutaneous or serum bilirubin if any concern^[1]
Yellow staining persisting beyond 2 weeks, pale stools, or dark urine — same-day medical review (rule out biliary atresia and other cholestasis)^[1]
On phototherapy: feed often, ensure adequate hydration, eye protection in place, and stay during routine cares; bilirubin rebound is rare but occurs in some^[1]

Referral criteria

Severe hyperbilirubinaemia approaching exchange thresholdNICU with phototherapy and exchange transfusion capability^[1]
Prolonged jaundice >2 weeks (term) or >3 weeks (preterm)Paediatric outpatient with split bilirubin and aetiology workup^[1]
Conjugated hyperbilirubinaemia or pale stoolsPaediatric hepatology / surgery for biliary atresia workup before 60 days for Kasai^[1]
Acute bilirubin encephalopathy or kernicterusEmergency NICU and emergency exchange transfusion^[1]

Clinical summary

Detection, risk-stratified phototherapy, and exchange transfusion thresholds for hyperbilirubinaemia in term and late-preterm neonates.

References

1.MoHFW Standard Treatment Guideline — Management of Jaundice in Newborns (2021); AAP Clinical Practice Guideline on Hyperbilirubinemia (2022); NICE CG98 Neonatal Jaundice (2022)

Drug

Class

Adult

Paediatric

Notes

Intensive phototherapy (LED units)^[1]

Phototherapy

Not applicable

Wavelength 460–490 nm at irradiance ≥30 µW/cm²/nm; multiple devices for severe disease; eye protection and hydration

First-line treatment; lowers bilirubin via configurational and structural isomerisation; LED units cooler and more efficient than fluorescent; do not interrupt for routine cares unless feeding

Intravenous immunoglobulin (Rh or ABO incompatibility)^[1]

Polyclonal IgG

Not applicable

0.5–1 g/kg IV over 2 h; may repeat at 12 h

Rh or ABO isoimmunisation rising despite intensive phototherapy and approaching exchange threshold; reduces need for exchange transfusion

Exchange transfusion blood product^[1]

Reconstituted whole blood

Not applicable

Double-volume exchange (160 mL/kg) using O Rh-negative leukoreduced packed cells reconstituted with AB plasma to haematocrit ~50%

Performed at NICU via umbilical vein; aliquot exchanges over 1.5–2 h; calcium and electrolyte monitoring; post-procedure phototherapy

Phenobarbitone (selected familial)^[1]

Liver enzyme inducer

Not applicable

5 mg/kg PO/IV daily

Crigler-Najjar type II; rarely used in routine neonatal jaundice; under specialist supervision