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.