Neonatal Jaundice ★

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Pathologic jaundice of the newborn is jaundice which either during the first day of life, has total bilirubin >12, direct bilirubin >2, or shows rate or rise of >5/day.

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Type of Jaundice	Onset & Duration	Type of Bilirubin	Key Features	Board Clues / Buzzwords
Physiologic Jaundice	Appears after 24 h
Peaks 3–5 days (term)
Resolves by \~1 week	Unconjugated	No symptoms, well baby, resolves spontaneously	Term baby, jaundice >24h, no other findings
Pathologic Jaundice	Appears <24 h OR very high OR prolonged (>1 wk)	Usually unconjugated	May be due to hemolysis, sepsis, G6PD, ABO/Rh	Early onset (<24 h), fast rise >5 mg/dL/day, lasts >2 weeks
Breastfeeding Jaundice
”not breastfeeding enough”	Early onset (1st week)	Unconjugated	Due to poor intake, dehydration	Weight loss, ↓ output, improves with better feeding
Breast Milk Jaundice
”enzyme in the milk”	Peaks at 7–10 days
May persist weeks	Unconjugated	Due to substances in milk inhibiting conjugation	Otherwise well, persists longer but benign
Hemolytic Jaundice (ABO, Rh)	<24 h onset, rapid rise	Unconjugated	Anemia, retics ↑, positive Coombs test	Early jaundice + anemia + hepatosplenomegaly
G6PD Deficiency	<24–48 h onset, acute	Unconjugated	Anemia, ↑ retics, Coombs negative, FHx	Male, Mediterranean/Asian, triggers (e.g., fava beans)
Infection (Sepsis)	Variable (early/late)	Unconjugated or mixed	Sick baby: fever, poor feeding	Fever + jaundice + poor feeding → always suspect sepsis
Crigler-Najjar Syndrome	Early onset, persistent	Severe unconjugated	Genetic UGT deficiency (Type I = severe, Type II = milder)	Very high bili, normal LFTs, no hemolysis
Biliary Atresia	Appears after 2 weeks	Conjugated (direct)	Pale stools, dark urine, hepatomegaly	Conjugated jaundice + clay stools + firm liver
Neonatal Hepatitis	After 1–2 weeks	Conjugated	Hepatomegaly, poor growth, dark urine	Viral infections common (CMV, hepatitis viruses)

Benign Neonatal Hyperbilirubinemia

ABO incompatibility

Rh incompatibility

Inherited Hyperbilirubinemia (Gilbert, Crigler-Najjar, Rotor, Dubin-Johnson Syndromes)

Biliary Atresia

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ABO incompatibility
- Neonatal anemia
- Hepatosplenomegaly
- Neonatal jaundice
- Usually present at birth or manifests within the first 24 hours of life
- In Rh incompatibility, unconjugated bilirubin levels may be dangerously high, causing kernicterus.
- Hypoxia
- Prematurity
- Scattered petechiae (rare but associated with poor prognosis)
Medscape: G6PD deficiency is one of the major risk factors for severe neonatal jaundice. Jaundice most often appears within the first 24 hours of life, usually earlier than physiologic jaundice but later than jaundice seen in blood group alloimmunization.
UTD: Unlike neonatal jaundice seen in hemolytic disease of the fetus and newborn (HDFN), G6PD-deficiency-related jaundice is rarely present at birth; the peak incidence of jaundice onset is two to three days after birth.
- Jaundice is more prominent than anemia, which is rarely severe.
Neonatal jaundice - Hereditary spherocytosis (HS) may present in the neonatal period with jaundice and hyperbilirubinemia, and the serum bilirubin level may not peak until several days after birth. Some experts have proposed that HS is underdiagnosed as a cause of neonatal jaundice. A requirement for phototherapy and/or exchange transfusion during this period is common.
Biliary atresia
- Jaundice – conjugated hyperbilirubinemia
  - Prolonged neonatal jaundice (> 2 weeks)
  - Onset 2 weeks after birth is possible.
  - Acholic stools, dark urine
  - Hepatomegaly
- Direct cholestasis defined as direct billurubin more than 20% of total billurubin or direct billurbim more than 2 mg/dL

Hyperbilrubinemia

Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.