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Pediatrics & Child Health

Neonatal Jaundice (IMNCI 0-2m Approach)

Yellow discoloration of the skin and sclera in a newborn due to elevated bilirubin levels. Requires assessment to differentiate physiological from pathological jaundice and identify infants needing urgent treatment to prevent kernicterus.

Also known as: Newborn Jaundice, Hyperbilirubinemia

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Referral and warning signs

When to refer

Urgent Referral to Hospital: Any jaundice appearing <24 hours of age. Jaundice involving palms and soles. Any jaundiced infant with danger signs (poor feeding, lethargy, fever, convulsions). Jaundice persisting >14 days (term) or >21 days (preterm).

Red flags

  • Jaundice onset <24 hours.
  • Jaundice extending to palms/soles.
  • Signs of bilirubin encephalopathy (lethargy, high-pitched cry, poor feeding, abnormal tone/movements).
  • Any associated danger sign (fever, sepsis signs).

Signs and symptoms

  • Yellow discoloration of skin and/or eyes (sclera).
  • Assess extent: Face only? Chest/abdomen? Palms and soles?
  • Assess timing: Onset <24 hours of age? Onset after 24 hours?
  • Associated symptoms: Poor feeding, lethargy, irritability, high-pitched cry, fever/hypothermia, abnormal movements (signs of bilirubin encephalopathy).

Risk factors

  • Prematurity.
  • ABO/Rh incompatibility.
  • G6PD deficiency.
  • Sepsis.
  • Cephalohaematoma / Bruising.
  • Exclusive breastfeeding with poor intake/weight loss.
  • Previous sibling with severe jaundice.
  • East Asian ethnicity.

Diagnosis

Clinical assessment

Visual inspection for jaundice and assessment of extent (cephalocaudal progression). Check timing of onset. Assess for danger signs (lethargy, poor feeding). Check palms and soles - yellow discoloration here indicates high levels.

Investigations

  • Transcutaneous Bilirubinometry (TcB) - screening tool if available.
  • Serum Bilirubin (Total and Direct/Conjugated) - required for diagnosis and management decisions.
  • Blood group (mother and baby), Direct Antiglobulin Test (DAT/Coomb's test) - if haemolysis suspected.
  • Full Blood Count (FBC), Reticulocyte count - assess anaemia/haemolysis.
  • G6PD screen (if relevant ethnicity/family history).
  • Sepsis screen (if suspected).

Diagnostic criteria

Based on IMNCI visual assessment for referral: Severe Jaundice: Any jaundice if age <24 hours OR Yellow palms and soles at any age. Jaundice: Jaundice appearing after 24 hours AND palms/soles NOT yellow.

Management

Non-pharmacological management

  • Severe Jaundice:
  • - Prevent low blood sugar (encourage breastfeeding/EBM/sugar water).
  • - Keep baby warm.
  • - Urgent Referral to Hospital for bilirubin level check and phototherapy +/- exchange transfusion.
  • Jaundice (Non-Severe):
  • - Encourage frequent breastfeeding (8-12 times/day) to promote bilirubin excretion.
  • - Advise mother on home care and danger signs.
  • - Follow up in 1 day to reassess extent.
  • - If jaundice persists >14 days (term) or >21 days (preterm), refer for investigation (possible cholestasis).

Pharmacological treatment

  • Hospital Level Treatment:
  • - Phototherapy (Blue light): Treatment threshold based on age, gestation, bilirubin level, risk factors.
  • - Exchange Transfusion: For very high bilirubin levels or signs of acute bilirubin encephalopathy.

Monitoring

Daily follow-up for non-severe jaundice until resolving. Close monitoring under phototherapy (bilirubin levels, hydration, temperature).

Complications

  • Acute Bilirubin Encephalopathy (lethargy, poor feeding, high-pitched cry, opisthotonus, seizures).
  • Kernicterus (Chronic Bilirubin Encephalopathy - irreversible neurological damage: cerebral palsy, hearing loss, dental dysplasia).

Prevention

  • Adequate feeding support (especially breastfeeding) to prevent dehydration/caloric deprivation.
  • Antenatal screening for blood group/Rh incompatibility.
  • Early recognition and monitoring of jaundice.

Patient education

  • Explain jaundice and differentiate mild vs severe.
  • Importance of frequent feeding.
  • How to visually assess jaundice extent (incl. palms/soles).
  • Danger signs associated with severe jaundice needing immediate care.
  • Importance of follow-up appointments.
  • Avoid sun exposure as treatment (ineffective and risky).

Uganda-specific notes

Visual assessment is primary at lower levels. Haemolysis due to ABO/Rh incompatibility and G6PD deficiency are relevant causes. Access to bilirubin testing and effective phototherapy is often limited to hospitals. Educating mothers on danger signs and need for referral is critical.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17, Section 17.2.2

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