Doctors Revision

IMCI · Age: 0 - 2 months

Severe Jaundice

Classification for a young infant with jaundice appearing within the first 24 hours of life OR jaundice involving the palms and soles at any age. Indicates potentially dangerously high bilirubin levels requiring urgent investigation and treatment to prevent brain damage (kernicterus).

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Care priority and warning signs

Care priority

Refer URGENTLY

Red flags

  • Jaundice onset < 24 hours
  • Yellow palms and soles
  • Signs of acute bilirubin encephalopathy (lethargy, poor feeding, high-pitched cry, abnormal tone/movements, seizures)
  • Rapidly rising jaundice
  • Signs of hemolysis (pallor, splenomegaly)
  • Signs of PSBI/sepsis

Assessment

  • Ask: Is the infant jaundiced (yellow discoloration of skin/eyes)?
  • Ask: If yellow, when did the yellow appear first? (Within first 24 hours?)
  • Look/Feel: Look for yellowing of eyes or skin in natural light. Press skin over bony prominence (forehead, chest) to check for underlying yellow colour.
  • Look/Feel: Look specifically at the young infant's palms and soles. Are they yellow?
  • Assess for signs of PSBI/Very Severe Disease concurrently.

Classification

  • Any jaundice if age less than 24 hours OR Yellow palms and soles at any age -> SEVERE JAUNDICE

Key features

  • Jaundice appearing in the first 24 hours of life is ALWAYS pathological.
  • Jaundice extending to palms and soles indicates high bilirubin levels (Kramer stage 4-5).
  • Both signs suggest risk of bilirubin neurotoxicity (kernicterus).
  • Requires immediate referral for bilirubin level measurement and treatment (phototherapy/exchange transfusion).

Management

Non-pharmacological management

  • Ensure adequate feeding (breastfeeding) to promote bilirubin excretion.
  • Keep infant warm.
  • Minimize handling if showing signs of encephalopathy.

Pre-referral treatment

  • Treat to prevent low blood sugar (Hypoglycemia): Encourage breastfeeding. Give EBM if needed.
  • Treat any co-existing PSBI/VSD with pre-referral antibiotics (Gentamicin+Ampicillin - Page 40).
  • Keep infant warm during transport (Page 40).

Follow-up

  • To be managed at referral hospital facility (bilirubin measurement, phototherapy, possible exchange transfusion, investigation of cause).

Counselling points

  • Explain that the yellow color appeared very early OR is very deep (reaching palms/soles) and this can be dangerous for the baby's brain, requiring urgent hospital care.
  • Advise frequent breastfeeding.
  • Explain how to keep the infant warm during transport.
  • Write a detailed referral note indicating severe jaundice (onset time, palms/soles affected) and any associated findings/treatments.

Differential diagnosis

  • Jaundice (Non-Severe / Physiological)
  • Causes of severe jaundice: ABO/Rh incompatibility (hemolysis), G6PD deficiency, Sepsis, Cephalhematoma/bruising, Congenital hypothyroidism, Crigler-Najjar syndrome, Gilbert's syndrome (less severe), Breast milk jaundice (usually later onset, prolonged), Biliary atresia (presents later with pale stools/dark urine)

Complications

  • Acute Bilirubin Encephalopathy
  • Kernicterus (Chronic Bilirubin Encephalopathy - leading to cerebral palsy, hearing loss, dental dysplasia)
  • Hearing impairment
  • Sepsis (if underlying cause)
  • Death

Prevention

  • Maternal blood group screening (ABO/Rh) during pregnancy.
  • Rh D immunoglobulin for Rh-negative mothers.
  • Early and frequent breastfeeding.
  • Adequate hydration.
  • Early detection and monitoring of jaundice in newborns.
  • G6PD screening in relevant populations.

References

IMCI Chart Booklet - Page 34, Page 40 (Pre-referral)

For learning and professional reference. Use current local guidance and clinical judgement.

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