Symptoms, Pathology & Treatment of Jaundice in the New Born

Jaundice occurring in the newborn is referred to as neonatal jaundice. It is quite common, usually harmless and resolves in two weeks (physiological jaundice). If it is severe and prolonged, it may be pathological, requiring further investigations to find the cause.
It is characterised by yellowish discoloration of the skin and eyes due to accumulation of a toxic pigment called bilirubin in the blood. Jaundice per se is not a disease but a symptom that may signify an underlying disease.
Approximately 60% of term babies and 80% of preterm babies develop jaundice.
Bilirubin Formation and Excretion
One of the important sources of bilirubin in the body is when red cells are broken down due to aging of the cells when they are replaced by new red cells from the bone marrow. The bilirubin from red cell breakdown is processed in the liver and excreted from the body.

Physiological Jaundice
•The most common cause of neonatal jaundice is physiological jaundice.
•This occurs because newborns have more red cells than adults and hence more is broken down.
•Additionally the newborn liver is immature and unable to handle the increased amounts of bilirubin being formed.
•This results in accumulation of bilirubin in the blood with symptoms of jaundice.

The physiological jaundice described above usually presents between day 2 – 4 after birth, peaks at one week and gradually resolves spontaneously in about two weeks.

Pathological Jaundice
In some cases however, jaundice is caused due to some serious underlying disease of the blood or liver. This is termed pathological jaundice. It is important to recognise and treat pathological jaundice in the neonate promptly because high bilirubin levels in the bloodstream (hyperbilirubinemia) can result in deposition of bilurubin in the brain with serious consequences.

Causes of Pathological Jaundice

  • ABO or Rh incompatibility between mother’s and baby’s blood group – (Increased Red cell destruction)
  • Inherited disorders of the red cell – (Increased Red cell break down)
  • Neonatal infections – Toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex, syphilis. These are referred to as TORCHS complex and should be ruled out
  • Inherited disorders of bilirubin metabolism – Criggler Najjar syndrome, Dubin Johnson syndrome, Gilbert syndrome
  • Other uncommon causes include diseases of the biliary system eg biliary atresia and certain inherited metabolic diseases

Features of Pathological Jaundice

  • It appears on the first day of life itself
  • Bilirubin levels in the blood may be very high with severe jaundice
  • Baby is ill and does not feed well and appears irritable
  • Jaundice is still present even after two weeks (prolonged jaundice); the baby passes pale chalky appearing stools (due to absence of bilirubin in the stool) and dark colored urine (due to increased bilirubin pigment)
  • Enlarged liver and spleen, small head size (microcephaly) seen in some congenital infections

Risk factors of developing Neonatal jaundice

  • Preterm or low birth weight babies
  • Male babies
  • East Asian ancestry
  • Breastfed babies
  • Sibling who had neonatal jaundice
  • Babies born to diabetic mothers
  • Populations living at high altitudes

Diagnosing Neonatal Jaundice
Neonatal jaundice is usually evident on physical examination. However, it may be difficult to discern on darker skin and when there is an index of suspicion, a blood test is done to measure bilirubin levels.
Some centres initially measure bilirubin using a device that measures bilirubin levels through the skin (transcutaneous screening). When the bilirubin value on transcutaneous measurement exceeds a certain value (250 micromol/L), blood testing may be done to measure bilirubin levels and confirm the diagnosis.
Tests to determine the cause of pathological jaundice
Once the diagnosis of pathological neonatal jaundice is established, other tests may be required to determine the cause of hyperbilirubinemia.

Other Tests

  • Liver function tests – to rule out primary liver disease
  • Urine culture and sensitivity – to rule urinary tract infection (UTI)
  • Neonatal infection screen (TORCH screen) – It is mandatory to do a TORCH screen
  • Tests to determine presence of increased fetal red cell break down and find the cause
  • Thyroid function tests – to test for congenital hypothyroidism
  • Imaging studies – ultrasound abdomen, specialized imaging to look for liver and biliary pathology
  • Liver biopsy – rarely, a liver biopsy may be needed if other tests prove non-diagnostic
  • Treatment of Neonatal jaundice

Physiological jaundice presenting a few days after birth has to be monitored by measuring serum bilirubin regularly and if it is not severe and gradually resolves over the next few days it may not need any treatment.

Treatment of pathological neonatal jaundice depends on the following:

  • Rate at which bilirubin levels are rising
  • Presentation of jaundice within 24 hours of birth
  • Whether baby is preterm: preterm babies are unable to tolerate high bilirubin levels well
  • General condition of the baby

The Treatment Modalities:


  • Phototherapy should be urgently begun if bilirubin levels are rapidly rising in the baby. It involves placing the baby under the light source with as much of the skin exposed as possible (the eyes should be protected with pads).
  • The light waves are absorbed by the skin and convert the bilirubin into a harmless substance which is then excreted.

Exchange transfusion

In exchange transfusion, a part of the baby’s blood is removed and replaced with matching blood transfusion. Bilirubin levels above a certain threshold level necessitates exchange transfusion. This is essential to prevent adverse effects of bilirubin toxicity on the brain.

  • Treatment of the cause
  • Antibiotics to treat UTI
  • Thyroid replacement in congenital hypothyroidism
  • Biliary system disease may require surgery within two months for a better outcome

This article was contributed by Lakshmi Venkataraman. MD Pathology