Is yellowish discoloration of light skin without scleral icterus in a previously healthy 2-month-old infant a concern for neonatal jaundice?

From the Guidelines

Yes, yellowish discoloration of light skin without scleral icterus in a previously healthy 2-month-old infant is a concern for neonatal jaundice and warrants medical evaluation. While physiologic jaundice typically resolves within the first 2 weeks of life, jaundice persisting or appearing at 2 months suggests pathologic causes that require investigation, as indicated by the American Academy of Pediatrics guidelines 1. Even without yellowing of the eye whites (scleral icterus), skin yellowing alone can indicate elevated bilirubin levels. Parents should seek prompt medical attention for their infant, as potential causes include breast milk jaundice, liver dysfunction, blood disorders, or metabolic conditions.

Key Considerations

• The pediatrician will likely order blood tests to measure bilirubin levels and possibly other liver function tests, as recommended by the guidelines for the management of hyperbilirubinemia in newborn infants 35 or more weeks of gestation 2.
• They may also examine the baby for other symptoms like dark urine, pale stools, poor feeding, or lethargy.
• Early detection is important because high bilirubin levels can lead to kernicterus, a form of brain damage, if left untreated.
• Treatment depends on the underlying cause but may include more frequent feeding, phototherapy, or addressing specific medical conditions, with phototherapy being a safe and effective intervention for severe hyperbilirubinemia, as supported by recent technical reports 3, 4.

Phototherapy Considerations

• Phototherapy is prescribed for treating neonatal hyperbilirubinemia and is performed by exposing newborn infants to light in the blue-green wavelength range, preferably at an optimal peak of 478 nm and at an irradiance of 25 to 35 mW/cm2/nm to at least 1 surface of the body 4.
• The use of phototherapy has been associated with a small risk of subsequent epilepsy, but the evidence is not conclusive, and the benefits of phototherapy in preventing severe hyperbilirubinemia outweigh the potential risks 3.

Conclusion Not Applicable

Instead, the focus is on the immediate need for medical evaluation and potential treatment to prevent long-term complications associated with neonatal jaundice.

From the Research

Definition and Causes of Jaundice

• Jaundice is caused by an accumulation of bilirubin in the blood, and its presentation in infants and children can be indicative of a wide range of conditions, with some self-limiting and others potentially life-threatening 5.
• Neonatal jaundice is the yellowish discoloration of the skin and/or sclerae of newborn infants caused by tissue deposition of bilirubin, and physiological jaundice is mild, unconjugated (indirect-reacting) bilirubinaemia, affecting nearly all newborns 6.

Clinical Features and Diagnosis

• The clinical features of jaundice manifest through yellow skin and sclera coloration, and evaluation of every patient includes detailed medical history and examination 7.
• In the laboratory, evaluation of enzymes of hepatic inflammation as well as cholestatic enzymes with serum bilirubin must be included, and additional laboratory analysis and imaging modalities are needed to differentiate jaundice etiology 7.
• The age at onset of jaundice, the level of gamma-glutamyl transpeptidase (γ-GT), and the liver length below the ribs may be helpful in the differential diagnosis of jaundice in infants 8.

Management and Treatment

• Standard recommendations for evaluating and treating jaundice in term babies include following all babies closely for jaundice, obtaining several laboratory tests in those with early jaundice or bilirubin levels more than 12 to 13 mg/dL, using phototherapy to try to keep bilirubin levels below 20 mg/dL, and doing exchange transfusions if phototherapy fails, regardless of the cause of the jaundice 9.
• However, these recommendations are likely to lead to unnecessary testing and treatment of many jaundiced term infants, and a less aggressive approach may be justified, with treatment deferred to relatively high levels of serum bilirubin 9.

Specific Considerations for the Given Scenario

• Yellowish discoloration of light skin without scleral icterus in a previously healthy 2-month-old infant may still be a concern for neonatal jaundice, as physiological jaundice levels typically peak at 5 to 6 mg/dL at 72 to 96 hours of age, and do not exceed 17 to 18 mg/dL, but higher levels of unconjugated hyperbilirubinaemia are considered pathological and occur in a variety of conditions 6.
• The absence of scleral icterus does not rule out the possibility of jaundice, and further evaluation, including laboratory tests and imaging modalities, may be necessary to determine the underlying cause of the jaundice 7, 8.