How should jaundice be managed?

Management of Jaundice

Age-Based Immediate Triage

Jaundice management depends critically on patient age: neonates require hour-specific risk stratification with objective bilirubin measurement and phototherapy when indicated, while adults need systematic evaluation for hepatobiliary obstruction with ultrasound as first-line imaging.

Neonatal Jaundice (≤35 weeks gestation and term infants)

Jaundice appearing in the first 24 hours of life is always pathologic and demands immediate total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) measurement with urgent evaluation for hemolytic disease. 1 This presentation requires active investigation for isoimmune hemolytic disease, G6PD deficiency, sepsis, or significant bruising. 1

Monitoring Protocol

• All infants must be monitored for jaundice development at least every 8-12 hours, assessed whenever vital signs are measured. 2
• Visual estimation of bilirubin is dangerously unreliable, particularly in darkly pigmented infants—always obtain objective TSB or TcB measurements. 1
• Jaundice progresses cephalocaudally from face to trunk to extremities, but clinical assessment alone leads to errors. 2

Essential Laboratory Workup

• Obtain blood type and direct antibody test (Coombs' test) on infant's cord blood, particularly if mother is Rh-negative or blood group O. 1, 3
• All pregnant women should be tested for ABO and Rh(D) blood types with serum screen for unusual isoimmune antibodies. 2
• Complete blood count with peripheral smear and reticulocyte count should be performed to assess for hemolysis. 1, 3
• G6PD enzyme activity should be measured in any infant with jaundice of unknown cause, especially if bilirubin rises despite treatment or rises after initial decline. 3
• Total and direct/conjugated bilirubin levels must be measured and interpreted according to infant's age in hours using nomograms. 1

Treatment Decision-Making

Use hour-specific phototherapy nomograms with risk stratification to determine treatment thresholds. 3 Risk factors that lower treatment thresholds include: 1, 3

• Gestational age 35-37 weeks
• Hemolytic disease
• G6PD deficiency
• Sepsis
• Acidosis
• Albumin <3.0 g/dL

Do not treat 35-37 week gestation infants as full-term—they are four times more likely to have serum bilirubin >13 mg/dL than 40-week infants. 4

Phototherapy Implementation

• Intensive phototherapy should be initiated immediately if indicated, maximizing exposed skin surface area. 3
• Expected TSB decrease is >2 mg/dL within 4-6 hours if phototherapy is effective. 3
• TSB should be measured to verify efficacy after starting phototherapy, with timing guided by TSB trajectory and infant age. 3
• Phototherapy can be discontinued when TSB has declined 2-4 mg/dL below the hour-specific threshold at initiation. 3

Escalation Criteria

Escalate care immediately if TSB is at or within 0-2 mg/dL below exchange transfusion threshold, with provision of intravenous hydration and emergent intensive phototherapy. 3 TSB should be measured at least every 2 hours during escalation. 3

Breastfeeding Management

• Advise mothers to nurse at least 8-12 times per day for the first several days. 2
• Do not routinely supplement nondehydrated breastfed infants with water or dextrose water—this will not prevent hyperbilirubinemia or decrease TSB levels. 2
• Poor caloric intake and dehydration associated with inadequate breastfeeding may contribute to hyperbilirubinemia development. 2

Follow-Up Requirements

• Follow-up TSB should be measured within 1-2 days after phototherapy discontinuation for most infants, and within 8-12 hours for infants with gestational age <38 weeks, positive DAT, or suspected hemolytic disease. 3
• Infants discharged before 48 hours should be seen by a healthcare professional within 2-3 days of discharge. 4
• Do not send 35-week gestation infants home before 48 hours. 4

Prolonged Jaundice Evaluation

Sick infants and those jaundiced at or beyond 3 weeks should have measurement of total and direct or conjugated bilirubin to identify cholestasis. 2 Any infant still jaundiced beyond 3 weeks must have direct bilirubin measured. 4 Check for:

• Pale stools or dark urine suggesting cholestasis 4
• Normal newborn thyroid screen results (congenital hypothyroidism causes indirect hyperbilirubinemia) 4
• Urine dipstick for bile if direct hyperbilirubinemia present 4

Adult Jaundice

Initial Diagnostic Approach

Begin with liver chemistry tests including bilirubin (conjugated and unconjugated), alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and total protein. 5 Clinical jaundice occurs when serum bilirubin exceeds 2.5-3 mg/dL. 5

Imaging Strategy

• Abdominal ultrasound is the first-line imaging study for evaluating jaundice, with sensitivity 32-100% and specificity 71-97% for detecting biliary obstruction. 6
• CT abdomen with IV contrast or MRI abdomen with MRCP are equivalent alternatives for initial imaging when no predisposing conditions are known. 6
• Use caution when administering iodinated contrast in jaundiced patients due to increased risk of acute kidney injury. 6

Categorization by Mechanism

Organize differential diagnosis by: 7

• Prehepatic causes: Hemolysis and hematoma resorption (elevated unconjugated bilirubin)
• Intrahepatic causes: Alcohol, infectious hepatitis, drug reactions, autoimmune disorders (conjugated or unconjugated hyperbilirubinemia)
• Posthepatic causes: Gallstones, biliary tract infection, pancreatitis, malignancies (conjugated hyperbilirubinemia)

Treatment Based on Etiology

For choledocholithiasis (bile duct stones), endoscopic internal biliary catheter with removable plastic stent is the preferred initial therapeutic approach. 6 ERCP with sphincterotomy and stone extraction is the standard treatment. 6

For severe alcoholic hepatitis (Maddrey discriminant function >32 or MELD score >20), treat with methylprednisolone 32 mg daily if no contraindications exist. 6 Abstinence from alcohol is the cornerstone of treatment. 6

Critical Infection Screening

Patients with jaundice, particularly those with alcoholic hepatitis, should have cultures of blood, urine, and ascites (if present) to rule out bacterial infections. 6 Infection often precedes development of acute kidney injury and multi-organ failure, which carries high mortality. 6

Common Pitfalls to Avoid

• Never rely on visual estimation of jaundice severity—always obtain objective measurements. 1
• Never ignore jaundice in the first 24 hours of life—it is pathologic until proven otherwise. 4
• Never use inadequate "homeopathic doses" of phototherapy—provide therapeutic doses. 4
• Never ignore failure of response to phototherapy—consider unrecognized hemolytic process. 4
• Late-rising bilirubin is typical of G6PD deficiency—consider ethnic background (Greece, Turkey, Sardinia, Nigeria, Sephardic Jews from Iraq, Iran, Syria, Kurdistan). 4
• Document presence or absence of jaundice and severity, particularly if discharging early. 4