Jaundice that appears in a newborn <24 hour old is most likely nonphysiologic and needs further evaluation.
Jaundice typically presents on the 2nd-3rd day of life. It is usually first seen on the face and forehead then progresses caudally to the trunk and extremities.
Visible jaundice in the feet may be an indication to check bilirubin level.
Visual estimation of bilirubin level is often inaccurate and unreliable.
Danger signs in a newborn infant with jaundice includes changes in brainstem evoked auditory potentials, changes in muscle tone, seizures and altered cry characteristics.
The presence of any of the danger signs require prompt attention to prevent kernicterus.


  • Jaundice that appears in a newborn <24 hour old is most likely nonphysiologic & needs further evaluation
    • Visible jaundice in the feet may be an indication to check bilirubin level
  • Visual estimation of bilirubin level is often inaccurate & unreliable

Laboratory Tests

Transcutaneous Bilirubinometry (TcB)

  • A noninvasive way to measure serum bilirubin using handheld devices
  • May be used as an initial screening test to detect possible development of hyperbilirubinemia
  • Said to be equivalent to total serum bilirubin & may decrease the need for more invasive TSB measurements; however, more studies may be needed to validate tests that measure TcB

Total Serum Bilirubin (TSB)

  • Measured if jaundice appears excessive for an infant’s age, when TcB level is >200 µmol/L (12 mg/dL), or if there is any doubt about the degree of jaundice
  • Often the only test needed for infants who present with moderate jaundice on the 2nd or 3rd day of life & who do not have features suggesting pathologic jaundice

Lab tests for determining cause of jaundice

  • Lab tests that will be requested will depend on the indications found in an infant
  • Hematology: Hemoglobin & hematocrit, direct Coomb’s test, peripheral blood film, reticulocyte count, blood type & Rh determination in infant & mother
  • Screening for G6PD deficiency in infants from high-risk populations
  • Total & conjugated bilirubin to identify cholestasis
  • Liver function tests: ALT, AST, GGT, alkaline phosphatase
    • A GGT/ALT ratio >1 is highly suggestive of biliary obstruction
  • Sepsis evaluation in infants who appear ill
    • Urinalysis, urine culture
    • Tests for parasitic & viral infections
  • Measurement of end tidal carbon dioxide in breath as an index of bilirubin production
  • Serum albumin to help evaluate risk of bilirubin toxicity
  • Thyroid function tests
  • Imaging of the liver & biliary tract including ultrasonography & radionuclide imaging


Clinical Assessment of Severity

  • Jaundice appears in a cephalo-caudal direction
  • For clinical assessment, the Kramer’s Rule may be used to estimate the range of indirect bilirubin levels
  • Area


    Indirect Bilirubin



    Head & neck




    Upper trunk




    Lower trunk & thighs




    Arms & lower legs




    Palms & soles




Source: Ministry of Health Malaysia. Clinical practice guidelines: management of neonatal jaundice (second edition). 2015.
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