Poor caloric intake and/or dehydration may contribute to the development of
hyperbilirubinemia. Increasing the frequency of nursing may decrease the likelihood of
hyperbilirubinemia in breastfed infants.
Jaundice should be assessed whenever vital signs are checked but at least every 8- 12
hours. Jaundice is usually seen in the face first and progresses caudally, but visual
estimation can lead to errors. A serum or transcutaneous bilirubin level should be
checked in every infant who is jaundiced within the first 24 hours of life, or if there is any
doubt about the degree of jaundice in any infant. All bilirubin levels should be
interpreted according to the infant’s age in hours using the nomogram. The cause of
jaundice should be investigated in any infant receiving phototherapy or if the level is
rising rapidly (crossing percentiles on the nomogram).
Infants with an elevated direct reacting bilirubin (conjugated) should have a urinalysis
and urine culture. Sepsis work up should be done if the history or exam indicates. Sick
infants or those jaundiced beyond 3 weeks should have a total and direct bilirubin level
checked to identify cholestasis. Results of the newborn screen should be checked for
thyroid abnormalities and galactosemia. G6PD levels should be checked on any infant
receiving phototherapy or if the response to phototherapy is poor (G6PD deficiency is
common in certain ethnic groups).