How can I differentiate between physiological and pathological jaundice in neonates?

To differentiate between physiological and pathological jaundice in neonates, consider the timing of onset, duration, associated symptoms, and specific risk factors ¹. Physiological and breast milk jaundice are common, usually transient and harmless, and typically appear within the first week of life ¹,². Breastfeeding can usually continue with physiological jaundice ¹,². Indicators suggesting pathological jaundice include:

• Early Onset: Jaundice appearing within the first 24 hours of birth ¹,².
• Late Onset: Jaundice first appearing after 7 days of age ¹.
• Prolonged Duration: Jaundice lasting more than 14 days in babies with a gestational age of 37 weeks or more, or more than 21 days in babies with a gestational age of less than 37 weeks ¹.
• Gestational Age: Babies born at less than 35 weeks gestational age are more vulnerable and require referral for serum bilirubin assessment ¹,².
• General Unwellness: Signs such as lethargy, fever, vomiting, significant weight loss, or irritability ¹.
• Feeding Problems: Poor feeding and concerns about weight, particularly in breastfed infants, as inadequate intake can exacerbate jaundice ¹.
• Stool and Urine Changes: Pale stools and dark urine, which can indicate liver disease ¹.
• Signs of Bilirubin Encephalopathy: Features like atypical sleepiness, poor feeding, irritability, vomiting, hypotonia followed by hypertonia ¹.
• Rapidly Rising Bilirubin: A bilirubin level increasing by more than 8.5 micromol/litre per hour ².
• High Bilirubin Levels: A serum bilirubin level greater than 340 micromol/litre in babies with a gestational age of 37 weeks or more ².
• Family History: A previous sibling who required phototherapy for neonatal jaundice ².

It is important to note that visual assessment alone is not a reliable indicator of bilirubin level and should not be used to estimate the severity of jaundice ¹,². Bilirubin levels should be measured, with serum bilirubin measurement used for babies in the first 24 hours of life or those with a gestational age of less than 35 weeks ².