¹ Universidade Federal Fluminense, Niterói-RJ; Centro Universitário Souza Marques, Rio de Janeiro-RJ, Brazil. ORCID: https://orcid.org/0000-0001-8269-9633

Neonatal jaundice is the leading cause of readmission to the hospital for newborns (NBs) after discharge from the maternity ward, keeping pediatricians and neonatologists on alert.¹

In the first days of life, indirect bilirubin physiologically acts as an antioxidant; its presence is secondary to hepatic immaturity, associated with a higher red blood cell mass and a shorter half-life of red blood cells. However, elevated indirect bilirubin can cause serious, irreversible damage to the central nervous system because the blood-brain barrier is immature in newborns.¹

Early in my career as a faculty member and clinician in Neonatology, it was common to observe, during autopsies, yellowish staining of the brain’s gray matter caused by bilirubin - kernicterus, a histopathological lesion of the basal ganglia resulting from bilirubin-induced encephalopathy.¹ This observation motivated my master’s (1993) and doctoral (2010) research, a continuous search for evidence to improve pediatric decision-making in the first days of life.

Over the years, the concept, diagnosis, and treatment of hyperbilirubinemia and its complications have evolved.² In this context, current guidelines distinguish between two breastfeeding-related conditions: jaundice due to insufficient milk intake (manifesting in the first days of life, due to low milk supply, dehydration, and weight loss exceeding 7 to 10%) and breast milk jaundice (with a later onset and prolonged course). ³

Another development over the years concerns the nomenclature and diagnosis of kernicterus. Now referred to as the kernicterus spectrum disorder (KSD), it ranges from bilirubin-induced neurological dysfunction (BIND) and isolated auditory neuropathy to the classic form with choreoathetosis and sensorineural hearing loss. Diagnosis no longer relies on autopsy and now combines brain magnetic resonance imaging (MRI) showing hyperintensity in the globus pallidus and subthalamic nuclei, brainstem auditory evoked potentials (BAEP), and validated clinical scales, such as the BIND-M.³^,⁴

The diagnostic approach and risk stratification have also been revised. Visual estimation based on the Kramer zones is imprecise and fails critically in dark-skinned newborns or those from ethnic minority groups, delaying diagnosis and perpetuating health disparities. For this reason, objective quantitative measurement via transcutaneous bilirubinometry or serum total bilirubin assay is recommended³^,⁵.

The original article, published in this issue by Hespanha et al., highlights the use of transcutaneous bilirubin assessment as a screening method and reinforces the low sensitivity of visual assessment based on Kramer zones⁶.

From a therapeutic standpoint, Bhutani’s single nomogram has been replaced by dynamic phototherapy and exchange transfusion curves stratified by gestational age. Risk factors for neurotoxicity have also been identified: gestational age less than 38 weeks, serum albumin less than 3.0 g/dL, isoimmune hemolytic disease, G6PD deficiency, sepsis, and clinical instability within the past 24 hours. The presence of these factors shifts the therapeutic threshold to lower levels.^3,5

Knowledge of the pathophysiology and causes of hyperbilirubinemia, along with a detailed medical history and physical examination, remains essential for early diagnosis, proper monitoring, and appropriate treatment, forming the most effective pillars for protecting newborns.

I conclude this editorial with a list of essential competencies for managing a jaundiced newborn.^7,8

1.      Proper analysis of the etiopathogenesis of indirect hyperbilirubinemia.

2.      Measure bilirubin levels, given the low accuracy of visual assessment for jaundice.

3.      Analyze bilirubin levels in relation to weight, gestational age, and hours of life.

4.      Consider clinical risk indicators, such as weak sucking, lethargy, and weight loss.

5.      Exploratory laboratory workup to monitor non-physiological jaundice.

6.      Management of a term or near-term newborn, 48 hours old, with jaundice due to indirect hyperbilirubinemia - watchful waiting, phototherapy, or discharge?

7.      Diagnostic evaluation during the outpatient follow-up of a jaundiced newborn at discharge.

I would like to express my special thanks to the editor-in-chief of the SOPERJ Journal of Pediatrics, Dr. Fernanda Pinto Mariz, for the opportunity to revisit the management of beings as immature and vulnerable as our newborns.

 

ReferENCES

 

1.      Bhutani VK, Johnson LH, Jeffrey Maisels M, Newman TB, Phibbs C, Stark AR, Yeargin-Allsopp M. Kernicterus: epidemiological strategies for its prevention through systems-based approaches. J Perinatol. 2004 Oct;24(10):650-62. doi: 10.1038/sj.jp.7211152. PMID: 15254556Review.

2.      Daggle L, Sharma N, Setiady I, Leonard K. Management of Neonatal Hyperbilirubinemia: Shedding Light on the American Academy of Pediatrics 2022 Clinical Practice Guideline Revision. Pediatr Ann. 2024 Jun;53(6):e208-e216. doi: 10.3928/19382359-20240407-02. 

3.      Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs SM, et al. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859.

4.      Le Pichon JB, Riordan SM, Watchko J, Shapiro SM. The Neurological Sequelae of Neonatal Hyperbilirubinemia: Definitions, Diagnosis and Treatment of the Kernicterus Spectrum Disorders (KSDs). Curr Pediatr Rev. 2017;13(3):199-209. PMID: 28814249.

5.      Bhutani VK, Johnson L, Sivieri EM. Predischarge screening for severe neonatal hyperbilirubinemia to prevent chronic bilirubin encephalopathy. Pediatrics. 1999;103(1):6-14. PMID: 9917432.

6.      Hespanha MD, SantosBM, Nieto MLS, Silva RPGVC, Silva FS. Comparação entre avaliação visual de icterícia, bilirrubina transcutânea e bilirrubina sérica total em recém-nascidos a termo saudáveis com necessidade de fototerapia. Rev. Pediatr. SOPERJ. 2026 jul; e20260417. https://revistadepediatriasoperj.org.br/rps/article/view/108.

7.      Lima GM, Porto MA, da Cunha AL. Medical education content required for kernicterus risk recognition. Iran J Pediatr. 2012 Jun;22(2):163-70. PMID: 23056881; PMCID: PMC3446061. Disponível em: https://pubmed.ncbi.nlm.nih.gov/23056881/.

8.      Lima GM; Porto MASC; Barbosa AP; Cunha, AJLA. Predictive risk factors for moderate to severe hyperbilirubinemia. Einstein, São Paulo; 2017;5:352-357. Disponível em: https://minerva.ufrj.br/F/?func=direct&doc_number=000775317&local_base=UFR01.

 

Scientific Editor:

Fernanda Pinto Mariz

ORCID: https://orcid.org/0000-0002-6981-2352

 

Publisher: Sociedade de Pediatria do Rio de Janeiro – SOPERJ

E-mail: secretaria@soperj.org.br

 

Financial support:

None.

 

Availability of research data:

The underlying content of the research text is contained in the article.

 

Conflict of interests:

None.

 

 

 

 

Rev Pediatria SOPERJ 2026;26(4): e20260264