Section 5

Gastrointestinal and hepatobiliary

tract & nutrition

18. Neonatal jaundice

19. Feeding of low birth weight babies
20. Feeding in A/REDF neonates
21. Neonatal cholestasis (including hepatic failure)
22. Suspected intestinal obstruction (atresia, ARM)
23. Necrotising enterocolitis
 18 Jaundice in the Newborns

Jaundice is the most common morbidity in the first week of life,

occurring in 60% of term and 80% of preterm newborn & it is the
most common cause of readmission after discharge from birth
hospitalization.1

Jaundice in neonates is visible in skin and eyes when total serum

bilirubin (TSB) concentration exceeds 5 to 7 mg/dL. In contrast,
adults have jaundice visible in eyes when TSB concentration
exceeds 2 mg/dL. Increased TSB concentration in neonate
results from varying contributions of three mechanisms namely
increased production from degradation of red cells, decreased
clearance by the immature hepatic mechanisms and reabsoption
by enterohepatic circulation (EHC).

High serum bilirubin levels can cause bilirubin induced

neurological dysfunction (BIND) in some babies. In most other
cases, jaundice is benign and does not require any therapeutic
intervention. Approximately 5-10% of them have clinically
significant jaundice that require treatment to lower TSB levels in
order to prevent BIND.

Physiological versus pathological jaundice

Jaundice attributable to physiological immaturity of neonates to
handle increased bilirubin production is termed as
‘physiological jaundice’. Visible jaundice usually appears
between 24 to 72 hours of age. TSB level usually rises in term
infants to a peak level of 12 to 15 mg/dL by 3 days of age and then
falls. In preterm infants, the peak level occurs on the 3 to 7 days of
age and TSB can rise over 15 mg/dL. It may take weeks before the
TSB levels falls under 2 mg/dL in both term and preterm infants.

‘Pathological jaundice’ is said to be present when TSB

concentrations are not in ‘physiological jaundice’ range, the
latter is defined arbitrarily and loosely as more than 5 mg/dL on
first day, 10 mg/dL on second day, and 12-13 mg/dL thereafter

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in term neonates.2 Any TSB value of 17 mg/dL or more should be

regarded as pathologic and should be evaluated for the cause,
and possible intervention such as phototherapy.3

It may be noted that the differentiation between ‘pathological’

and ‘physiological’ is rather arbitrary and is not clearly defined.
Presence of one or more of following conditions would qualify a
neonate to have pathological jaundice2:

1. Visible jaundice in first 24 hours of life. However slight

jaundice on face at the end of first day (say 18 to 24 h) is common
and can be considered physiological.
2. Presence of jaundice on arms and legs on day 2
3. Yellow palms and soles anytime
4. Serum bilirubin concentration increasing more than 0.2
mg/dL/hour or more than 5 mg/dL in 24 hours
5. If TSB concentration more than 95th centile as per age-
specific bilirubin nomogram
6. Signs of acute bilirubin encephalopathy or kernicterus
7. Clinical jaundice persisting beyond 2 weeks in term and 3
weeks in preterm neonates

Causes of pathological jaundice

Common causes of pathological jaundice include:

1. Hemolysis: blood group incompatibility such as those due

to ABO, Rh and minor groups, enzyme deficiencies such as
G6PD, and autoimmune hemolytic anemia
2. Decreased conjugation due to liver enzyme immaturity
3. Increased enterohepatic circulation due to lack of adequate
enteral feeding that includes insufficient breastfeeding or
the infant not being fed because of illness, and
gastrointestinal obstruction
4. Extravasated blood: cephalhematoma, extensive bruising
etc

Clinical assessment of jaundice

• The parents should be counselled regarding benign nature
of jaundice in most neonates, and for the need to be watchful
and seek help if baby appears too yellow. The parents should

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be explained about how to see for jaundice in babies (in

natural light, no yellow background and see skin and eyes of
the baby).

• Visual inspection of jaundice (Panel 1) is believed to be

unreliable, but if it is performed properly (i.e. examining a
naked baby in bright natural light and in absence of yellow
background), it has reasonable accuracy (as good as
transcutaneous bilirubinometry if done diligently)
particularly when TSB is less than 12 to 14 mg/dL or so.
Absence of jaundice on visual inspection reliably excludes
the jaundice. At higher TSBs, visual inspection is unreliable
and, therefore, TSB should be measured to ascertain the
level of jaundice.4

• All neonates should be examined at every opportunity but

not lesser than every 12 hr during first 3 to 5 days of life for
jaundice. The babies being discharged from the hospital at
48 to 72 hours should be seen again after 48 to 72 hours of
discharge (TSB peaks at around 72 hours in term babies and
later than 72 hours in preterm babies).

• The neonates at higher risk of jaundice should be identified

at birth and kept under enhanced surveillance for
occurrence and progression of jaundice. These infants
include5:

• TSB/TcB value in the high-risk or high-intermediate–

risk zone as per Bhutani chart (if measured before
discharge)
• Gestational age less than 38 weeks
• Exclusive breastfeeding especially if it is not well
established; presence of feeding difficulties; evidence of
inadequate breastfeeding such excess weight loss,
reduced urine or stool frequency.
• Hemolytic diasese (Rh, ABO, G6PD deficiency)
• History of significant jaundice in the previous sibling
• Cephalohematoma or significant bruising
• East Asian race

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• Inadequacy of breastfeeding is a common cause of

exaggerated jaundice during initial few days (breastfeeding
jaundice; BFJ). Breastfeeding problems such as improper
positioning and attachment, cracked or sore nipple, and
engorgement resulting into reduced milk transfer to baby
may enhance enterohepatic circulation enhancing the
bilirubin load in the body. Prevention of BFJ requires
optimum support to the mothers. Breastfeeding support
must include, in addition to providing adequate
information, actual helping the mothers to learn proper
positioning and attachment, and adequate measures to
address breastfeeding problems. It generally requires
multiple counselling sessions to enable mothers to
successfully breastfeed her baby.

Panel 1 Visual inspection of jaundice

1. Examine the baby in bright natural light. Alternatively, the baby can be
examined in bright white fluorescent light. Make sure there is no yellow or
off-white background. You may have to move the baby from mother’s
bed/OPD to a brightly lit area.
2. The baby should be naked.
3. Examine blanched skin and gums or sclerae
4. Note the extent of jaundice (Kramer’s rule)6
5. Depth of jaundice (degree of yellowness) should be carefully noted (light staining
as lemon yellow; deep staining as orange yellow), as it is an important indicator
of level of jaundice and it does not figure out in Kramer’s rule.
A deep yellow staining (even in absence of yellow soles or palms) may be
associated with severe jaundice and therefore TSB should be estimated in such
circumstances.
Kramer zones Approximate TSB level
Mild jaundice Deep jaundice
(Lemon yellow (Orange yellow
color) color)
1 (Face and neck) 5 to 7 mg/dL 7 to 9 mg/dL
2 (Chest and upper 7 to 9 mg/dL 9 to 11 mg/dL
abdomen)
3 (Lower abdomen 9 to 11 mg/dL 11 to 13 mg/dL
and thighs)
4 (Legs and arms/ 11 to 13 mg/dL 14 to 16 mg/dL
forearms)
5 (Palms and soles) 13 to 15 mg/dL 17 mg/dL or more

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Measurement of serum bilirubin

1. Transcutaneus bilirubinometry (TcB)4
a. TcB is a useful adjunct to TSB measurement, and routine
employment of TcB can reduce need for blood sampling
by nearly 30%. However, certain devices (Bilicheck)
have a significant recurring cost of consumables such as
disposable tips etc.
b. TcB can be used in infants of 35 weeks or more of
gestation and after 24 hr of age. TcB is unreliable in
infants less than 35 weeks gestation and during initial 24
hr of age. TcB has a good correlation with TSB at lower
levels, but it becomes unreliable once TSB level goes
beyond 12 to 14 mg/dL. TcB is not useful for the babies
undergoing phototherapy (with or without a light
occluding skin patch).
c. Hour specific TcB can be used for prediction of
subsequent hyperbilirubinemia. TcB value below 50th
centile for age would rule out the risk of subsequent
hyperbilirubinemia with high probability (high
negative predictive value).7
d. Trends in TcB values by measuring 12 hr apart would
have a better predictive value than a single value.8
e. We routinely perform TcB measurement in infants of 35
wk or more gestation to screen for hyperbilirubinemia.
A TcB value of greater than 12 to 14 mg/dL is confirmed
by TSB measurement.

2. Measurement of TSB
a. Indication of TSB measurement:
i. Jaundice in first 24 hour
ii. Beyond 24 hr: if visually assessed jaundice is likely
to be more than 12 to 14 mg/dL (as beyond this TSB
level, visual assessment becomes unreliable) or
approaching the phototherapy range or beyond for
that baby.
iii. If you are unsure about visual assessment
iv. During phototherapy for monitoring the progress
and after phototherapy to check for rebound in
select cases (such as those with hemolytic jaundice)

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b. Frequency of TSB measurement depends upon the

underlying cause (hemolytic versus non-hemolytic),
severity of jaundice and host factors such as age and
gestation. In general, in non-hemolytic jaundice in term
babies with TSB levels being below 20 to 22 mg/dL, TSB
can be performed every 12 to 24 hr depending upon age
of the baby. Whereas, a baby with Rh isoimmunisation
would require TSB measurement every 6 to 8 hours
during initial 24 to 48 hours or so.
c. Methods of TSB measurements
i. B i o c h e m i c a l : H i g h p e r f o r m a n c e l i q u i d
chromatography (HPLC) remains the gold
standard for estimation of TSB. However, this test is
available for research purpose only. The laboratory
estimation of TSB is usually performed by Van den
Bergh reaction. It has marked inter-laboratory
variability with coefficient of variation being up to
10 to 12 percent for TSB and over 20 percent for
conjugated fraction.10
ii. Micro-method for TSB estimation: It is based on
spectrophotometry and estimates TSB on a
microblood sample (10 microliter). It is useful in
neonates, as bilirubin is predominantly
unconjugated.

Approach to a jaundiced neonate

A stepwise approach should be employed for managing
jaundice in neonates (Figure 18.1).

All the neonates should be visually inspected for jaundice every

8 to 12 hr during initial 3 to 5 days of life. TcB can be used as an aid
for initial screening of infants. Visual assessment (when
performed properly) and TcB have reasonable sensitivity for
initial assessment of jaundice.

As a first step, serious jaundice should be ruled out.

Phototherapy should be initiated if the infant meets the criteria
for serious jaundice. TSB should be determined subsequently in
these infants to determine further course of action.

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Though recommended by AAP5, universal screening of all

infants with TSB in order to predict the risk of subsequent
hyperbilirubinemia does not seem to be a feasible option in
resource restricted settings.

Perform visual assessment (VA) of jaundice: every 8 to 12 h

during initial 3 to 5 days of life.
VA can be supplemented with transcutneous bilirubinometry (TcB), if available

Step 1: Does the baby have serious jaundice*?

Yes No

Start Step 2: Does the infant have significant

phototherapy jaundice to require TSB measurement#?

Yes No

Measure TSB level and determine if

Continued observation
baby requires phototherapy or
every 12 to 24 hr for
exchange transfusion
initial 3 to 5 days
(refer to Table 18.1, Fig 18.2, Fig 18.3)

Step 3: Determine the cause of jaundice

and provide supportive
and follow up care

#
Serious jaundice: Measure serum bilirubin if:
a. Presence of visible jaundice in first a. Jaundice in first 24 hour
24 hour b. B e y o n d 2 4 h r : i f o n v i s u a l
b. Yellow palms and soles anytime assessment or by transcutenous
c. S i g n s o f a c u t e b i l i r u b i n bilirubinometry, TSB is likely to be
encephalopathy or kernicterus: more than 12 to 14 mg/dL or
hypertonia, abnormal posturing approaching phototherapy range
such as arching, retrocollis, or beyond.
opisthotonus or convulsion, fever, c. If you are unsure about visual
high pitched cry) assessment
d. TcB/TSB value more than 95 th
centile as per age specific nomogram

Figure 18.1: Approach to an infant with jaundice

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Management of jaundice
1. Infants born at gestation of 35 weeks or more
American Academy of Paediatrics (AAP) criteria should be used
for deciding need for phototherapy or exchange transfusion in
these infants.5 AAP provides two age-specific nomograms- one
each for phototherapy and exchange transfusion. The
nomograms have lines for three different risk categories of
neonates (Figure 18.2 and 18.3). These lines include one each for
lower risk babies (38 wk or more and no risk factors), medium
risk babies (38 wk or more with risk factors, or 35 wk to 37 wk and
without any risk factors) and higher risk (35 wk to 37 wk and
with risk factors).

TSB value is taken for decision-making and direct fraction

should not be reduced from it. As a rough guide, phototherapy is
initiated if TSB vales are at or higher than 10, 13, 15 and 18
mg/dL at 24, 48, 72 and 96 hours and beyond, respectively in
babies at medium risk. The babies at lower and higher risk have
their cut-offs at approximately 2 mg/dL higher or 2 mg/dL
lower than that for medium risk babies, respectively.

Risk factors include presence of isoimmune hemolytic anemia,

G6PD deficiency, asphyxia, temperature instability,
hypothermia, sepsis, significant lethargy, acidosis and
hypoalbuminemia.

Figure 18.2. AAP nomogram for phototherapy in hospitalized

infants of 35 or more weeks’ gestation (reproduced with
permission5

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 Jaundice in the Newborns

Figure 18.3 depicts nomogram for exchange transfusion in three

risk categories of babies. Any baby showing signs of bilirubin
encephalopathy such as hypertonia, retrocollis, convulsion,
fever etc should receive exchange transfusion without any
delay.

Figure 18.3. AAP nomogram for exchange transfusion in infants 35

or more weeks’ gestation (reproduced with permission) 5

2. Preterm babies
There are no consensus guidelines to employ phototherapy or
exchange transfusion in preterm babies. The proposed TSB cut-
offs for phototherapy and exchange transfusion are arbitrary
and clinical judgement should be exercised before making a
decision (Table 18.1).

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Table 18.1: Phototherapy and exchange cut-offs of total serum

bilirubin (mg/dL) for babies 34 weeks gestation or lower (Source:
NICE guidelines)
Gestation Phototherapy Exchange transfusion
(wk)
12h 24h 48h 72h 12h 24h 48h 72h
and and
more more
23 3.2 4.0 5.9 7.6 6.1 7.6 10.5 13.5
24 3.2 4.4 6.4 8.2 6.1 7.9 11.1 14
25 3.5 4.7 6.7 8.8 6.4 8.2 11.4 14.6
26 3.5 4.7 7.0 9.4 6.4 8.2 11.7 15.2
27 3.6 5.0 7.3 10 6.5 8.5 12.0 15.8
28 3.8 5.0 7.6 10.5 6.7 8.5 12.3 16.4
29 3.8 5.3 8.2 11.1 6.7 8.8 12.9 17
30 4.0 5.3 8.5 11.7 6.9 8.8 13.2 17.6
31 4.1 5.6 9.0 12.3 7.0 9.1 13.7 18.1
32 4.1 5.9 9.4 12.9 7.0 9.4 14.0 18.7
33 4.2 6.1 9.9 13.5 7.1 9.7 14.6 19.3
34 4.2 6.1 10.2 14 7.1 9.7 14.9 19.9

Therapeutic options
1. Phototherapy
Phototherapy (PT) remains the mainstay of treating
hyperbilirubinemia in neonates. PT is highly effective and
carries an excellent safety track record of over 50 years. It acts by
converting insoluble bilirubin (unconjugated) into soluble
isomers that can be excreted in urine and feces. The bilirubin
molecule isomerizes to harmless forms under blue-green light
(460 to 490 nm); and the light sources having high irradiance in
this particular wavelength range are more effective than the
others.

Types of phototherapy lights

The most commonly used PT units include blue compact
florescent lamps (CFL), high intensity light emitting diodes
(LED) and fibroptic units.

With the easy availability and low cost in India, CFL PT is being
most commonly used device. Often, CFL devices have four blue

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and two white (for examination purpose) CFLs but this

combination can be replaced with 6 blue CFLs in order to
increase the irradiance output. The blue LED units are being
used commonly and have been found to equally effective. LED
has advantage of long life (up to 50,000 hrs) and is capable of
delivering higher irradiance than CFL lamps.

Fiber-optic units can be used to provide undersurface PT in

conjugation with overhead CFL/LED unit to enhance the
efficacy of PT but as a standalone source, fiber-optic unit is lesser
effective than CFL/LED unit.

It is important that a plastic cover or shield be placed before

phototherapy lamps to avoid accidental injury to the baby in
case a lamp breaks.

Maximizing the efficacy of phototherapy

The irradiance of PTx lights should be periodically measured,
and a minimum level of 30 µW/cm2/nm in the wavelength
range of 460 to 490 nm must be ensured. As the irradiance varies
at different points on the footprint of a unit, it should be
measured at several points. The lamps should be changed if the
lamps are flickering or ends are blackened, or irradiance falls
below the specified level or as per the recommendation of
manufacturers.

Expose maximal surface area of the baby. Avoid blocking the

lights by any equipment, a large diaper or eye patch, a cap or hat,
tape, dressing or electrode etc. Ensure good hydration and
nutrition of the baby. Make sure that light falls on the baby
perpendicularly if the baby is in incubator. Minimize
interruption of PT during feeding sessions or procedures.

Administering phototherapy
Make sure that ambient room temperature is optimum
(250 - 280 C) to prevent hypothermia or hyperthermia in the baby.
Remove all clothes of the baby except the diaper. Cover the
baby’s eyes with an eye patch, ensuring that the patch does not
block the baby’s nostrils. Place the naked baby under the lights
in a cot or bassinet if weight is more than 2 kg or in an incubator
or radiant warmer if the baby is small (<2 kg).

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 AIIMS Protocols in Neonatology

Keep the distance between baby and light 30 to 45 cm (or as per

manufacturer recommendation).

Ensure optimum breastfeeding. Baby can be taken out for

breastfeeding sessions and the eye patch can be removed for
better mother-infant interaction. However, one should
minimize interruption to enhance effectiveness of
phototherapy. There is no need to supplement or replace breast
milk with any other types of feed or fluid (e.g. breast-milk
substitute, water, sugar water, etc.)

Monitoring & stopping phototherapy

Monitor temperature of the baby every 2 to 4 hours. Measure
TSB level every 12 to 24 hours.

Discontinue PT if two TSB values are below age-specific cut

offs.5 Measure TSB values 12 to 24 hours after stopping
phototherapy to check for rebond.

Role of sunlight
Exposing the baby to sunlight does not help in treatment of
jaundice and is associated with risk of sunburn and therefore
should be avoided.

2. Exchange transfusion
Double volume exchange transfusion (DVET) should be
performed if the TSB levels reach to age specific cut-off for
exchange transfusion or the infant shows signs of bilirubin
encephalopathy irrespective of TSB levels.

In di ca t i on s f or D V ET a t b i r t h i n i n f a n t s w i t h R h
isoimmunization include:
1. Cord bilirubin is 5 mg/dL or more, OR
2. Cord Hb is 10 g/dL or less

Indications of partial exchange transfusion

At birth, if a baby shows signs of hydrops or cardiac
decompensation in presence of low PCV (<35%), partial
exchange transfusion with 50 mL/kg of packed cells should be
done to restore oxygen carrying capacity of blood, before doing
DVET.

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The DVET should be performed by pull and push technique

using umbilical venous route. Umbilical catheter should be
inserted just enough to get free flow of blood.

Table 18.2: Type and volume of blood for exchange transfusion

SN Condition Type of blood
1 Rh isoimmunization Rh negative and blood group ‘O’ or that of baby
Suspended in AB plasma and cross matched
with baby’s and mother’s blood
2 ABO incompatibility Rh compatible and blood group ‘O’ (Not that of
baby) suspended in AB plasma cross matched
with baby’s and mother’s blood
3 Other conditions Baby’s group and Rh type cross matched with
(G6PD deficiency, baby’s and mother’s blood
non-hemolytic, other
isoimmune
hemolytic jaundice
• Volume of blood: Twice the blood volume of baby (total volume: 160 to 180 mL/kg)
• To prepare blood for DVET, mix two-thirds of packed cells and one-third of plasma

3. Intravenous immunoglobulins (IVIG)

IVIG was used quite commonly for reducing hemolysis and
consequent hyperbilirubinemia in Rh isoimmunisation and
ABO incompatibility. However, subsequent studies did not
prove the efficacy and its use. We do not use IVIG for treating
isoimmune hemolytic jaundice.

4. IV hydration
Infants with severe hyperbilirubinemia and evidence of
dehydration (e.g. excessive weight loss) should be given IV
hydration. An extra fluid of 50 mL/kg of N/3 saline over 8 hr
decreases the need for exchange transfusion.11

5. Other agents
There is no proven evidence of benefit of drugs like
phenobarbitone, clofibrate, or steroids to prevent or treat
hyerbilirubinemia in neonates and therefore these agents
should not be employed in treatment of jaundiced infants.

Prolonged jaundice
There is no good definition of prolonged jaundice (PJ).

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 AIIMS Protocols in Neonatology

Generally, persistence of significant jaundice for more than 2 wk

in term and more than 3 weeks in preterm babies is taken as PJ.
Though, it is not uncommon to see persistence of mild jaundice
in many infants for 4 to 6 weeks of age. Most of these babies do
well without any specific intervention or investigation.

The first and foremost step to manage an infant with PJ is to rule

out cholestasis. Yellow colored urine is a reasonable marker for
cholestasis; however the urine color could be normal during
initial phase of cholestasis. For the practical purpose, an infant
with PJ with normal colored urine can be considered to have
unconjugated hyperbilirubinemia. If the infant has dark colored
urine, the infant should be managed as per cholestasis
guidelines.

Infants with true PJ (unconjugated hyperbilirubinemia) should

be assessed clinically for severity and possible cause of
prolongation of jaundice (Table 18.3). If the clinical assessment
of jaundice suggests TSB levels below phototherapy cut offs for
age (say <15 to 18 mg/dL in term infant), the infant may not be
subjected to any unnecessary investigations. As many of these
infants have PJ as a result of inadequate feeding, appropriate
measures are taken to optimize breastfeeding. Thyroid screen
can be considered in such infants at this stage if routine
metabolic screen for hypothyroidism has not been carried out at
birth.

If baby appears significant jaundice at this stage, TSB level

should be performed and possible underlying cause should be
looked for. In such infants, G6PD level, thyroid screen, ABO of
infant & mother if not done earlier should performed to
delineate possible cause (Figure 18.4).

Infants having TSB in phototherapy range should be started on

phototherapy. The adequacy of breastfeeding should be
assessed by history, observation of breastfeeding session, and
degree of weight loss. Many of the mothers, even at this stage,

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have persisting breastfeeding problems such as poor

attachment, sore nipple etc.

Breast milk jaundice (BMJ) is relatively a common cause of

jaundice; but, inadequacy of breastfeeding being more common
than breast milk jaundice the latter should be carefully ruled
out. BMJ being an innocuous entity, cessation of breastfeeding is
not required in practically any case. Infants with BMJ should be
treated with phototherapy, if required. For a rare infant with
TSB hovering in exchange range, a brief trial of interruption of
breastfeeding can be considered. We haven’t stopped
breastfeeding even for once for treatment of BMJ in last 15 years!

In an infant failing to respond to these measures, a diagnosis of

Crigglar Najjar syndrome (CNS) should be entertained. A trial
of phenobarbitone can be considered to establish the diagnosis.

Table 18.3: Causes of prolonged jaundice

Common
1. Inadequacy of breastfeeding
2. Breast milk jaundice
3. Cholestasis
4. Continuing hemolysis e.g. Rh, ABO and G6PD hemolysis
Rare
1. Extravasated blood e.g. cephalhematoma
2. Hypothyroidism
3. Criggler Najjar Syndrome
4. GI obstruction such as malrotation
5. Gilbert syndrome

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Persistence of jaundice >2 wk in term & >3 wk in

preterm babies

Check if the infant is passing high

coloured urine (staining nappies)

If ‘No’:
1. Visually assess severity of jaundice
If yes: manage as per
(measure TSB, if required)
cholestasis guidelines
2. Assess for and manage inadequate
breastfeeding
3. Perform clinical examination to
ascertain the cause: extravasated
blood, hemolysis, hypothyroidism1

Level of jaundice/TSB not in PTx TSB in PTx range:

range: • Initiate PTx
• Manage conservatively • Perform: G6PD, thyroid
• Follow up as needed until screen, ABO of infant &
resolution of jaundice mother, if not done earlier

• TSB persistently high, unresponsive to PTx

and hovering in exchange range: consider
cessation of breastfeeding for 48 h (required in
exceptional cases only)
• TSB persistent high despite PTx/cessation of
breastfeeding: consider phenobarbitone trial
to rule out CNS

1
thyroid screen can be considered at this stage
TSB: total serum bilirubin; CNS: Criggler Najjar syndrome; PTx: phototherapy

Figure 18.4: Approach to a neonate with prolonged jaundice

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