CLINICAL PRACTICE GUIDELINES

FEBRUARY 2003 MOH/P/PAK/62.03 (GU)

MANAGEMENT
OF
JAUNDICE IN HEALTHY TERM NEWBORNS

MINISTRY OF HEALTH MALAYSIA ACADEMY OF MEDICINE

Statement of Intent

This clinical practice guideline is meant to be a guide for clinical practice, based on the
best available evidence at the time of development. Adherence to these guidelines may
not necessarily ensure the best outcome in every case. Every health care provider is
responsible for the management of his/her unique patient based on the clinical picture
presented by the patient and the management options available locally.

Review of the Guidelines

This guideline was issued in 2003 and will be reviewed in 2005 or sooner if new
evidence becomes available

Secretariat
c/o Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia
21st Floor, Bangunan PERKIM
Jalan Ipoh
51200 Kuala Lumpur.

Available on the following website : http:// www.moh.gov.my/medical

: http:// www.acadmed.org.my
 ACKNOWLEDGEMENT

With deepest gratitude and appreciation to the following:

All members of the expert committee for their contribution in drawing up this
guideline

The Ministry of Health Malaysia and Academy of Medicine for their

collaboration and cooperation

All those who had provided valuable input and feedback

The secretariat for their patience, support and services rendered.

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 GUIDELINES DEVELOPMENT AND OBJECTIVES

2.1 Guidelines Development

The workgroup comprised a group of paediatricians. This guideline are based on the best
available current evidence and adapted from the recommendations of the American
Academy of Paediatrics and The Collage of Family Physician of Canada practice
guidelines the local situation.

2.2 Objectives
The aim of these guidelines is to assist health care providers in clinical decision making
by providing well-balanced information on the management of jaundice in newborns. It is
also hoped to standardize clinical management.

2.3 Clinical Question

The clinical questions of these guidelines is how Jaundice in newborns been treated and
also prevented?

2.4 Target Population

These guidelines are developed to apply to all healthy newborns with jaundice

2.5 Target Group

These guidelines are developed for all health care providers.

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 LEVELS OF EVIDENCE SCALE

Level Strength of evidence Study design

1 Good Meta-analysis of RCT, Systematic Review
2 Good Large sample RCT
3 Good to Fair Small sample RCT
4 Non- randomized controlled prospective trial
5 Fair Non- randomized controlled prospective trial
with historical control
6 Fair Cohort studies
7 Poor Case-control studies
8 Poor Non-controlled clinical series, descriptive studies
multi centre
9 Poor Expert committees, consensus, case reports,
anecdotes

SOURCE: ADAPTED FROM CATALONIAN AGENCY FOR HEALTH TECHNOLOGY

ASSESSMENT (CAHTA), SPAIN

iii
 SUMMARY

Jaundice is apparent clinically when the level of bilirubin in the serum rises above 85
µmol/L (5mg/dl). While in-utero, unconjugated bilirubin is cleared by the placenta
resulting in a cord serum bilirubin level usually of 35 µmol/L (2mg/dl) or less. However,
after birth, the level of jaundice is depend on the type of jaundice present. Continuation
elevation of serum bilirubin can result in kernicterus.
When newborns present with jaundice, the following clinical assessment need to be
carried out like taking history, physical examination, and assessment of severity of
jaundice. If any of the following signs and symptoms: jaundice below umbilicus,
jaundice up to soles of feet, rapid rise of serum bilirubin > 8.5 µmol/L/hr, prolonged
jaundice > 14 days, family history of haemolytic disease/kernicterus and clinical
symptoms of sepsis are present that kernicterus need to be referred for hospital
management.
The choice of treatment for jaundice are phototherapy and exchange transfusion; for
breastfeeding jaundice, continuation of frequent breast feeding and supplementing breast-
feeding with formula, with or without phototherapy, can be considered.

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 GUIDELINES COMMITTEE
Dr Kuan Geok Lan Chairman
Consultant Paediatrician
Melaka Hospital

Dr Wong Swee Lan

Head & Consultant Paediatrician
Department of Paediatric
Kuala Lumpur Hospital

Dato’ Dr N L Lim
Consultant Paediatrician
Selayang Hospital

Dr. Susan Pee

Consultant Paediatrician
Sultanah Aminah Johor Bahru Hospital

Dr S Yogeswary
Consultant Paediatrician
Tengku Ampuan Rahimah Klang Hospital

Dr P Umathevi
Consultant Paediatrcian
Seremban Hospital.

Dr. N Nachal
Consultant Paediatrician
Tengku Ampuan Rahimah Klang Hospital

Prof C T Lim
Consultant Paediatricians
University Malaya Medical Centre

Guidelines Coordinators

Dr S Sivalal
Deputy Director
Medical Development Division
Ministry of Health Malaysia

Dr Rusilawati Jaudin
Principal Assistant Director
Health Technology Assessment Unit
Ministry of Health Malaysia

Dr Zailiza Suli
Assistant Director
Health Technology Assessment Unit
Ministry of Health Malaysia

Ms Sin Lian Thye

Nursing Sister
Health Technology Assessment Unit
Ministry of Health Malaysia

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 TABLE OF CONTENT

AKCNOWLEDGEMENT i
GUIDELINES DEVELOPMENT AND OBJECTIVE ii
LEVEL OF EVIDENCE SCALE iii
SUMMARRY iv
EXPERT COMMITTEE v
1 INTRODUCTION 1
1.1 What is Jaundice 1
1.2 What Can Go Wrong In Jaundice 1
1.3 Causes of Neonatal Jaundice 2
1.4 Factors Affecting Severity of NNJ 2
1.5 G6PD Deficiency 2
2 MANAGEMENT OF NEONATAL JAUNDICE (NNJ) 3
2.1 History 3
2.2 Physical Examination 3
2.3 Clinical Assessment of the Severity of Jaundice 3
2.4 When Should A Neonate Be Referred For 4
Hospital Management?
2.5 Investigation for NNJ 4
2.6 Transcultaneous Bilirubinometry 5

3 TREATMENT 5
3.1. Phototherapy 5
3.1. 1. Types of phototherapy 6
3.1. 2. The methods of providing intensified 6
phototherapy are as follow
3.1.3 Colours of phototherapy light 7
3.2 Exchange Transfusion 8
3.3 Drug Treatment 9
3.4 Breastfeeding and Jaundice 9

4 PREVENTION MEASURES FOR SEVERE NNJ 10

5 ALGORITHM 11
6 REFERENCES 13

vii
1. INTRODUCTION
1.1 What is Jaundice?
Jaundice is apparent clinically when the level of bilirubin in the serum rises above
85µmol/l (5mg/dl). While in-utero, unconjugated bilirubin is cleared by the placenta,
resulting in a cord serum bilirubin level usually of 35µmol/L (2mg/dl), or less. However,
after birth, the level of jaundice, i.e. physiological jaundice is a reflection of the bilirubin
load to the liver, rate of hepatic excretion (liver maturity) and ability of the serum binding
protein to retain the bilirubin within the plasma. The great variation in individual
responses to a bilirubin load prevents the definition of a specific level as physiological
jaundice - levels beyond which therapy has been shown to do more good than harm
(Maisels, 1985). The pattern of physiological jaundice also varies with other factors like
prematurity, ethnicity.
In hemolytic jaundice, serum bilirubin levels exceed physiological levels and can be due
to sepsis and inherited hemolytic diseases like glucose 6-phosphate dehyrogenase (G6PD
) deficiency, ABO and Rh isoimmunisation.
Prolonged jaundice refers to jaundice persisting beyond the first two weeks of life in
the term neonate, and causes include late onset breast milk jaundice, congenital
hypothyroidism and other rare inherited conditions.
Babies with breast milk jaundice have prolonged levels of unconjugated bilirubin in
otherwise healthy infants, and β glucuronidase in the breast milk appears to be an
important factor in this condition. There are two types of Neonatal Jaundice associated
with breastfeeding, the first know as breastfeeding jaundice is related to inadequate
nursing on the breast resulting in dehydration and otherwise physiological jaundice
becoming more intense; and the second is breastmilk jaundice which is associated with
prolonged jaundice extending beyond the first two week of life. One or more substances
like enzyme (glucoronidase), 3 alpha, and 20 beta pregnanediol in breastmilk is though to
be may be responsible for breastmilk jaundice. (Kuhr, 1982 [Level 6]; Adam, 1985;
Maisels, 1986, Saigal, 1982; De Carvelho, 1981) [Level 7]

1.2 What Can Go Wrong In Jaundice?

Elevated serum bilirubin can result in kernicterus, when unconjugated bilirubin is
deposited in the cell wall of neurons in basal ganglia, brain stem and cerebellum resulting
in cell death. Kernicterus is associated with a high mortality, and survivors usually suffer
sequelae like athetoid cerebral palsy, high frequency hearing loss, paralysis of upward
gaze and dental dysplasia. The factors influencing bilirubin toxicity in the brain cells of
the neonate are complex and incompletely understood. There is no specific level of total
serum bilirubin above which kernicterus can be predicted to happen.

1.3 Causes Of Neonatal Jaundice (NNJ)

The following are the recognised causes of NNJ:
• Haemolysis due to ABO or Rh isoimmunisation, G6PD deficiency,
hereditary spherocytosis, drugs
• Sepsis - septicaemia, meningitis, UTI, intra-uterine infection
• Polycythaemia
• Physiological jaundice & idiopathic jaundice

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• Breastfeeding and Breastmilk jaundice.

1.4 Factors Affecting Severity of NNJ

The following factors are said to affect the severity of jaundice
• Dehydration
• Large weight loss after birth
• Extravasation of blood, cephalohaematoma, contusion
• Swallowed maternal blood
• Infant of diabetic mother
• Acidosis
• Asphyxia
• GI tract obstruction: increase in enterohepatic circulation

1.5 G6PD Deficiency

G6PD deficiency is an inherited disorder of the red blood cell, inherited in an x-linked
recessive manner – males are affected while the females are carriers. G6PD is an enzyme
essential in keeping glutathione in the reduced state that in turn is vital to maintain the
integrity of the red cell membrane. In G6PD deficiency the red blood cells are prone to
haemolysis when exposed to oxidants or when certain foods or herbs are ingested. A list
of drugs and herbs that can precipitate haemolysis is provided in the appendix (Luzzato,
1992).

The incidence of G6PD deficiency varies among the various ethnic groups as follows -
Chinese 3.1%, Malay 1.4%, and Indian 0.2% (Robinson et al., 1976). These results were
obtained by using a fluorescent screening method, that had been found to be as sensitive
and specific as other screening tests (Fairbanks & Fernandez 1969).

2. MANAGEMENT OF NEONATAL JAUNDICE (NNJ)

2.1 History:
The following information needs to be obtained:
• Age of onset, rate of progress of jaundice (both clinically and also if serial serum
bilirubin (SB) results are available)
• Previous infants with NNJ, kernicterus, neonatal death, G6PD deficiency
• Mother’s blood group (from antenatal history)
• Gestation: although term gestation is taken as 37 completed weeks, infants born at
37- 38 weeks of gestation are more prone to hyperbilirubinaemia, the incidence of
hyperbilirubinaemia increasing with decreasing gestational age (Friedman et al.,
1987, Linn et al., 1985, Maisals , 1988).
• Presence of symptoms such as apnoea, difficulty in feeding, feed intolerance
and temperature instability.

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2.2 Physical examination
• General condition–whether ill-looking or lethargic, presence of hypotonia, or
abdominal distension.
• Pallor, presence of cephalohaematoma/subaponeurotic haematoma, petechiae,
purpura, ecchymosis, and hepatosplenomegaly

2.3 Clinical Assessment of the Severity of Jaundice

When a neonate is jaundiced, the yellow discoloration of skin first appears on the face
and it progresses to the trunk, to the palm of the hand, and then the sole of the feet-ie
cephalo-caudal progression. The intensity of yellow discoloration also correspondingly
increases from the face caudally as the severity of jaundice increases. Jaundice can be
detected by blanching the skin of the neonate with digital pressure exposing the colour of
the underlying skin. The severity of neonatal jaundice is assessed clinically using
Kramer’s chart based on dermal zones of neonatal jaundice, where the levels of serum
bilirubin correlate with the area of skin that is jaundiced, as indicated in the table 1below.
This is applicable to full term infants with jaundice not due to all hemolytic conditions
included Rh incompatibility.

Table 1: correlation between levels of serum bilirubin with the area of skin that is
Jaundiced
Area of body Range of indirect bilirubin mg/dl(µmol/L)
Head & neck 4-8 (68-135)
Upper trunk 5-12 (85-204)
Lower trunk and thigh 8-16 (136-272)
Arms & lower legs 11-18 (187-306)
Palms and soles >18 (>306)
(NB: It may be difficult to assess jaundice in dark skinned infants).

2.4 When Should A Neonate Be Referred For Hospital Management? (When To

Get Worried?)
The following are indications for referral:
• Jaundice below umbilicus, corresponding to serum bilirubin of 12-15 mg/dl (200-
250 µmol/L).
• Jaundice up to level of the sole of the feet - likely to need exchange transfusion.
• Jaundice within 24 hours of life.
• Rapid rise of serum bilirubin of more than 8.5 µmol/L/hour (>0.5 mg/dl/hour).
• Prolonged jaundice of more than 14 days - other causes/conditions need to be
excluded e.g. neonatal hepatitis, biliary atresia.
• Family history of significant haemolytic disease or kernicterus
• Clinical symptoms/signs suggestive of other diseases e.g. sepsis.

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2.5 Investigations for NNJ Include:
• Total serum bilirubin - sufficient in most cases
• Unconjugated & conjugated fractions in specific conditions eg prolonged NNJ
• Infant’s blood group, maternal blood group (if not already known)
• Direct Coomb’s test
• G6PD status (if not already known)
• Full blood count
• Reticulocyte count
• Peripheral blood film (if hereditary spherocytosis suspected)
• Blood culture, Urine microscopy and culture (if infection is suspected)

2.6 Transcutaneous Bilirubinometry

This is an instrument measuring bilirubin level using spectrophotometry. While there is
good correlation between transcutaneous serum bilirubin readings and serum bilirubin
levels in term infants over the range of 10-13mg/dl (175 – 225µmol/L), at higher serum
bilirubin levels, it has higher negative predictive values, and is thus better for screening
purposes. Transcutaneous bilirubinometry had been said is sensitive and cost effective.
However, gestational age of infants, sites of reading, phototherapy, and skin pigmentation
can potentially affect the reliability of the readings. There is inadequate evidence to
advocate the use of Tran scutaneous bilirubinometry

3 TREATMENT

3.1 Phototherapy
The aim of phototherapy is to prevent potentially dangerous bilirubin levels and to
decrease the need for exchange transfusion, since phototherapy changes bilirubin into
more soluble forms to be excreted in the bile or urine. The effectiveness of phototherapy
is affected by the intensity, or irradiance, of the phototherapy light, increased irradiance
producing increased effectiveness, until the saturation dose of 40 µW/cm2/nm of
appropriate light is reached. The minimum irradiance is 6-12 µW/cm2/nm. Other factors
affecting the effectiveness are the spectrum of light delivered by the phototherapy unit,
the surface area of the infant exposed to phototherapy, and the distance of the light source
from the baby, the optimum distance being 35 - 50 cm in conventional lights. In addition,
overheating of the flourescent lamps used in phototherapy causes a rapid decay of the
phosphor resulting in incorrect emission spectrum of the lamps. Increasing bilirubin
concentration has a positive effect on the efficacy of phototherapy. Finally, the postnatal
age and gestational age of the infant also has a bearing, phototherapy being most
effective in very small preterm infants, and least effective in severely growth retarded
full term infants.

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3.1.1 Types of phototherapy
Types of Light wavelength Light intensity Color/type of bulbs
phototherapy (nm) (µW/cm2/nm)
Conventional 425-475 6-12 -Many variation
phototherapy -Blue/special blue/
-Day light fluorescent
tube
- Tungsten- halogen
lamps

Fibre optic 400 – 500 35 Fibreoptic cable

phototherapy (+/- 20%) containing 2000 –
(Biliblanket) 2400 individual
acrylic fibres

Intensified 26 – 40 High intensity blue

phototherapy over head lamps with
lamps placed below
infant also
Fibreoptic blanket
with standard
overhead
phototherapy
Several phototherapy
lamps placed around
the infant

3..1.2 The methods of providing intensified phototherapy are as follows:

i. high intensity blue lights ( F20 T12 / BB ) with 7 overhead lamps, and 4 lamps
placed below the infant. To mitigate the alarming blue effect, special blue tubes
may be used in the central portion of a standard phototherapy unit with daylight
fluorescent tubes on either side.
ii. combined fibreoptic blanket with standard phototherapy system above, thus
increasing the surface area of the infant exposed to light.
iii. several phototherapy lamps placed around the infant, if a fibreoptic unit is not
available.
iv. placing a white reflecting surface (e.g. sheet) around the bassinet, so that light is
reflected onto the baby's skin when using a single phototherapy unit so as to
increase the area of exposure.

3.1.3 Colours of phototherapy light

White light is recommended for non-hemolytic jaundice regardless of gestational age and
birth weight, since it is effective, inexpensive, and adequate in most cases (Tan, 1986)
[Level 4]..Blue light, however provides a more rapid response and shorter duration of
treatment (Donzelli, 1995) [Level 4]. High intensity blue light is the treatment of choice
for infants with rapidly increasing or high venous serum bilirubin not responding to white
phototherapy as mentioned above. However, the rebound is greater, and nursing and
clinical monitoring is more difficult (Tan, 1992) [Level 4]

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Phototherapy : Practical considerations.
Position light source 35-50 cm from top surface of the infant (when conventional
fluorescent photolight are used)
Expose infant appropriately
Cover infant's eyes
Turn infant every 2 hours
Monitor serum bilirubin levels as indicated
Monitor infant's temperature 4 hourly to avoid chilling or overheating
Allow parental-infant interaction
Turn off light during feeding and blood taking
Measure intensity of phototherapy light periodically using irradiance meters
Discontinue phototherapy when bilirubin is less than threshold levels and has been falling
for 24 hours. In infants without haemolytic disease, the average bilirubin rebound after
phototherapy is less than 1 mg/dl (17 µmol/dl). Discharge from hospital need not be
delayed in order to observe the infant for rebound, and in most cases, no further
measurement of bilirubin is necessary. However, if phototherapy is initiated early and
discontinued before the infant is 3 to 4 days old, additional ambulatory follow-up may be
necessary
Hydration- there is no evidence to support any influence of excess fluid administration on
serum bilirubin concentration. Some infants admitted with high bilirubin levels may also
be mildly dehydrated, and may need fluid supplementation. More frequent breastfeeding
is recommended because it inhibits the enterohepatic circulation of bilirubin and thus
lowers the serum bilirubin level. Other routine supplementation e.g. with dextrose water
is not indicated

Once the baby is on phototherapy, visual observation as a means of monitoring is

unreliable. Serum bilirubin levels must guide the management.

3.2 Exchange Transfusion (ET)

Bilirubin levels beyond which kernicterus may occur if an ET is not carried out have not
been established. The modality of treatment should be based on the clinical history, risk
factors and physical examination of the infants. The table and graph below illustrates the
recommended levels for various modalities of treatment adapted from the American
Academy of Pediatrics as well as the College of Family Physicians of Canada taking into
consideration that Malaysian babies have been known to have higher levels of significant
jaundice and consequently at higher risk of developing kernicterus.
Exchange transfusion is recommended if serum bilirubin levels though declining with
intensive phototherapy, persists above the level for exchange transfusion. It is also
recommended in those infants whose levels continue to rise to exchange transfusion

6
 levels despite being on phototherapy. Cessation of feeds and hydration with intravenous
fluids is only recommended when an exchange transfusion is impending.

Table 2: Recommended action levels for management of neonatal jaundice in healthy

term newborns
Total Serum Bilirubin levels (µmol/l )
Hours of life Phototherapy ET if ET + Intensive
Phototherapy fails phototherapy
*< 24 - - -
24 200 340 400

48 250 400 425

72 250 420 450

>72 >250 450 475

* Term infants who are clinically jaundiced at 24 hrs. of age or less are not considered

healthy and require further evaluation.

500
450
400
350
Total serum 300
Bilirubin (µmol/L)
250
200
150
100
Photo
50
KIV ET
ET 0
24 48 72 96

Hours of life

Graph 1: Recommended action levels for phototherapy and exchange transfusionin

healthy term newborns
(source: level of various modalities of treatment adapted from the American Academy of
Pediatrics & College of Family Physicians of Canada)

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3.3 Drug Treatment
Phenobarbitone, cholestyramine (Nicolopoulos, 1978, Tan et al., 1984) [Level 7], agar
(Harold et al., 1973 [Level 8] Gerard et al., 1983, Caglayan et al., 1993) [Level 7] and
vitamin E (Gross, 1979) [Level 8] have been investigated in the past to treat neonatal
hyperbilirubinemia, but there is no evidence to support the use of these. More recently tin
potoporphyrin and tin mesoporphyrin (Jorge, 1999, [Level 3]; Valaes, 1994 [Level 6];
Kappas 1995 [Level 3] have been used. These competitively inhibit the activity of heme
oxygenase, the rate limiting enzyme in heme catabolism, thus reducing the production of
bilirubin. Side effects are transient erythema at the site of the intramuscular injection of
the metalloporphyrin if concomitant phototherapy is also administered. There is limited
knowledge (Cooke, 1999) [Level 8] on long term effects of these drugs and hence they
are currently not recommended.

3.4 Breastfeeding and Jaundice

1. Interruption of breastfeeding in healthy term newborns is discouraged and
frequent breast-feeding (at least 8-10 times every 24 hours) should be continued.
2. Supplementation of breast-feeding with formula with or without phototherapy can
be considered. Supplementing with water or dextrose water does not lower bilirubin level
in jaundiced, healthy, breast-feeding infants (Nicoll., 1982 ) [Level 8]

Table 3. Treatment Options for Jaundiced Breast-fed Infants

__________________________________________________________________
Observe
Continue breast-feeding; administer phototherapy
Supplement breast -feeding with formula with or without phototherapy
__________________________________________________________________

4 PREVENTIVE MEASURES FOR SEVERE NNJ

1. Maternal prenatal testing should include ABO and Rh(D) typing. When the
mother is Rh-negative, a direct Coombs’ test, ABO blood type, and an Rh(D) type
on the infant’s (cord) blood are recommended (American Academy of Pediatrics,
1992, Ministry of Health Malaysia, 1999).
2. All infants must have a glucose -6-phosphate dehydrogenase (G6PD) screening
done on cord blood (Ministry of Health Malaysia, 1999). The results of G6PD
screening must be known before discharge and special management is indicated
for those infants found deficient (Ministry of Health Malaysia, 2000).
3. Infants whose mothers are of O blood group and infants with a strong family
history of severe neonatal jaundice should be observed for at least 24 hours in the
ward. If earlier discharge is necessary, arrangements must be made for these
infants to be reviewed the following (Ministry of Health Malaysia , 1999).
4. Mothers must be assisted and provided support to manage breastfeeding
successfully before discharge.

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5. Approximately one third of healthy breast-fed infants have persistent jaundice
after 2 weeks of age (Alonso, 1991). A measurement of total and direct serum
bilirubin should be obtained and a history of dark urine or light stools should be
sought. If the history, physical examination and direct bilirubin results are normal,
continued observation is appropriate
6. Parents must be alerted to the significance of early onset (within 24 hours) and
severe jaundice and advised that in these situations medical attention is necessary.
7. Follow-up should be provided to all neonates discharged less than 48 hours after
birth by a health care professional in an ambulatory setting, or at home within 2-3
days of discharge (Seidman et al., 1995, Catz et al., 1995 )

9
5. Algorithm Management of Jaundice in Healthy Terms Newborns

Newborns with Jaundice

Carry out clinical assessment

History
Physical examination
Assess severity of Jaundice

Signs & symptoms present

- Jaundice below umbilicus
- Jaundice up to soles of feet
- Rapid rise of serum bilirubin > 8.5 Exist this algorithm
mol/l/hrs
- Prolonged jaundice >. 14 days No Symptoms
- Family history – heamolytic
disease/kernicterus
- Clinical symptoms -sepsis

Jaundice Breast Fed -

infant

Refer Pediatrician

Observe
Continue breast feeding –
Investigation
phototherapy
- total serum bilirubin Supplement breast feeding with
- unconjugated & conjugated fraction in
formula – with/without
specific conditions
phototherapy
- Direct Coomb’s test
- G6PD status
- Full blood count
- Reticulocyte count
- Peripheral blood film
- Blood culture, urine microscopy & culture
- Transcutaneous Bilirubinometry

Measure infant Total Serum

Bilirubin

10
Hours of life Total Serum Bilirubin Levels (µmol/l)
Phototherapy ET if Phototherapy ET + Intensive Phototherapy
Fails
* < 24 - - -
24 200 340 400
48 250 400 425
72 250 420 450
>72 >250 450 475

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6. REFERENCES
1. Adams JA, Hey DJ, Hall RT. Incidence of hyperbilirubinemia in breast- vs.
formula-fed infants. Clin Pediatr (Phila). 1985 Feb;24(2):69-73

2. Alonso EM, Whitington PF, Whitington SH, Rivard WA, Given G. Enterohepatic
circulation of non-conjugated bilirubin in rats fed with human milk. J Pediatr.
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3. American Academy of Pediatrics, American College of Obstetricians and

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i

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23. Nicolopoulos D Combined treatment of neonatal jaundice with cholestyramine
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