Jaundice occurs in approximately 60–80 % of newborn infants, is characterized by elevated levels of bilirubin in the blood (hyperbilirubinemia), and has a benign course in most cases [1–4]. However, due to bilirubin encephalopathy, current recommendations from the Brazilian Society of Pediatrics (SBP) and the two most recent guidelines of the American Academy of Pediatrics (AAP) indicate the need for all infants to undergo a risk assessment for hyperbilirubinemia at least once before hospital discharge [3,5,6].

Visual assessment of jaundice on physical examination is not reliable for estimating total bilirubin (TB) or identifying infants at risk for a rapid increase in TB, especially those with dark skin [7]. Thus, TB measurement by serum or transcutaneous methods is recommended [1,3,5,6].

Severe (TB > 25 mg/dL) and extreme (TB > 30 mg/dL) hyperbilirubinemia, if not identified and treated promptly, can cause severe permanent neurological damage, defined as bilirubin encephalopathy [5,6,8,9], whose main risk factors are the level of TB reached and the duration of exposure to bilirubin [8,9]. Therefore, accurate assessment of newborns at an increased risk of developing severe hyperbilirubinemia is now a major challenge in the prevention of acute and chronic bilirubin encephalopathy [4–6,10].

In Brazil, programs for monitoring neonatal jaundice in the first week of life have not been systematically evaluated [11]. In the last 25 years, a Brazilian university tertiary hospital has implemented a follow-up clinic to monitor neonatal jaundice during the first week of life, aiming to monitor newborn infants prone to developing concerning levels of hyperbilirubinemia. Consistent with American studies, this program demonstrated the effectiveness of implementing a well-established bilirubin screening protocol before hospital discharge, resulting in fewer readmissions for phototherapy, lower bed occupancy rates, reduced hospitalization costs, and, most importantly, improved mother-infant bonding and breastfeeding [12,13–16].

Thus, this study evaluated the implementation of a similar follow-up protocol for newborns with jaundice, born at a gestational age > 35 weeks and weighing > 2000 g during the first week of life, at risk of hyperbilirubinemia, and born in a non-teaching secondary-level general hospital.

During the 5 months of the study, 605 infants were born at the hospital. Of these, 60 were referred to the neonatal intensive care unit and 45 to the intermediate care unit and were not included in the study. Of the remaining 500 patients, with a birth weight ≥ 2000 g and gestational age of ≥ 35 weeks, 432 were evaluated. The remaining 68 patients were excluded because they did not have bilirubin control at discharge, as TcB was undergoing maintenance (Figure 1).

Figure 1.

Selection flowchart of newborn infants with gestational age > 35 weeks and weight > 2000 g born between September 2023 and February 2024.

Approximately one-quarter of mothers (22.2 %) had comorbidities, specifically diabetes mellitus (n = 65/15,0 %) and arterial hypertension (n = 51/11.8 %). Vaginal delivery occurred in 132 women (30.5 %), and delayed umbilical cord clamping was performed in 349 (80.8 %).

Most newborns were female (53.0 %), with a median (IQR) gestational age of 39 (38–39) weeks and mean birth weight [SD] of 3207 [408] g (range, 2160–4145). Among the 432 neonates evaluated, 36 (8.3 %) were classified as small for gestational age. The median length of hospital stay until discharge was 48 (42–51) hours (range, 20–168), and the median (IQR) weight loss rate at discharge was 6.5 (4.7–8.0) %.

The mean TcB level, measured in 425 newborns, was 6.8 [0.1] mg/dL (range, 0–16). The TsB values measured in eight newborns had a mean of 14.2 [0.8] mg/dl (range, 11.2–18.1).

Of the total sample, 302 newborns (69.9 %) had TB below the 40th percentile for age in hours and were referred to the primary care clinics; 106 of them (24.5 %) were between the 40th and 75th percentiles; of these, 72 (67.9 %) were also referred to the pimary care service, and 34 (32.1 %) were referred to the jaundice clinic for reassessment within 72 h because of risk factors for hyperbilirubinemia. Among these, 15 (44.2 %) had low milk intake, four (11.8 %) had blood incompatibility, eight (23.5 %) had siblings with a history of jaundice, one (2.9 %) had a positive direct Coombs test, three (8.8 %) had cephalohematoma, and three (8.8 %) were of Asian descent. Three infants (0.7 %) were in the 95th percentile, and all were referred for follow-up.

As shown in Flowchart 1, in the assessment of compliance with the study protocol, 21 infants (4.8 %) were between the 75th and 95th percentiles. Of these, five (23.8 %) were not referred to the follow-up clinic; however, an active search was conducted after discharge, and adequate follow-up at the primary care facilities was confirmed.

Of the total number of infants evaluated, 53 (12.3 %) were referred for outpatient follow-up. The return rate was 83.0 % (n = 44). Only one consultation was necessary for 84.1 % (n = 37) of the newborns, 11.3 % (n = 5) returned twice, and 4.54 % (n = 2) returned thrice. An active search was conducted for nine (17.0 %) newborns who did not return for follow-up. One of these was not found, three were admitted via the emergency care unit, and five were monitored at basic health units.

Fifteen newborns were readmitted for phototherapy (3.5 %). Their median TB value at readmission was 19.9 ± 0.1mg/dL (IQR, 17.7–20.3). Of these, 53.3 % were female, and none of the three who had TB values ≥ 15mg/dL at discharge were readmitted. Two newborns were readmitted with levels > 25mg/dL, and none > 30 mg/dL. All patients responded quickly to treatment, with a median phototherapy time of 36 (30–48) hours (range, 12–130). None of the patients required an exchange transfusion. Neurological examinations at discharge of the readmitted patients were normal. Of the newborns with bilirubinemia between the 40th and 75th percentiles at discharge, 5.6 % reached bilirubin levels ≥ 20mg/dL.

The implementation of structured strategies for monitoring neonatal jaundice after hospital discharge is crucial for reducing severe hyperbilirubinemia cases and preventing neurological complications. Several studies have reinforced the effectiveness of systematic outpatient follow-up programs, especially for newborns with a gestational age of 35–37 weeks, who are considered the most vulnerable [10,12,16].

Appropriate clinical guidance and risk stratification during hospitalization should be complemented by protocols that include early reassessment after hospital discharge, as advocated by Pan and Rivas [17] who highlight the importance of surveillance until 2 months of age. Home monitoring with supervised phototherapy, adopted by European institutions, has also demonstrated safety and effectiveness in preventing adverse outcomes related to neonatal jaundice [18]. Similarly, Kaplan et al. [19] highlighted the relevance of continuous outpatient surveillance systems with an emphasis on the first early return visit after discharge as a key measure for the timely detection of progressive increases in bilirubin. Such international experiences corroborate the findings of this study and highlight the importance of organizing health services to ensure the early diagnosis and timely management of neonatal hyperbilirubinemia.

This study demonstrated the feasibility of a protocol for monitoring neonatal jaundice in newborns at risk of hyperbilirubinemia, achieving a high outpatient return rate (83 %). It occurred despite challenges faced by public hospitals in scheduling discharge from joint accommodation and referral to outpatient clinics, including difficulties in transporting mothers and newborns back to the hospital. Olusanya et al. [20] highlighted the logistical challenges and need for effective strategies to ensure adequate follow-up of newborns, especially in low- and middle-income countries, where healthcare access barriers are more pronounced. Accordingly, the authors suggest taking advantage of routine immunization visits or other early postnatal opportunities to examine newborns for jaundice onset and progression.

Notably, as part of the safe hospital discharge process, besides measuring TcB and, in some cases, TsB, physicians assessed the family’s capacity to return to the hospital, and either kept the newborn hospitalized to monitor jaundice progression or, by mutual agreement, discharged the infant with scheduled outpatient follow-up [5,6,13].

Bhutani et al. [21] demonstrated that TsB and/or Tcb TB measurements before discharge can accurately predict significant hyperbilirubinemia risk, allowing early intervention and avoiding complications. Similarly, this approach is consistent with the AAP guidelines on the diagnosis, monitoring, and treatment of neonatal jaundice, which recommends assessing newborns for hyperbilirubinemia risk before hospital discharge, using TB measurement and risk factors in the previous guideline. The AAP recommends that the return interval be guided by the difference between the TB at discharge and the TB value indicative of phototherapy, including the risk factors for hyperbilirubinemia [5,6]. Additionally, the 2021 SBP guidelines on neonatal hyperbilirubinemia management recommend weighing the risks and benefits of hospital discharge when epidemiological and/or clinical-laboratory risk factors for significant jaundice are identified [3].

Guidance provided to mothers at the time of discharge is crucial to ensure adherence to the monitoring program, reinforcing the importance of follow-up and the risks associated with hyperbilirubinemia [5,13]. Additionally, rigorous monitoring is essential to prevent the development of severe hyperbilirubinemia and its complications, such as bilirubin encephalopathy [10,13,21]. Surveys conducted through questionnaires in low- and middle-income countries have shown that, although parents can recognize jaundice in newborns, they have insufficient knowledge about its causes, risk factors, and, especially, the warning signs of disease progression and complications. These include the need for hospital treatment, regardless of parental education level or parity. The authors emphasized that sociocultural motivations and traditional practices for managing jaundice may contribute to low adherence to recommended measures for the management and treatment of neonatal jaundice. [22–24] In one study, parents themselves suggested that awareness campaigns and social media programs could help raise awareness of the issue [24]. In Brazil, the Child Health Handbook–Passport to Citizenship, a book given to parents at birth, provides a brief warning about jaundice and its signs [25].

As a suggestion, neonatal units and organizations such as the SBP or nongovernmental groups that promote child health could produce brochures, apps, or posters to educate parents about neonatal jaundice. This approach has been adopted in Australia, where Queensland Health authorities produce specific educational materials for newborn parents [26]. These include informational brochures that clearly explain what neonatal jaundice is, how it presents, and the warning signs that parents should recognize. Detailed guidance is provided on phototherapy and supportive care, advising when to seek medical attention if symptoms persist. The material highlights the importance of follow-up after discharge to safeguard newborn health and ensure continuity of care.

The study also revealed a significant reduction (approximately threefold) in hospitalizations for phototherapy, supporting the effectiveness of the protocol in minimizing prolonged stays in the well-baby nursery and readmission after discharge. However, during the initial implementation phase, requests for readmission of newborns treated at Emergency Care Units increased. An online meeting was held with pediatricians from various institutions in the city, and the issue was quickly resolved. This initiative promoted greater standardization in newborn management, reinforced safe monitoring practices, and helped avoid unnecessary hospitalizations. One point highlighted by local pediatricians who participated in the meeting was that they felt more confident knowing newborns would receive adequate outpatient follow-up and that bilirubin results would be available quickly. For many, this was their first experience with TB assessment and its diagnostic and management role in neonatal jaundice. This finding corroborates the results of Bahr et al., who also observed that in a network of US hospitals, universal TcB screening before hospital discharge significantly reduced severe hyperbilirubinemia, readmissions, and the need for intensive phototherapy [27]. Furthermore, the authors noted that the protocol was well accepted by healthcare professionals, who reported greater safety and confidence when making clinical decisions based on objective data, favoring more standardized and efficient care.

This study demonstrates the feasibility of implementing a systematic jaundice monitoring and follow-up protocol in a secondary hospital, resulting in a significant reduction in hospitalizations for phototherapy and no cases of exchange transfusion, with results like those of other studies published in Brazil [12,13]. The protocol proved effective in ensuring that all newborns, regardless of socioeconomic status, had access to standardized and safe care.

In a subsequent study, it would be valuable to explore the impact of continuing education for healthcare professionals to ensure proper adherence to protocols across different settings. Integration of health systems, as observed in the study, ensures continuity of care, which is crucial to program success and enables rapid and effective interventions, avoiding complications associated with hyperbilirubinemia and improving newborn outcomes [3,6].

Another noteworthy point is the fixed phototherapy thresholds used in this study, which facilitated the health team's adherence to phototherapy indications. The higher thresholds, compared with those of the SBP, were like those currently recommended by the AAP [6]. This protocol proved safe and was associated with a reduced rate of phototherapy, as demonstrated by Balasubramanian et al. They measured the impact of the new AAP guidelines for monitoring and treating hyperbilirubinemia in newborns aged ≥ 35 weeks and found a 50 % reduction in phototherapy use and a 35 % reduction in readmissions compared with the 2004 and 2022 guidelines [28]. Digital decision-support tools based on AAP nomograms (e.g., Bilitool) are widely used in some settings; however, local practice in Brazil is primarily guided by SBP recommendations, which differ from AAP thresholds.

The extension of the minimum length of stay to 48 h may also have contributed to the observed reduction in phototherapy utilization. Because bilirubin levels physiologically rise after 24 h, a longer in-hospital observation window may have improved the identification of upward bilirubin trajectories and enabled timely risk stratification and counseling before discharge. Therefore, the reduction in phototherapy readmissions should be interpreted as the combined effect of systematic bilirubin screening, structured follow-up, and modified discharge timing.

This study has limitations that should be considered when interpreting the results. First, the absolute number of key outcome events, particularly readmissions for phototherapy, was small, which reduces the precision of effect estimates and limits more robust comparative or multivariable analyses. Second, although the return rate among those referred for follow-up was high, 17 % of referred newborns did not attend the scheduled visit. Active searching allowed the clinical trajectory of most of these infants to be identified; however, one case could not be located, and it is not possible to ensure that all absent infants evolved similarly to those who returned, which may introduce bias. Third, the initial implementation phase was subject to operational failures (e.g., non-referral of some newborns in intermediate-high risk zones), although follow-up was subsequently confirmed. Finally, this was a single-center study in a public secondary hospital, and reproducibility in other settings depends on local care flows, resources, and team training.

In conclusion, implementing a structured outpatient follow-up program for neonatal jaundice in a secondary public hospital was feasible and was associated with high adherence and no exchange transfusions, while reducing readmissions for phototherapy during the study period.

Not applicable.

The data that support the findings of this study are available from the corresponding author.