Skip to Main Content


Rare disorder characterized by development of a gray-brown discoloration that may persist for months in neonates undergoing phototherapy for neonatal hyperbilirubinemia.


Neonatal Jaundice.




Combination of hepatocellular dysfunction and increased bilirubin products from photodestruction during phototherapy. The exact source of the pigment is unknown; it may be a photoisomer of natural bilirubin. Phototherapy with bilirubin acts as a catalyst, forming photoproducts from copper-bound porphyrins, causing skin discoloration.


Age and clinical course (appearance of the discoloration with the use of phototherapy), liver biopsy (hepatocellular dysfunction with decreased excretion of bile constituents and photooxidation products at the level of bile canaliculi). Causative factor for the hyperbilirubinemia should be determined by appropriate tests.


Discoloration usually improves over time. Outcome usually is benign in cases where the hyperbilirubinemia is caused by icterus neonatorum, although the prognosis depends on the causative liver disease. Risk of bilirubin encephalopathy may be increased.


Exclude other causes of discoloration (e.g., cyanosis, gray baby syndrome from chloramphenicol overdose). Evaluate severity of hepatic dysfunction and determine the underlying cause of impairment. Kernicterus should be excluded and appropriate treatment instituted (exchange transfusion, phenobarbital). Preoperative investigations should include a complete blood count, liver function tests, coagulation studies, arterial blood gas analysis, urea, and creatinine.


Anesthetic issues related to neonatal period should be considered (immaturity of various systems, differences in pharmacokinetics and pharmacodynamics). Adequate hydration should be maintained in patients with significant hyperbilirubinemia to prevent development of renal failure. Administer vitamin K. If prothrombin time is abnormal, clotting factors should be available. Hypotension should be avoided to minimize the reduction in hepatic perfusion. Anesthetic management of the neonate must take into account the causative factor for the development of hyperbilirubinemia. The perioperative risk is significantly increased in the presence of kernicterus. Factors known to precipitate seizures in neonates should be avoided (e.g., hypoxia, hypercarbia, hyponatremia, hypoglycemia).


Hepatocellular dysfunction prolongs the elimination half-life of drugs excreted via the biliary system (e.g., pancuronium, vecuronium). Atracurium or cisatracurium is the drug of choice for paralysis. Halothane should be avoided in view of a theoretical risk of hepatitis, especially since sevoflurane is available for inhalational induction. Anesthetic agents that are proconvulsants should be avoided.

Ashley JR, Littler CM, Burgdorf WH, et al: Bronze baby syndrome. J Am Acad Dermatol 12:325, 1985.  [PubMed: 3973126]
Bertini G, Dani C, Fonda C, et al. Bronze baby syndrome and the risk of kernicterus. Acta Paediatr 94:968, 2005.  [PubMed: 16188824]
Rubaltelli FF, Da Riol R, D'Amore ES, Jori G: The bronze baby syndrome: evidence of increased tissue concentration of copper porphyrins. Acta Paediatr 85:381, 1996.  [PubMed: 8696003]

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


Create a Free MyAccess Profile

* Required Fields

Note: If you have registered for a MyAccess profile on any of the Access sites, you can use the same MyAccess login credentials across all sites.

Passwords must be between 6 and 40 characters long (no whitespace), cannot contain characters #, &, and must contain:
  • at least one lowercase letter
  • at least one uppercase letter
  • at least one digit

Benefits of a MyAccess Profile:

  • Remote access to the site off-campus on any device
  • Notification of new content via custom alerts
  • Bookmark your favorite content such as chapters, figures, tables, videos, cases and more
  • Save and download images to PowerPoint
  • Self-Assessment quizzes saved for quick review
  • Custom Curriculum access for both instructors and learners

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.