Abstract Neonatal Hyperbilirubinaemia is a common finding during the first postnatal week. Physiological jaundice occurs in first week of life in 60% of term and 80% of premature neonates. Non physiologic or pathologic jaundice occurs in 5-10% of newborns which require intervention. According to AAP guidelines laboratory investigation for jaundice include total serum bilirubin, blood Type and coombs test and if the baby has an elevation of direct reacting or conjugated bilirubin, there should be a urine analysis and urine culture. Here we are presenting 5 cases that developed indirect hyperbilirubinaemia and routine workup done according to AAP guidelines were normal. On extensive investigation all cases found to have urinary tract infection despite of having indirect bilirubin and they needed course of antibiotics according to sensitivities and follow up ultrasound. From our experience we suggest that UTI should be considered as a cause of neonatal jaundice especially when indirect bilirubin peaks after one week of life at mean age of 10.8 ± 2.38 days. Keywords: Hyperbilirubenemia. UTI (urinary tract infection). Introduction Hyperbilirubenemia is the commonest morbidity in neonatal period. The incidence of jaundice in the first week of birth is 60% among term and 80% among premature neonates. About 5-10% of newborns required intervention. 1-3 Jaundice attributable to physiological immaturity, usually appears between 24 to72hrs of age in term and by 5th to7th day in preterm neonates and disappears by 10-14 days of life. 2 Most jaundice is benign, but because of potential toxicity of bilirubin to developing brain, newborn infants must be monitored to identify those who might develop severe hyperbilirubinaemia and in rare cases acute bilirubin encephalopathy or kernicterus. 1 AAP has published guidelines outlining the management of healthy newborn with hyperbilirubinaemia, which includes maternal and infant blood grouping, Rh typing, direct coombs test and total serum bilirubin level and if the baby has direct hyperbilirubinaemia then investigate for urinary tract infection. Urinary tract infections (UTIs) are a common problem in febrile infants younger than 8 weeks of age, with prevalence between 5% and 11%. Jaundice can be one of the earliest symptoms of urinary tract infection therefore investigating for UTI in the infants with unexplained hyperbilirubinaemia is suggested as part of the workup for jaundice. 2 Complete clinical assessment is needed in all cases of prolonged jaundice, however the indications and extent of investigation remain unclear. 3 With the literature review it is somehow clear that unexplained, prolonged and direct hyperbilirubinaemia requires urine analysis but the question remains, should one investigate urine in case of indirect hyperbilirubinaemia. Clinical manifestations of UTI are non specific in neonates. The incidence of UTI is between 0.1% and 1% of all newborn, with higher incidence in premature infants. 3 The manifestation of sepsis and UTI are nonspecific in neonates and the consequences of misdiagnosis and delayed treatment could lead to significant morbidity. Here we are presenting summary of five newborns who developed indirect hyperbilirubinaemia after one week of life. Hyperbilirubinaemia workup was found to be normal. However on extensive investigation they were found to have positive urine culture with gram negative organism. Case Summaries We are reporting 5 cases that presented with neonatal jaundice in the second week of life at mean age of 10.8 ± 2.38 days and were treated with photo therapy. On examination no signs of infection were found and on investigation no common cause like ABO incompatibility, Rh incompatibility, and G6PD deficiency was detected. On further investigating the babies, Case 1, 2, 4 and 5 had proven urinary tract infection with positive urine C/S with different sensitivities. Case 3 although had no growth in urine culture (Baby had received antibiotic at another hospital) but her urine detailed report was significant for TLC count of 16/HPF. On follow up ultrasound KUB all were reported as normal. All specimens were collected aseptically through bladder catherization. Details of cases are illustrated in the table. 735 J Pak Med Assoc Urinary tract infection presenting as jaundice in neonates Noureen Afzal, Maqbool Qadir, Sonia Qureshi, Rehan Ali, Shakeel Ahmed, Khalil Ahmad Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi. Corresponding Author: Noureen Afzal. Email: noureen.afzal@aku.edu Case Series