Jaundice

General Overview

• Usually due to hyperbilirubinemia (Bili >2xULN)
  • If jaundiced but normal bilirubin, consider carotenemia
• Mostly unconjugated

DDx Unconjugated Bilirubin

• Overproduction (hemolysis)
• Impaired hepatic uptake (reduced blood flow, drugs)
• Impaired conjugated (Gilber or Crigler-Najjar)

Risk for Severe Hyperbilirubinemia

• Jaundice in first 24h of life (always pathologic)
• Positive direct antiglobulin test (DAT/Coombs)
• Known hemolytic disease (G6PD)
• Premature
• Previous sibling with severe hyperbilirubinemia/phototherapy
• Bleeding/bruising (cephalohematoma)
• East Asian
• Exclusive breastfeeding

History

• Prenatal, antenatal, postnatal/neonatal course
• Family History

Physical Exam

• Vitals r/o sepsis, r/o anemia
• Weight, and % weight loss from BW
• Hydration/feeding status
• Sclerae most sensitive (if sclerae unaffected, consider carotenemia)
• Signs of bleeding, bruising, hematoma (hemolysis)
• Abdominal exam (hepatosplenomegaly)

Management

• Rule out sepsis
• Phototherapy as indicated
• Investigations
  • CBC (hemoglobin)
    • If no anemia, rule out liver disease
  • Total bilirubin
    • If conjugated, requires different work-up
    • Serum bilirubin q4h until decreasing then q12h until normal
  • Neonatal blood type
  • Coombs test (r/o autoimmune hemolysis)
  • Smear
  • Consider G6PD in severe hyperbilirubinemia or high risk population/family history

Hyperbilirubinemia in Infants

• Mothers screened for ABO, Rh(D), RBC Ab
  • If mother not tested, consider blood group and DAT (Coombs test)
• Follow-up weight (and compare to birth weight), intake, voiding, stooling, jaundice
• TcB (Transcutaneous) screen at 72h of life and prior to discharge
  • Add TcB to 95% confidence interval to estimate maximum probably TSB concentration
  • Total serum bilirubin if abnormal TcB or clinical jaundice