Neonatal jaundice

Background

• Must distinguish between unconjugated and conjugated hyperbili
  • Conjugated is always pathologic

Risk Factors

• Isoimmune hemolytic disease
• G6PD deficiency
• Asphyxia
• Significant lethargy
• Temperature instability
• Sepsis
• Acidosis
• Prematurity
• Poor PO intake

Clinical Features

• Jaundice

Differential Diagnosis

Common

• Physiologic
• Breast Milk Jaundice
  • Due to substances in milk that inhibit glucuronyl transferase
  • May start as early as 3rd day, reaches peak by 3rd week of life
  • Unlikely to cause kernicterus
• Breast-Feeding Jaundice (starvation jaundice)
  • Patient does not receive adequate oral intake, best diagnosed by looking for signs of dehydration and comparing weight to birth weight
    • Results in reduced bowel movement/bilirubin excretion

Uncommon

• Direct (conjugated, post- liver obstructive)
  • congenital biliary atresia
  • neuroblastoma
  • cholesterol cysts
• Cellular
  • hepatitis
  • galactosemia
  • sepsis
  • TORCHS
  • tyrosinemia
  • alpha 1 antitrypsis deficiency
• Indirect (unconjugated, pre-liver)
  • sepsis
  • hypotension
  • rH/ABO incompatibility
  • G6PD Deficiency
  • RBC membrane defects

Evaluation

1. See phototherapy chart (treatment section) for total bilirubin cutoff by age
2. History extremely important
   • Mother's blood type (important if mother is RH negative or O blood type)
   • PO intake, signs of dehydration?
   • Baby's general appearance (well appearing?)

Work-Up

• Tbil/Dbil
• CBC (for hemolytic anemia)
• Consider coombs or T&S (mom & baby)

Management

• Breast Milk Jaundice
  • Do not need to routinely stop breast-feeding
  • Treat with phototherapy when necessary
• Breast-Feeding Jaundice (Starvation Jaundice)
  • Supplement with expressed breast milk or formula
• Exchange transfusion
  • Consider if signs of bilirubin encephalopathy
    • Hypertonia, arching, retrocollis, opisthotonos

Phototherapy Guidelines

Total Bilirubin Cutoff by Risk Group

Age	Low Risk	Medium Risk	High Risk
Birth	7.0	5.0	4.0
24h	11.5	9.0	8.0
48h	15	14	10
72h	17.5	15	14
96h	20	17.5	14.5
5+days	21	17.5	15

• Low Risk: ≥38 weeks + no risk factors
• Medium Risk: (≥38 weeks + risk factors) or (35-37 weeks and no risk factors)
• High Risk: 35-37 weeks + risk factors

See Also

• Neonatal resuscitation
• Jaundice

External Links

• http://bilitool.org/