September 11, 2023

Before You See an Infant with Jaundice

26 minutes

In this episode, we discuss things you’ll need to know and think about before seeing an infant with jaundice. We will focus on infants from birth to 2 months of age. We will discuss the pathophysiology of hyperbilirubinemia, the difference between unconjugated and conjugated hyperbilirubinemia, the differential diagnosis, key elements of the history and physical exam, laboratory and imaging workup, and management.

Introduction to jaundice and hyperbilirubinemia

Jaundice is the yellowing of skin, sclerae, and mucous membranes caused by hyperbilirubinemia

Hyperbilirubinemia can be further separated into unconjugated or conjugated forms, which allows us to further differentiate etiology

Review of bilirubin breakdown pathway, to include enterohepatic circulation

Unconjugated hyperbilirubinemia etiologies:

Excessive or increased production of bilirubin

Cephalohematomas

Hemolysis: ABO and Rh incompatibilities; Red Blood Cell (RBC) membrane or enzyme defects, RBC oxidative stress (secondary to sepsis, asphyxia, and acidosis)

Decreased clearance of bilirubin

Breast milk jaundice

Prematurity

Hypothyroidism

Gilbert Syndrome

Crigler-Najjar Syndrome

Suboptimal Intake Jaundice

Medications

Combination of both

Physiologic jaundice

Conjugated hyperbilirubinemia etiologies:

Always pathologic

Biliary atresia

Briefly mentioned the vast range of other etiologies: infectious, genetic, metabolic, and anatomic

Key elements of history and physical examination for a jaundiced infant

History:

Onset

Feeding patterns (what, how much/often, quality of feeding)

Urine and stool diapers

Prenatal history

Delivery history

Family history

Physical exam:

Growth curves

Assessing liver size: percussion vs scratch test

Neurologic exam

Review of laboratory and imaging work up for a jaundiced infant

Brief discussion on management of unconjugated hyperbilirubinemia etiologies

Feeding

Phototherapy

Review of neurotoxicity risk factors

Brief discussion on management of conjugated hyperbilirubinemia, specifically biliary atresia

Early referral to Pediatric Gastroenterology

Kasai portoenterostomy

Liver transplant

Maximizing nutrition

Resources/Links:

Kemper, A. R., Newman, T. B., Slaughter, J. L., Maisels, M. J., Watchko, J. F., Downs, S. M., ... & Russell, T. L. (2022). Clinical practice guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 150(3).

Pan, D. H., & Rivas, Y. (2017). Jaundice: newborn to age 2 months. Pediatrics in Review, 38(11), 499-510.

Chou, J. PediTools. AAP 2022 Hyperbilirubinemia management guidelines. https://peditools.org/bili2022/. Published 2012. Updated 2023. Accessed Aug 18, 2023.

...more

View all episodes

By MedReady

4.9

2121 ratings