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 hyperbilirubinemiaHyperbilirubinemia can be further separated into unconjugated or conjugated forms, which allows us to further differentiate etiologyReview of bilirubin breakdown pathway, to include enterohepatic circulationUnconjugated hyperbilirubinemia etiologies: Excessive or increased production of bilirubin CephalohematomasHemolysis: 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 jaundicePrematurityHypothyroidismGilbert SyndromeCrigler-Najjar SyndromeSuboptimal Intake JaundiceMedicationsPhysiologic jaundiceConjugated hyperbilirubinemia etiologies: Always pathologicBiliary atresiaBriefly mentioned the vast range of other etiologies: infectious, genetic, metabolic, and anatomicKey elements of history and physical examination for a jaundiced infant OnsetFeeding patterns (what, how much/often, quality of feeding)Urine and stool diapersPrenatal historyDelivery historyFamily historyGrowth curvesAssessing liver size: percussion vs scratch testNeurologic examReview of laboratory and imaging work up for a jaundiced infantBrief discussion on management of unconjugated hyperbilirubinemia etiologies FeedingPhototherapyReview of neurotoxicity risk factorsBrief discussion on management of conjugated hyperbilirubinemia, specifically biliary atresia Early referral to Pediatric GastroenterologyKasai portoenterostomyLiver transplantMaximizing nutritionKemper, 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.