Neonatal jaundice

Background

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

Work-Up

1. Tbil/Dbil
2. CBC (for hemolytic anemia)
3. Coombs or T&S (mom & baby)

DDx

Common

1. Physiologic
2. Breast Milk Jaundice
   1. Due to substances in milk that inhibit glucuronyl transferase
   2. May start as early as 3rd day, reaches peak by 3rd week of life
   3. Unlikely to cause kernicterus
3. Breast-Feeding Jaundice (starvation jaundice)
   1. Pt does not receive adequate oral intake
      1. Results in reduced bowel movement/bilirubin excretion

Uncommon

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

Treatment

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

Phototherapy Guidelines

See http://bilitool.org/

Age	Low risk pt cut-off	Med risk pt cut-off	High risk pt cut-off
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+day	21	17.5	15

• Use total bilirubin

Low Risk: >=38wk + no risk factors

Med Risk: (>=38wk + risk factors) or (35-37 wk and no risk factors)

High Risk: 35-37wk + risk factors

Risk Factors

1. Isoimmune hemolytic disease
2. G6PD deficiency
3. Asphyxia
4. Significant lethargy
5. Temperature instability
6. Sepsis
7. Acidosis

Source

UpToDate, Tintinalli