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

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)
    • Pt does not receive adequate oral intake
      • 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)

Diagnosis

  • See phototherapy chart (treatment section) for total bilirubin cutoff by age

Work-Up

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

Treatment

  • 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

Use total bilirubin

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: >=38wk + no risk factors
  • Medium Risk: (>=38wk + risk factors) or (35-37 wk and no risk factors)
  • High Risk: 35-37wk + risk factors
See http://bilitool.org/

References