Difference between revisions of "Neonatal jaundice"

(Differential Diagnosis)
(Management)
 
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==Clinical Features==
 
==Clinical Features==
*Jaundice
+
*[[Jaundice]]
 
*Scleral icterus
 
*Scleral icterus
*Lethargy
+
*Lethargy (if progression to severe elevation)
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
===Indirect (Unconjugated) Hyperbilirubinemia===
+
{{Neonatal jaundice differential diagnosis}}
''More common causes are listed first, followed by less common causes
 
*[[Breast milk jaundice]]
 
**Due to substances in milk that inhibits glucuronyl transferase. It may start as early as 3rd day and reaches peak by 3rd week of life. It is unlikely to cause kernicterus
 
*[[Breast feeding jaundice]]
 
**Patient does not receive adequate oral intake which then causes reduced bowel movement/bilirubin excretion. Best diagnosed by looking for signs of dehydration and comparing weight to birth weight.
 
*Blood group incompatibility: ABO, Rh factor, minor antigens
 
*Diabetic mother/gestational diabetes
 
*Internal hemorrhage
 
*Physiologic jaundice
 
*Polycythemia
 
*[[Sepsis]]
 
*Hemoglobinopathies: thalassemia
 
*Red blood cell enzyme defects: [[G6PD Deficiency]], pyruvate kinase
 
*Red blood cell membrane disorders: spherocytosis, ovalocytosis
 
*Hypothyroidism
 
*[[Immune thrombocytopenic purpura]]
 
*Mutations of glucuronyl transferase (i.e., Crigler-Najjar syndrome, Gilbert syndrome)
 
  
 
+
==Evaluation==
===Direct (Conjugated) Hyperbilirubinemia===
+
{{Neonatal jaundice evaluation}}
''Conjugated bilirubinemia implies a hepatic or post hepatic cause. More common causes are listed first.
 
*Hyperalimentation cholestasis
 
*Neonatal [[hepatitis]]
 
*Cytomegalovirus infection
 
*[[Sepsis]]
 
*TORCH infection
 
*Biliary atresia
 
*Cystic fibrosis
 
*Hepatic infarction
 
*Inborn errors of metabolism (e.g., galactosemia, tyrosinosis)
 
 
 
==Evaluation and Workup-Up==
 
===Laboratory evaluation===
 
*Tbil/Dbil
 
*CBC (for hemolytic anemia)
 
*Consider coombs or T&S (mom & baby)
 
===Evaluation===
 
#See [http://bilitool.info BiliTool] (treatment section) for total bilirubin cutoff by age
 
#History extremely important
 
#*Mother's blood type (important if mother is RH negative or O blood type)
 
#*Assess for any signs of decreasing oral intake or signs of dehydration?
 
#*Baby's general appearance (well appearing?)
 
  
 
==Management==
 
==Management==
 
*Breast Milk Jaundice
 
*Breast Milk Jaundice
 
**Do not need to routinely stop breast-feeding
 
**Do not need to routinely stop breast-feeding
**Treat with phototherapy when necessary
+
**If bilirubin elevated beyond 10 mg/dL:
 +
***Stop feeding for 1-2 days, substitute with bottle, and then resume breast milk
 +
***Recurrence of prior hyperbilirubinemia is uncommon upon resuming
 +
**Treat with phototherapy when levels exceed 20 mg/dL
 
*Breast-Feeding Jaundice (Starvation Jaundice)
 
*Breast-Feeding Jaundice (Starvation Jaundice)
 
**Supplement with expressed breast milk or formula
 
**Supplement with expressed breast milk or formula
*Exchange transfusion
+
*[[Exchange transfusion]]
**Consider if signs of bilirubin encephalopathy
+
**Consider if signs of bilirubin encephalopathy, typically only occurs when the indirect bili level exceeds 25
 
***Hypertonia, arching, retrocollis, opisthotonos
 
***Hypertonia, arching, retrocollis, opisthotonos
 +
*Direct hyperbilirubinemia
 +
**If new diagnosis, always admit to the hospital for further evaluation
  
 
===Phototherapy Guidelines===
 
===Phototherapy Guidelines===
{| class="wikitable"
+
{{Phototherapy guidelines}}
|+Total Bilirubin Cutoff by Risk Group
+
Note: Phototherapy is only used for an indirect hyperbilirubinemia
|-
 
| '''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
 
  
|-
+
==Disposition==
| 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==
 
==See Also==
*[[Neonatal resuscitation]]
+
{{See also neonatal jaundice}}
*[[Jaundice]]
 
  
 
==External Links==
 
==External Links==
 
*[http://bilitool.org BiliTool]
 
*[http://bilitool.org BiliTool]
 +
*[https://peditools.org/bili/ PediTools]
  
 
==References==
 
==References==
 
<references/>
 
<references/>
 
[[Category:Pediatrics]]
 
[[Category:Pediatrics]]

Latest revision as of 00:30, 7 October 2018

Background

  • Neonatal jaundice can affect up to 84% of term newborns and is often a benign process that is quickly corrected once identified. It is also the most common cause for hospital readmission for neonates post birth.[1]
  • The most important piece of the evaluation is distinguishing between unconjugated and conjugated hyperbilirubinemia since a conjugated (direct) hyperbilirubinemia is always pathologic and often more severe

Risk Factors for Neonatal Jaundice

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

Clinical Features

  • Jaundice
  • Scleral icterus
  • Lethargy (if progression to severe elevation)

Differential Diagnosis

Indirect (Unconjugated) Hyperbilirubinemia

More common causes are listed first, followed by less common causes

  • Breast milk jaundice
    • Due to substances in milk that inhibits glucuronyl transferase. It may start as early as 3rd day and reaches peak by 3rd week of life. It is unlikely to cause kernicterus
  • Breast feeding jaundice
    • Patient does not receive adequate oral intake which then causes reduced bowel movement/bilirubin excretion. Best diagnosed by looking for signs of dehydration and comparing weight to birth weight.
  • Blood group incompatibility: ABO, Rh factor, minor antigens
  • Diabetic mother/gestational diabetes
  • Internal hemorrhage
  • Physiologic jaundice
  • Polycythemia
  • Sepsis
  • Hemoglobinopathies: thalassemia
  • Red blood cell enzyme defects: G6PD Deficiency, pyruvate kinase
  • Red blood cell membrane disorders: spherocytosis, ovalocytosis
  • Hypothyroidism
  • Immune thrombocytopenic purpura
  • Mutations of glucuronyl transferase (i.e., Crigler-Najjar syndrome, Gilbert syndrome)

Direct (Conjugated) Hyperbilirubinemia

Conjugated bilirubinemia implies a hepatic or post hepatic cause. More common causes are listed first.

Evaluation

  • The most important component of the workup is differention of direct vs indirect bilirubinemia
  • See BiliTool and the phototherapy guide for total bilirubin cutoff by age recommendations
  • History extremely important
    • Mother's blood type (important if mother is RH negative or O blood type)
    • Assess for any signs of decreasing oral intake or signs of dehydration?
    • Baby's general appearance (well appearing?)
  • Total bilirubin/Direct bilirubin levels
  • CBC (for evaluation of hemolytic anemia or polycythemia vera)
  • Consider coombs or T&S (mom & baby)

Management

  • Breast Milk Jaundice
    • Do not need to routinely stop breast-feeding
    • If bilirubin elevated beyond 10 mg/dL:
      • Stop feeding for 1-2 days, substitute with bottle, and then resume breast milk
      • Recurrence of prior hyperbilirubinemia is uncommon upon resuming
    • Treat with phototherapy when levels exceed 20 mg/dL
  • Breast-Feeding Jaundice (Starvation Jaundice)
    • Supplement with expressed breast milk or formula
  • Exchange transfusion
    • Consider if signs of bilirubin encephalopathy, typically only occurs when the indirect bili level exceeds 25
      • Hypertonia, arching, retrocollis, opisthotonos
  • Direct hyperbilirubinemia
    • If new diagnosis, always admit to the hospital for further evaluation

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

Note: Phototherapy is only used for an indirect hyperbilirubinemia

Disposition

See Also

External Links

References

  1. Sgro M, Campbell D, Shah V. Incidence and causes of severe neonatal hyperbilirubinemia in Canada. CMAJ. 2006;175(6):587–590.