This post contains links to Neonatal Jaundice podcasts and scripts (Parts 1 through 3) from PedsCases*.
Link to Script for Neonatal Jaundice, Parts 1 through 3.
Neonatal Jaundice (Part 1) Podcast Excerpts:
- Jaundice (also known as hyperbilirubinemia) is COMMON and affects over half of term babies and almost ALL premature neonates.
- Severe hyperbilirubinemia must be treated in order to prevent bilirubin-induced neurologic dysfunction, the long term result which is kernicterus.
- When suspecting neonatal jaundice, use a Bhuntani nomogram to quantify the degree of hyperbilirubinemia, to determine whether treatment is needed.
Neonatal Jaundice (Part 2) Podcast Excerpts:
- The majority of term infants with hyperbilirubinemia do NOT have an underlying serious medical condition. Physiologic jaundice resolves spontaneously as the babe’s hepatic system matures.
- Pathologic unconjugated hyperbilirubinemia has a multitude of causes but can simply be divided into two main categories of increased production and decreased clearance.
- Conjugated hyperbilirubinemia is ALWAYS pathologic. Biliary atresia must be differentiated from the other causes as the treatment is surgical rather than medical, and has a better outcome when performed earlier.
History (See p 10 of Script PDF for details)
Physical (See p 11 of Script PDF for details)
Investigations (See pp 12+ 13 of Script PDF for details)
The first and most important test, is to QUANTIFY the level of bilirubin in order to determine if it needs to be treated or not.
Current guidelines state that either [a blood sample or a transcutaneously] should be measured in all infants within the first 72 hours of life, sometimes with the metabolic screening test (heel poke).
The Bhutani nomogram can then be used to compare the babe’s bilirubin levels to the thresholds for treatment, and determine the risk of progression to severe hyperbilirubinemia.
In infants that have severe or prolonged hyperbilirubinemia, they should be further investigated with a conjugated bilirubin in order to determine whether this is a conjugated or unconjugated hyperbilirubinemia.
If the hyperbilirubinemia is unconjugated, further work-up may be necessary. If hemolysis is suspected, a CBCdif, blood group of mother and infant, a peripheral blood smear, and a Coombs test* should be performed.
*The Coombs’ Tests – Direct Comb’s Test and Indirect Combs Test from the Sanford Medicine Newborn Nursery.
Returning to Neonatal Jaundice (Part 3)
If the baby is unwell or has a fever, a septic work-up should take place with a CBCdif, blood & urine cultures, and possibly a lumbar puncture.
If neonatal metabolic screening has not been undertaken, a TSH and
G6PD screen should also occur.
If the hyperbilirubinemia is determined to be conjugated, the work-up should be focused on determining whether the cause is hepatic or extra-hepatic in nature. Liver enzymes (in the form of AST & ALT), coagulation studies (done with a PT & PTT) and an albumin should all be drawn.
Suspected infection should elicit a CBCdif, TORCH screen and
An abdominal U/S and/or HIDA scan can be used to rule out biliary
atresia or cysts, and lastly, a metabolic screen (if not already performed) should be done to rule out hypothyroidism and cystic fibrosis.
- When taking a history around jaundice, always ask about birth history, nutritional history and family history to help rule out underlying pathologic causes.
- Any neurological signs or symptoms found on physical exam are a huge red flag and warrants immediate investigation.
- Current guidelines encourage screening for hyperbilirubinemia within the first 72 hours of life with either a transcutaneous bilirubin or a blood draw. Other investigations for jaundice are only warranted when a pathologic cause is suspected or the hyperbilirubinemia is considered prolonged or severe.
- Hyperbilirubinemia is treated by addressing the underlying cause. In unconjugated hyperbilirubinemia, symptomatic treatment involves phototherapy.
- Exchange transfusion should be started immediately if any infant presents with signs of acute bilirubin encephalopathy.
Additional Resource From the American Academy of Pediatrics:
- Hyperbilirubinemia in the newborn infant > or =35 weeks’ gestation: an update with clarifications [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Pediatrics. 2009 Oct;124(4):1193-8. doi: 10.1542/peds.2009-0329. Epub 2009 Sep 28.
Additional Resources (From Stanford Medicine Newborn Nursery):
Jaundice, Coombs, and Phototherapy