Jaundice in Infants – Indirect

Jaundice is the presence of a yellow hue of the skin, sclerae, or mucous membranes due to elevation of serum bilirubin; it usually becomes apparent at a total serum bilirubin level of 5 mg/dL. It is present in approximately 60% of term infants and 80% of premature infants during the first week of life. Although the indirect form is neurotoxic, differentiating the nonpolar, lipid-soluble, indirect form from the potentially more serious polar, water-soluble direct form represents the most important first step.

Differential Diagnosis

• Icterus neonatorum (physiologic jaundice)
  –The most common form of indirect jaundice in infants under 14 days of age
  –Caused by increased bilirubin production with transient limited conjugation abilities
• Breast-feeding jaundice
  –Occurs in first week of life in 13% of breast-fed infants
  –Secondary to poor volume intake
• Breast-milk jaundice
  –Occurs in about 2% of breast-fed infants after day 7 of life
  –Secondary to glucuronidase in breast milk
• Hematologic: Hemolysis increases bili load
  –Rh incompatability
  –ABO incompatability
  –Glucose-6-phosphate dehydrogenase (G6PD) deficiency
  –Pyruvate kinase deficiency
  –Hereditary spherocytosis
  –Elliptocytosis
  –Thalassemia
  –Polycythemia
• Extravascular blood
  –Cephalohematoma
  –Trauma
  –Swallowed maternal blood
• Endocrinologic
  –Hypothyroidism
  –Maternal diabetes
• Sepsis
• Metabolic
  –Crigler-Najjar I
  –Crigler-Najjar II (Arias syndrome)
  –Crigler-Najjar III
• Cardiopulmonary
  –Congestive heart failure
  –Patent ductus arteriosus
  –Portal vein thrombosis
• Anatomic
  –Pyloric stenosis
  –Duodenal atresia/stenosis
  –Duodenal web
• Drugs
  –Oxytocin
  –Sulfonamides
  –Ceftriaxone
  –Chuen-Lin
• Lucey-Driscoll syndrome

Workup and Diagnosis

• History
  –Prenatal/perinatal: Pregnancy complications, gestational age, maternal blood type/Rh, drug use, infections, delivery method, delivery intervention, birth weight, newborn screen results, previous miscarriages
  –HPI: Onset of jaundice, feeding tolerance, appropriate weight gain, trauma, evidence of bleeding/bruising, urine output, stool output/diarrhea, emesis, lethargy, drug exposure
  –Diet history: Breast- and/or formula-fed, length of time on each breast, latch strength
  –Family history: Bleeding disorders, perinatal deaths, endocrinopathies

• Physical exam
  –Weight, overall appearance, level of jaundice, fontanelle size, cranial abnormalities, scleral icteris, mucous membranes, cardiac murmurs, hepatosplenomegaly, bruising, bleeding, reflexes, tone, seizures
• Labs: Fractionated bilirubin (total, indirect, direct), CBC with smear, reticulocyte count
• Hemolysis: Blood type/Rh, Coombs, hemoglobin electrophoresis
• Thyroid function tests (check state newborn screen)
• Limited value of imaging unless looking for obstruction or bleeding
• Hearing evaluation if kernicterus likely

Treatment

• Treatment options vary based on level of bilirubin, age of presentation, and cause
  –Goal is prevent levels high enough to cause kernicterus
• Phototherapy involves the use of photon energy to change the structure of bilirubin and permit excretion without glucuronidation
  –Decisions for use are age-based
  –Considered when serum level above 14 mg/dL
• Exchange transfusion should be considered with serum levels above 25 mg/dL
• IVF or breast-feed more frequently to increase volume
  
• Correct endocrine abnormality
• Improve perfusion if cardiac problem
• Correct anatomic abnormality
• Consider enteral binding agents
  –Cholestyramine, charcoal, calcium phosphate
• Crigler-Najjar: Phenobarbital, may need liver transplantation

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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