Neonatal Jaundice

also see Adult jaundice

More than half of newborns will develop clinical jaundice in the first week of life. Risk factors include maternal diabetes, male gender, prematurity, and Asian ethnicity.
Physiologic jaundice is characterized by bilirubin rising at a rate of <5 mg/dL per 24 hours, with a peak of 5 to 6 mg/dL during the second to the fourth days of life and a decrease to <2 mg/dL by 5 to 7 days

<24 h Hemolysis due to ABO, Rh incompatibility
Congenital infection (rubella, toxoplasmosis, cytomegalovirus infection)
Excessive bruising from birth trauma (cephalohematoma or intramuscular hematoma)
Acquired infection (e.g., sepsis, pneumonia)
2–3 d Physiologic
3 d–1 wk Acquired infection (e.g., sepsis, urinary tract infection, pneumonia) Complete sepsis evaluation:
 - LP
 - Blood Culture
 - Peripheral smear
 - CBC, CMP
 - Retic Count
 - Total Bili
 - Coombs test
Management:
 - Empiric ABx
Congenital decrease in glucuronyl transferase (e.g., Crigler-Najjar syndrome, Gilbert syndrome)
Congenital infections (syphilis, toxoplasmosis, cytomegalovirus infection)
>1 wk Breast milk jaundice
Acquired infection (e.g., sepsis, urinary tract infection, pneumonia)
Biliary atresia
Congenital and acquired hepatitis
Red cell membrane defects (e.g., sickle cell anemia, spherocytosis, elliptocytosis)
Red cell enzyme defects (e.g., glucose-6-phosphate dehydrogenase deficiency)
Hemolysis due to drugs
Endocrine disorders (hypothyroidism)
Metabolic disorders (galactosemia, fructosemia)
Pyloric stenosis

 
Hemolytic Rh and ABO incompatibility Check maternal Coombs' antibody for signs of isoimmunization
 
Hereditary spherocytosis Spherocytes may be noted on peripheral smear. Confirm with a red cell osmotic fragility test.
 
G6PD deficiency


 
An X-linked disorder seen most commonly in African, Mediterranean, and Asian families.


 
Non-Hemolytic Enclosed hemorrhage
(Cephalohematoma)
As blood is resorbed, bilirubin levels will ↑.
Inherited disorders of Conjugation Examples include Crigler-Najjar and Gilbert syndrome.
Physiologic (normal) May be due to ↑ hematocrit (even in the absence of true polycythemia) & initial lack of gut flora. In order for jaundice to be physiologic, it must appear after the first 24 hours of life, may not rise by > 5 mg/dL per day, & should not exceed 15 mg/dL total. Bilirubin levels should peak on day 4 or 5 of life; jaundice typically resolves by the first week.
 
Breast milk jaundice Most likely related to free fatty acids in breast milk, which can → ↑enterohepatic circulation of bilirubin. Typically appears after the first week and may persist for many weeks.
 
Breast-feeding jaundice Related to dehydration while the mother's milk supply is coming in; resolves when feeding is well established.
 
Infection Congenital and acquired infections may → jaundice.

 
The rate of kernicterus fell sharply following the introduction of phototherapy and exchange transfusions, but recently it has risen again with the ↑ in early hospital discharges.

Any jaundice that arises in the first 24 hours of life should be considered pathologic and requires further evaluation

Causes of neonatal jaundice: CHIMPS
Cephalohematoma
Hemolysis
Inherited disorders
Milk
Physiologic
Sepsis

Admit Orders: Hyperbilirubinemia

1. Admit to:
2. Diagnosis: Hyperbilirubinemia.
3. Condition: Guarded.
4. Vital Signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights, monitor skin color, monitor for lethargy and hypotonia.
7. Diet:
8. IV Fluids: Isotonic fluids at maintenance rate (100-150 mL/kg/day). Encourage enteral feedings if possible, Hold Breast feeding.
9. Special Medications:
  -Phenobarbital 5 mg/kg/day PO/IV q12-24h [elixir: 15 mg/5mL, 20 mg/5mL; inj: 30 mg/mL, 60 mg/mL, 65 mg/mL, 130 mg/mL].
  -Phototherapy if bilirubin level is above 15-20 mg/dL. Bili-Blanket
  -Exchange transfusion for severely elevated bilirubin.
10. Symptomatic Medications:
11. Extras and X-rays:
12. Labs: Total bilirubin, indirect bilirubin, albumin, CMP, CBC, reticulocyte count, blood smear. Blood group typing of mother and infant, a direct Coombs’ test. In infants of Asian or Greek descent, glucose-6-phosphate dehydrogenase (G6PD) should be measured.