A Practical Approach to Neonatal Jaundice - UCSF Fresno

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The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. Figure 2. associated with the development of severe hyperbilirubinemia, as listed in Table 2. 2 An infant who was deliveredatlessthan38weeks’gestationandwhois breastfeeding exclusively is at higher risk of developing severe hyperbilirubinemia than a formula-fed infant whowasdeliveredat40weeks’gestation. 2 The combination of risk factor awareness, a screening predischarge TcBorTSBlevelplottedonanomogram,andclinical judgment can guide the physician in determining the timing of discharge and follow-up evaluations. Newbornsshouldbeexaminedwithin24to72hoursof hospital discharge to assess for jaundice and general wellbeing. 2 An infant should be seen by the age of 72 hours if discharged before 24 hours; by the age of 96 hours if dischargedbetween24and47.9hours;andbytheageof 120 hours if discharged between 48 and 72 hours. 2 Earlier follow-up (within 24 to 48 hours) should be instituted for infants with more risk factors for severe hyperbilirubinemia, shorter hospital stays, or predischarge bilirubinlevelsinthehigh-intermediateorhigh-riskzones. Table 2. Risk Factors for Development of Severe Hyperbilirubinemia in Infants Delivered at 35 Weeks’ Gestation or Later Major risk factors Predischarge TcB or TSB level in high-risk range Jaundice in first 24 hours after delivery ABO incompatibility and positive Coombs’ test G6PD deficiency Delivery at 35 to 36 weeks’ gestation Sibling received phototherapy Cephalohematoma or significant bruising Exclusively breastfeeding, especially if not well established East Asian race Minor risk factors Predischarge TcB or TSB level in high-intermediate–risk range Delivery at 37 to 38 weeks’ gestation Jaundice before hospital discharge Sibling had jaundice Macrosomia; mother has diabetes Mother older than 25 years Male sex G6PD = glucose-6-phosphate dehydrogenase; TcB = transcutaneous bilirubin; TSB = total serum bilirubin. Adapted with permission from American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics. 2004;114(4):1138]. Pediatrics. 2004;114(1):301. 1258 American Family Physician www.aafp.org/afp Volume 77, Number 9 May 1, 2008
Neonatal Jaundice For example, Baby C is a breastfed infant delivered at 36 weeks’ gestation who has a predischarge bilirubin level in the low-intermediate range. Therefore, he has two major risk factors for severe hyperbilirubinemia and should be seenintheprimarycareofficewithin24hoursofhospitaldischarge.BabyD,whohasthesamepredischarge bilirubin level as Baby C, is a formula-fed infant delivered at 39 weeks’ gestation. Therefore, Baby D has no risk factorsandcanbeseen48hoursafterdischarge. Outpatient evaluation should include follow-up on weight,intake,voiding,andstooling. A TSBorTcBlevel should be obtained in the outpatient setting if jaundice is increasing or if the clinical assessment is unclear as totheseverityofjaundice.Becausevisualestimationof jaundice is often inaccurate, liberal testing of TcB and TSBlevelsisasaferapproach. 2 Table 3. Differential Diagnosis of Neonatal Hyperbilirubinemia Hyperbilirubinemia type Hemolysis present Hemolysis absent Unconjugated Conjugated Common Blood group incompatibility: ABO, Rh factor, minor antigens Infection Rare Hemoglobinopathies: thalassemia Red blood cell enzyme defects: G6PD, pyruvate kinase Red blood cell membrane disorders: spherocytosis, ovalocytosis Common Breast milk jaundice Infant of mother with diabetes Internal hemorrhage Physiologic jaundice Polycythemia Rare Hypothyroidism Immune thrombocytopenia Mutations of glucuronyl transferase (i.e., Crigler- Najjar syndrome, Gilbert syndrome) Pyloric stenosis Common Cytomegalovirus infection, hyperalimentation cholestasis, neonatal hepatitis, sepsis, TORCH infection, urinary tract infection Rare Biliary atresia, cystic fibrosis, hepatic infarction, inborn errors of metabolism (e.g., galactosemia, tyrosinosis) G6PD = glucose-6-phosphate dehydrogenase; TORCH = toxoplasmosis, other viruses, rubella, cytomegaloviruses, herpes (simplex) viruses. Adapted with permission from Gowen CW Jr. Anemia and hyperbilirubinemia. In: Kliegman R. Nelson Essentials of Pediatrics. 5th ed. Philadelphia, Pa.: Elsevier Saunders; 2006:318. HOSPITAL PROTOCOLS Allnewbornnurseriesneedtoestablishaprotocolfor identifying and evaluating hyperbilirubinemia. Some institutions with such a protocol report a reduced proportion of neonates with hyperbilirubinemia, its complications, and subsequent hospitalizations. 17,18 One study showed that the combined use of the AAP nomogram andapredischargerisk-factorassessmenthasastronger predictive value than the nomogram alone, especially in infantswithelevatedTSBlevels. 19 Protocols should specify circumstances in which nurses can obtain bilirubin measurements. Some hospitals perform universal screening with TcB or TSB measurement on every newborn. If universal screeningisnotperformed,bilirubinmeasurementshouldbe performedoneverynewbornwithjaundiceinthefirst 24 hours after birth, when jaundice appears excessive for age, and when the degree of jaundice is unclear. 2 Routine discharge counseling should include an explanation of monitoring for jaundice;thisshouldideallybeprovidedin verbal and written formats. Printer-friendly patient information handouts about infant jaundice are available in English and Spanish at http://familydoctor.org/756.xml. Evaluation of Elevated Bilirubin Levels The differential diagnosis of neonatal hyperbilirubinemia is broad. Table 3 6 lists the mostcommoncauses;however,thepointat which intervention is recommended is based onpercentilesfortheinfant’sageinhours, regardless of the cause. Laboratory evaluation may vary based on certain indications in the infant (Table 4 2 ). A healthy, full-term (i.e., completion of 36 weeks’ gestation) infant with a mildly elevatedbilirubinleveldoesnotrequireany laboratory studies beyond TSB measurement. An infant with physical examination findings that explain the level of jaundice (e.g.,largehematoma)doesnotrequirefurtherwork-up,althoughtheinfantmayrequire ongoing monitoring. Other laboratory studiesshouldbeconsiderediftheinfantrequires phototherapy (Figure 3 2 ) or if the TSB level is increasing rapidly. ABO incompatibility and glucose-6-phosphate dehydrogenase (G6PD) deficiencyarethemostcommoncausesof hemolytic anemia. If these conditions are May 1, 2008 Volume 77, Number 9 www.aafp.org/afp American Family Physician 1259
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