In this episode, we discuss things you’ll need to know and think about before seeing an infant with jaundice. We will focus on infants from birth to 2 months of age. We will discuss the pathophysiology of hyperbilirubinemia, the difference between unconjugated and conjugated hyperbilirubinemia, the differential diagnosis, key elements of the history and physical exam, laboratory and imaging workup, and management.

• Introduction to jaundice and hyperbilirubinemia
  
  
  • Jaundice is the yellowing of skin, sclerae, and mucous membranes caused by hyperbilirubinemia
  
  
  • Hyperbilirubinemia can be further separated into unconjugated or conjugated forms, which allows us to further differentiate etiology
  
  



• Review of bilirubin breakdown pathway, to include enterohepatic circulation


• Unconjugated hyperbilirubinemia etiologies:
  
  
  • Excessive or increased production of bilirubin
    
    
    • Cephalohematomas
    
    
    • Hemolysis: ABO and Rh incompatibilities; Red Blood Cell (RBC) membrane or enzyme defects, RBC oxidative stress (secondary to sepsis, asphyxia, and acidosis)
    
    
  
  
  
  • Decreased clearance of bilirubin
    
    
    • Breast milk jaundice
    
    
    • Prematurity
    
    
    • Hypothyroidism
    
    
    • Gilbert Syndrome
    
    
    • Crigler-Najjar Syndrome
    
    
    • Suboptimal Intake Jaundice
    
    
    • Medications
    
    
  
  
  
  • Combination of both
    
    
    • Physiologic jaundice
    
    
  
  
  



• Conjugated hyperbilirubinemia etiologies:
  
  
  • Always pathologic
  
  
  • Biliary atresia
  
  
  • Briefly mentioned the vast range of other etiologies: infectious, genetic, metabolic, and anatomic
  
  



• Key elements of history and physical examination for a jaundiced infant
  
  
  • History:
    
    
    • Onset
    
    
    • Feeding patterns (what, how much/often, quality of feeding)
    
    
    • Urine and stool diapers
    
    
    • Prenatal history
    
    
    • Delivery history
    
    
    • Family history
    
    
  
  
  
  • Physical exam:
    
    
    • Growth curves
    
    
    • Assessing liver size: percussion vs scratch test
    
    
    • Neurologic exam
    
    
  
  
  



• Review of laboratory and imaging work up for a jaundiced infant


• Brief discussion on management of unconjugated hyperbilirubinemia etiologies
  
  
  • Feeding
  
  
  • Phototherapy
  
  
  • Review of neurotoxicity risk factors
  
  



• Brief discussion on management of conjugated hyperbilirubinemia, specifically biliary atresia
  
  
  • Early referral to Pediatric Gastroenterology
  
  
  • Kasai portoenterostomy
  
  
  • Liver transplant
  
  
  • Maximizing nutrition
  
  

Resources/Links:

• Kemper, A. R., Newman, T. B., Slaughter, J. L., Maisels, M. J., Watchko, J. F., Downs, S. M., ... & Russell, T. L. (2022). Clinical practice guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 150(3).


• Pan, D. H., & Rivas, Y. (2017). Jaundice: newborn to age 2 months. Pediatrics in Review, 38(11), 499-510.


• Chou, J. PediTools. AAP 2022 Hyperbilirubinemia management guidelines. https://peditools.org/bili2022/. Published 2012. Updated 2023. Accessed Aug 18, 2023.