Jaundice can be a normal part of the neonatal period (certainly both of my kids looked like the Yellow M&M for a short period in their beginnings); however, hyperbilirubinemia also generates the concern for the development of kernicterus (abnormal accumulation of unconjugated bilirubin in the brain).
- The AAP has a practice guideline (Management of hyperbilrubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:297-316. APP.) that aims to help us determine how to manage these patients and prevent complications. We have all seen the nomogram that we reference when determining whether a neonate needs phototherapy or exchange transfusion.
- There is also a handy website (that I have absolutely no affiliation with… but I do use anytime this issue comes up)… check it out: http://bilitool.org/)
Some Important Points to Keep in Mind:
- Physiologic jaundice in healthy, full-term newborns typically develops during the 2nd – 3rd day of life.
- Physiologic jaundice in healthy, full-term newborns typically resolves by the 5th or 6th day.
- Premature neonates are at greater risk! Also, the nomogram only pertains to those greater than 35 weeks gestational age.
- The nomogram is based on TOTAL bilirubin (not fractionated bilirubin).
- Consider DDx:
a. Conjugated – biliary atresia, hepatitis (HSV?), biliary cholestasis, alpha-1-antitrypsin deficiency
b. Unconjugated – SEPSIS, ABO incompatibility, hereditary spherocytosis, Gilbert’s syndrome, Crigler-Najjar syndrome, glucose-6-phosphate deficiency, breastfeeding vs. breast-milk.
Evaluation (after you’ve determined there is hyperbilirubinemia):
- Total and Fractionated Bilirubin
- Blood Type with Rh factor
- Coomb’s test
- CBC w/ Diff
- Reticulocyte count
- Consider sepsis work-up as well. Remember that these neonates don’t do many things to show you that they are sick… hyperbilirubinemia may be the one red flag that they are able to raise.