Jaundice Icteric in Pediatric Emergency

Jaundice in early infancy

There are many causes of jaundice in early infancy. It is clinically defined as the yellow colouration of the skin and sclera. The best approach is to define it, if it is unconjugated or a conjugated jaundice, as this will dictate the approach to investigation and treatment.

Physiological jaundice

Jaundice is very commonly noted in the first 2 weeks of life. It is part of a normal physiological process and affects 50–70% of babies. Mild jaun-dice with onset after 24 hours of life and which is fading by 14 days needs no investigation or treatment.

Causes of neonatal jaundice

Unconjugated

• Breast milk jaundice: 3–5% of breastfed babies
• Prematurity: exaggerated physiological pattern; may last 4 weeks
• Bruising or cephalohematoma: breakdown of heme
• Hemolysis (Rhesus, ABO, G6PD or pyruvate kinase (PK) deficiency, spherocytosis): early onset for ABO, Rhesus
• Sepsis: rarely presents with jaundice alone (occasional for UTI); usually unwell
• Metabolic (e.g. hypothyroidism): prolonged jaundice, can be mixed conjugated/unconjugated
• Polycythemia: delayed cord clamping, twin-to-twin transfusion
• Gilbert or Crigler—Najjar: rare, usually presents as prolonged jaundice
• GI obstruction (e.g. pyloric stenosis)

Conjugated—pale stools/dark urine, raised conjugated bilirubin (>25% total or >25 µ mol/Liter)

• Biliary atresia
• Choledochal cyst
• Neonatal hepatitis (congenital infection, alpha-1 antitrypsin deficiency,often idiopathic)
• Metabolic (galactosemia, fructose intolerance—ask about sucrose/fructose in food/medication)
• Complication of total parenteral nutrition (TPN)

Breast milk jaundice

This is the most common cause of prolonged jaundice beyond 14 days but other causes should be eliminated before this diagnosis is made. A breastfed baby with prolonged unconjugated jaundice, normal stool and urine colour, normal FBC, blood film and Coombs test who is well and thriving probably has breast-milk jaundice. Do not stop breastfeeding. The child should have a review in a general pediatric clinic if not improving or if there are any changes—especially in stool colour.

Conjugated hyperbilirubinemia

This must be excluded as the causes of this pattern need urgent evaluation and treatment. Surgery for biliary atresia is most successful when the condition is diagnosed and treated early. Don’t forget to ask about the color of urine and stools. View a dirty nappy yourself if possible.

Phototherapy or rarely exchange transfusion

This may be necessary in a baby with severe unconjugated jaundice associated with prematurity, hemolytic disease, or rare disorders such as Crigler—Najjar. Outside of these conditions, unconjugated jaundice is unlikely to lead to CNS or hearing problems, and no treatment is usually necessary