Pediatric emergency medicine trisk 0889 0889
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Exclusively breast-fed infants are at risk for exaggerated physiologic jaundice due
to a relative caloric deprivation during the first few days of life. Decreased
volume and frequency of feeds may result in a mild dehydration, as well as
increased enterohepatic circulation. This is mitigated by increasing the frequency
of feedings, improving latch and positioning, and occasionally by supplementing
with formula in order to improve caloric intake.
Pyloric stenosis, duodenal atresia, malrotation with volvulus, meconium ileus,
and Hirschsprung disease may present with jaundice along with other clinical
signs of gastrointestinal (GI) obstruction. In neonates, obstruction can increase
enterohepatic circulation resulting in unconjugated hyperbilirubinemia. Older
children with jaundice in the setting of GI obstruction generally have a
conjugated hyperbilirubinemia (see Chapter 44 Jaundice: Conjugated
Hyperbilirubinemia ).
Jaundice may be evident in cases of serious infection, such as sepsis and the
congenital TORCH (Toxoplasmosis, Other [e.g., syphilis, parvovirus], Rubella,
Cytomegalovirus, Herpes simplex virus) infections. Bacterial endotoxins reduce
bile flow, thereby impairing its excretion and leading to hyperbilirubinemia.
Sepsis is exceedingly rare among well-appearing jaundiced neonates who have no
additional signs or symptoms.
Intrauterine or breast milk exposure to certain drugs or toxins may also lead to
impaired excretion of bilirubin in the neonate.
EVALUATION
Evaluation should always begin with a detailed history and physical examination.
It is imperative to know the serum bilirubin level early in the course of
evaluation. The need for additional studies—laboratory testing, imaging studies—
is guided by the findings on history and physical examination.
History
Certain features of the birth history are critical in the evaluation of a neonate who
presents with jaundice and concern for hyperbilirubinemia: gestational age, date
and time of birth, birth weight, details of delivery (e.g., use of instrumentation
such as forceps or vacuum), and maternal blood type and Rh status, as well as
maternal exposure to infections such as syphilis. The history should also include a
detailed feeding history, including type of milk and quantity, duration, and
frequency of feeds. Urine output and character of stool should be elicited.
Additionally, the presence or absence of other features that may indicate etiology
(e.g., fever, emesis, lethargy) should be established. Exposures and previous
bilirubin levels and the results of Coombs test should be reviewed, if applicable.
