Pediatric emergency medicine trisk 0892 0892
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Hepatic function should be assessed in patients with hepatomegaly or in those
with hyperbilirubinemia in the absence of anemia. Neonates with symptoms or
newborn screen suggestive of congenital hypothyroidism should have a free T4
level obtained, along with TSH.
Imaging Studies
If clinical signs of obstruction are present, the patient should undergo appropriate
imaging studies such as abdominal radiographs, ultrasound, or upper GI series
with contrast.
MANAGEMENT
The goal of neonatal hyperbilirubinemia management is to prevent BIND. The
jaundiced newborn needs to be kept well hydrated, and enteral feeding should be
encouraged to promote bilirubin excretion. When bilirubin levels rise
significantly, phototherapy and exchange transfusion may be indicated.
Phototherapy
Indications for phototherapy vary according to the age of the neonate; in the term
neonate who develops jaundice and has no evidence of hemolysis, indications for
phototherapy as recommended by the AAP Subcommittee on Hyperbilirubinemia
are shown in Figure 45.1 . When there is evidence of isoimmune hemolysis,
phototherapy should be started immediately and a neonatologist should be
consulted regardless of TSB level.
Phototherapy may be delivered by an overhead bank of lights or via a fiberoptic light source in a blanket and should be initiated in the ED if an alternate site
is not available quickly. The mechanism of phototherapy involves wavelengths of
light that alter the unconjugated bilirubin in the skin, and convert it to less toxic,
water-soluble photoisomers that may be excreted in the bile and urine without
conjugation. TSB levels decline by 1 to 2 mg/dL within 4 to 6 hours using
conventional phototherapy.
During phototherapy, the baby should be undressed to maximize the exposed
surface area of the skin. The infant must wear an eye shield when using overhead
lights in order to prevent retinal damage. Other risks of phototherapy include
temperature instability, loose stools, rash, and interruption of breast-feeding.
Studies suggest an association with phototherapy and subsequent development of
long-term complications such as seizures and childhood cancers; although risks
are modest and uncertain, they highlight the pitfalls of overtreatment and
unnecessary exposure to phototherapy. Phototherapy is relatively contraindicated
