Pediatric emergency medicine trisk 2473 2473
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Conjugated bilirubin is reported as direct and is elevated because of obstructed
excretion.
Goals of Treatment. The goals of ED evaluation of the icteric infant include
rapid diagnosis of the acutely treatable causes of icterus (sepsis, obstruction,
metabolic disease), prevention of kernicterus and brain injury, and reassurance
when the jaundice is physiologic.
Clinical Considerations
Clinical Recognition. In a child with true jaundice, the sclera will be yellow.
Jaundice in the first 24 hours of life of a term newborn is pathologic. Full-term,
well-appearing neonates over 1 day of age often have physiologic or breast-milk
jaundice. Physiologic jaundice is benign. Bilirubin levels spike close to day 3 of
life and then decrease. Breast-feeding jaundice may present in the first few days,
before sufficient milk production, or may present later, for unknown reasons.
Breast-fed infants may have prolonged unconjugated hyperbilirubinemia lasting
up to several weeks, thought to be related to compounds in breast-milk.
Clinical Assessment. Infants presenting with jaundice require a careful history,
looking for timing of jaundice onset, stool and urine color, breast or bottle
feeding, maternal and infant blood type, traumatic delivery, and maternal history
of diabetes, hepatitis, and medications. A careful examination should assess for
cephalohematoma and signs of infection. Acholic stools generally indicate biliary
obstruction or severe hepatic failure.
CBC, total bilirubin level, and direct bilirubin level should be obtained. A
direct Coombs test should be obtained if maternal blood type in unknown,
hemoglobin is low, or total bilirubin is at levels requiring intervention (see
below). Consider blood typing mother and neonate for ABO and Rh factors if
unknown. Rh incompatibility is uncommon in mothers who have received
prenatal care.
Infants presenting with elevated indirect bilirubin, direct bilirubin less than
15% of the total, and normal stool color have unconjugated hyperbilirubinemia.
Causes of unconjugated hyperbilirubinemia include physiologic jaundice, breastmilk jaundice, breast-feeding jaundice, hemolytic disease, blood group
incompatibility, infection, dehydration, polycythemia, abnormalities in the
conjugating enzyme (UDP-glucuronosyltransferase or UGT) as with Crigler–
Najjar syndrome or Lucey–Driscoll syndrome, Gilbert syndrome, or
hypothyroidism.
