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Jaundice in early infancy

  • See also

    Recognition of the seriously unwell neonate and young infant

    Key Points

    1. If significant jaundice is clinically suspected, a serum bilirubin level should be performed as visual estimation of jaundice is unreliable
    2. The majority of jaundice in well infants is physiological, and does not require investigation and management
    3. Features suggestive of pathological jaundice include: onset <24 hours old, unwell baby, elevated conjugated bilirubin component, prolonged jaundice, pale stool.  These require prompt investigation and management

    Background

    • Jaundice (or hyperbilirubinaemia) occurs in approximately 60% of full term and 80% of pre-term babies within the first week of life
    • Hyperbilirubinaemia occurs when there is an imbalance between bilirubin production, conjugation and elimination
    • Kernicterus is a rare complication of neonatal unconjugated hyperbilirubinaemia that can lead to major long-term neurological sequelae

    Assessment

    • Jaundice within the first 24 hours
    • Unwell/febrile child
    • Dark urine and pale stools (biliary obstruction)
    • Significant weight loss >10% within the first week of life
    • Cephalohaematoma or significant bruising

    History

    Feature

    Further information

    Age of onset

    • <24 hours is pathological
    • >2 weeks is prolonged

    Antenatal course

    • Maternal blood group and antibodies
    • Maternal infectious serology

    Birth

    • Birth trauma
    • Instrumental delivery

    Feeding

    • Breast vs formula feeds
    • Poor weight gain

    Output (urine/stools)

    • Hydration status
    • Dark urine and pale stools (biliary obstruction)

    Family history

    • ABO/Rhesus
    • Spherocytosis/ G6PD deficiency
    • Prolonged jaundice
    • Thyroid dysfunction

    Examination

    • General tone
    • Neurological exam
    • Hydration status: capillary refill time, heart rate, mucous membranes
    • Plethora                                 
    • Bruising/ cephalohaematoma
    • Hepatosplenomegaly
    • Pattern and degree of jaundice

    Management

    Investigations

    • Total serum bilirubin (SBR): unconjugated (indirect) and conjugated (direct), then FBE and Coombs depending on clinical presentation
    • Transcutaneous bilirubinometers (TCB) can be used as a screening tool to assess bilirubin levels from 24 hours – 2 weeks of age in near-term infants.
      • Needs confirmation with serum bilirubin if within 50 micromol of treatment threshold
      • Reliability of TCB decreases after phototherapy commenced
      • SBR should always be used to check rebound levels
    • TCB/SBR should be plotted on an appropriate gestation-based chart/nomogram in order to determine need for treatment

    Type

    Causes

    Investigations

    Early Onset:
    ( <24 hours)

    PATHOLOGICAL

    All should have:

    • FBE
    • SBR
    • Coombs

    Sepsis

    Please refer to Recognition of the seriously unwell neonate and young infant

    Haemolysis:

    • Isoimmunisation – ABO or Rhesus D alloantibodies
    • RBC enzyme defects – G6PD, hereditary spherocytosis, alpha thalassemia
    • Haemorrhage – cerebral, intra-abdominal 
    • Blood extravasation – (bruising/birth trauma)

    FBE, film and reticulocytes
    Neonatal blood group
    Direct antiglobulin test (Coombs)
    (G6PD screen)

     

    Peak Onset
    (24 hours – 14 days)

    No further investigations needed unless red flags

     

    Physiological jaundice

    No further investigations required unless red flags

    Dehydration/insufficient feeding

    Serum sodium, BGL
    No further investigations required

    Sepsis

    Please refer to Recognition of the seriously unwell neonate and young infant

    Haemolysis

    FBE, film and reticulocytes
    Neonatal blood group
    Direct antiglobulin test (Coombs)
    (G6PD screen)

    Breastmilk jaundice

    Diagnosis of exclusion after considering above causes

    Bruising, birth trauma

    No further investigations required

    Prolonged/ conjugated
    (>2 weeks)

    All should have:

    • SBR (unconjugated/ conjugated),
    • FBE, film and reticulocytes,
    • TFTs
    • group and DAT
    • LFTs if conjugated bilirubin >10%

    Sepsis

    Please refer to Recognition of the seriously unwell neonate and young infant

    Haemolysis

    FBE, film and reticulocytes
    Neonatal blood group
    Direct antiglobulin test (Coombs)
    (G6PD screen)

    Dehydration/ insufficient feeding

    Serum sodium, BGL
    No further investigations required

    Breastmilk jaundice

    Diagnosis of exclusion after considering above causes

    Hypothyroidism

    TFTs (to exclude central hypothyroidism)

    Conjugated
    (At any age point)

    If conjugated fraction >10% of total bilirubin

     

    Refer to a specialty unit

    Neonatal hepatitis

    LFTs, maternal infectious serology, metabolic screening

    Extrahepatic obstruction:
    Biliary atresia, choledochal cyst, bile plug

    LFTs, coags, abdominal US
    Note: a normal ultrasound does not exclude biliary atresia

    Metabolic 

    Alpha-1 anti-trypsin levels, urinary reducing substances

    Drugs/Parenteral nutrition

    Investigations as appropriate after history and exam

    Treatment

    1)  Assessment & treatment of jaundice:

    • Severity of jaundice is judged based on a newborn’s age and gestation, as well as clinical presentation, hydration status, and other risk factors
    • Please refer to local charts

    Phototherapy

    • Refer to local protocol regarding intensity of lights required (including biliblanket use) and monitoring
    • Ongoing close monitoring of weight, hydration, and bilirubin levels should be performed during treatment as per local protocol, with serial checks of SBR to ensure resolution of hyperbilirubinaemia

    Exchange transfusion

    • Should only be performed in, or in conjunction with, a Neonatal Intensive Care Unit
    • Contact local paediatric retrieval service for support

    2) Treatment of the cause

    Cause

    Management

    Sepsis

    Immediate treatment as per SEPSIS – assessment and management with IV antibiotics

    Haemolysis

    Discuss with local paediatric services

    Dehydration/ feeding concerns

    Hydration, feeding plan and support
    Consider maternal and child health nurse & lactation consultant involvement

    Physiological jaundice

    Exaggerated physiological response
    Should resolve by 2–3 weeks

    Breast Milk Jaundice

    Diagnosis of exclusion
    Do NOT stop breastfeeding
    May last up to 6 weeks, no further bilirubin levels necessary, unless jaundice is deemed to be worsening

    Hypothyroidism

    Discuss with local paediatric services

    Extra-hepatic obstruction
    Uncommon but early diagnosis improves outcome

     

    May present with dark urine, pale stools & conjugated hyperbilirubinaemia
    NOT excluded by negative abdominal US
    If suspected discuss with tertiary paediatric services within 24 hours

    Consider consultation with local paediatric team when

    • Child is unwell
    • Cause of jaundice is unclear
    • Conjugated bilirubin is >10% of total level

    Consider transfer when

    • Jaundice level rising despite adequate treatment offered at your local centre
    • Patient needs exchange transfusion

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • Causes requiring further treatment or investigation have been excluded
    • Baby is clinically well and feeding well

    Discharge advice

    • Sunlight exposure is not recommended as a treatment for jaundice
    • Arrange early follow-up with maternal and child health nurse and/or GP to ensure adequate oral intake, especially if:
      • <7 days old
      • exclusively breastfeeding or still establishing adequate oral feeds
      • bilirubin level is borderline for requiring treatment
    • Re-check bilirubin in 24–48 hours if borderline level or still rising
    • Parents should be advised to seek medical review if:
      • jaundice is present for 2–3 weeks and cause has not previously been established
      • parents believe jaundice is worsening or there is any other cause for clinical concern

    Parent information

    Jaundice in Newborns – Children’s Health Queensland
    Jaundice and Your Newborn Baby – The Royal Women’s Hospital
    What is jaundice and phototherapy – The Royal Women’s Hospital
    Phototherapy at home

    Additional notes

    NSW
    Jaundice Identification and Management in Neonates >32 Weeks Gestation

    Queensland
    Neonatal Jaundice
    Nomograms for jaundice management for all weight/gestations

    Victoria
    Jaundice in neonates – Safer Care Victoria

    Last updated October 2020

  • Reference List

    1. Nice Guidelines 2016, Jaundice in newborn babies under 28 days, National Institute for Health and Care Excellence, viewed August 2020 <http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf>
    2. Safer Care Victoria 2020, Jaundice in neonates, Victorian Agency for Health Information, viewed August 2020 <https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn/jaundice-in-neonates>
    3. Queensland Clinical Guidelines 2019, Neonatal Jaundice, Queensland Health, viewed August 2020 <https://www.health.qld.gov.au/__data/assets/pdf_file/0018/142038/g-jaundice.pdf>