Chapter 60 Jaundice (Case 23)

Case

A 48-hour-old term infant has jaundice extending to the abdomen. He was delivered at 39 weeks gestation via spontaneous vaginal delivery. Maternal blood type is A positive. His birth weight was 3240 grams and he is breastfeeding every 4 hours. Today his weight is 2950 grams.

Differential Diagnosis

Speaking Intelligently

All newborns have an increase in serum bilirubin that usually peaks by 72 hours of age, and jaundice is a common finding. Although most jaundice is benign, infants must be monitored and carefully assessed to identify those at risk for development of severe hyperbilirubinemia. This includes review of risk factors, assessment of feeding adequacy, and possibly a measurement of bilirubin, either transcutaneous or a serum level. A nomogram that plots bilirubin according to age in hours helps stratify infants into risk groups and identify who needs close follow-up. When assessing a newborn before discharge, I note how well the baby is nursing. Successful establishment of lactation with frequent feeding and minimal weight loss helps minimize peak serum bilirubin levels. A previous child who required phototherapy, gestation of less than 38 weeks, bruising or a cephalohematoma, and maternal-infant ABO blood group incompatibility are some additional risk factors associated with possible development of significant hyperbilirubinemia. Risk increases with more than one risk factor. With early hospital discharge, it is key to assess risk and arrange for the first office visit within 24 to 48 hours of discharge.

At high serum levels, bilirubin can diffuse into the brain and is toxic to the neonatal central nervous system. In rare cases, severe hyperbilirubinemia may result in acute bilirubin-induced neurologic dysfunction (BIND). Kernicterus, a syndrome of neurologic damage with muscle tone abnormality, cognitive deficits, and hearing impairment, results when these changes are permanent.

Patient Care

Clinical Thinking

• Review prenatal information.

• Assess adequacy of feeding, especially if breastfed.

• Because visual estimation of the degree of jaundice is inaccurate, it is wise to check a transcutaneous or serum bilirubin level on all infants with visible jaundice.

• Total bilirubin is assessed based on the age of the infant in hours and plotted on an hour-specific nomogram to identify risk level as low, low intermediate, high intermediate, or high (Figure 60-1).

• Review the history, and perform testing to determine the cause of jaundice. Is it “physiologic?” Is it worsened by feeding difficulty and/or excessive weight loss? Is there hemolysis resulting from ABO incompatibility, G6PD deficiency, or other hemolytic disease?

• Determine whether phototherapy is necessary (Figure 60-2). In many cases without active hemolysis, home phototherapy is safe with daily monitoring of feeding, weight gain, and bilirubin levels.

Figure 60-1 Risk designation of term and near-term well newborns based on their hour-specific bilirubin values.

(Reproduced with permission from Bhutani VK, Johnson L, Sivieri EM: Predictive ability of a predischarge hour-specific bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics, 103:6-14, 1999, Fig. 2, Copyright © 1999 by the AAP.)

Figure 60-2 Guidelines for phototherapy in hospitalized infants of 35 or more weeks of gestation.

(Reproduced with permission from AAP Clinical Practice Guideline. Subcommittee on Hyperbilirubinemia: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 114:297-316, 2004, Fig. 3, Copyright © 2004 by the AAP.)