Hyperbilirubinemia

Originally published at Pediatric EM Morsels on July 1, 2011. Reposted with permission.

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Jaundice can be a normal part of the neonatal period (certainly both of my kids looked like the Yellow M&M for a short period in their beginnings); however, hyperbilirubinemia also generates the concern for the development of kernicterus (abnormal accumulation of unconjugated bilirubin in the brain).

•  The AAP has a practice guideline (Management of hyperbilrubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:297-316. APP.) that aims to help us determine how to manage these patients and prevent complications. We have all seen the nomogram that we reference when determining whether a neonate needs phototherapy or exchange transfusion.
• There is also a handy website (that I have absolutely no affiliation with… but I do use anytime this issue comes up)… check it out: http://bilitool.org/)

Some Important Points to Keep in Mind:

• Physiologic jaundice in healthy, full-term newborns typically develops during the 2nd – 3rd day of life.
• Physiologic jaundice in healthy, full-term newborns typically resolves by the 5th or 6th day.
• Premature neonates are at greater risk! Also, the nomogram only pertains to those greater than 35 weeks gestational age.
• The nomogram is based on TOTAL bilirubin (not fractionated bilirubin).
• Consider DDx:
  a. Conjugated – biliary atresia, hepatitis (HSV?), biliary cholestasis, alpha-1-antitrypsin deficiency
  b. Unconjugated – SEPSIS, ABO incompatibility, hereditary spherocytosis, Gilbert’s syndrome, Crigler-Najjar syndrome, glucose-6-phosphate deficiency, breastfeeding vs. breast-milk.

Evaluation (after you’ve determined there is hyperbilirubinemia):

• Total and Fractionated Bilirubin
• Blood Type with Rh factor
• Coomb’s test
• CBC w/ Diff
• Reticulocyte count
• Consider sepsis work-up as well. Remember that these neonates don’t do many things to show you that they are sick… hyperbilirubinemia may be the one red flag that they are able to raise.