Pediatric presentation
Jaundice in children
In the newborn a bilirubin-and-time question with a treatment threshold; after two weeks, the fraction that matters is the conjugated one.
What are you worried about?
- Hemolysis in the first 24 hours
- Bilirubin levels that threaten kernicterus
- Biliary atresia, with a surgical clock of about 60 days
- Sepsis and urinary tract infection presenting as jaundice
- Acute liver failure in the older child
Differential, by age
Newborn birth to 28 days
- Physiological jaundice
- Breastfeeding and breast milk jaundice
- ABO or Rh incompatibility, G6PD deficiency
- Cephalhematoma
- Sepsis
- Biliary atresia
- Hypothyroidism
Infant 1 to 12 months
- Biliary atresia presenting late
- Neonatal hepatitis
- Metabolic disease
- Urinary tract infection
Toddler 1 to 3 years
- Viral hepatitis
- Hemolysis
- Drug-induced
School age 6 to 11 years
- Viral hepatitis (A, Epstein-Barr virus)
- Hemolytic disease
- Autoimmune hepatitis
- Gilbert syndrome
Adolescent 12 to 17 years
- Viral hepatitis
- Acetaminophen and other drug injury
- Autoimmune hepatitis
- Wilson disease
- Gilbert syndrome
Key history
- Hours or days of age at onset; gestational age; birth weight and the weight now
- Feeding: breast or formula, volumes, frequency, wet diapers, stool colour
- Blood groups of mother and baby, a sibling who needed phototherapy, family history of hemolysis or G6PD deficiency
- Bruising or cephalhematoma from delivery; maternal diabetes
- In the older child: acetaminophen, other drugs, supplements, travel, contacts, autoimmune history
Key examination
- Measure the bilirubin; do not grade jaundice by eye, especially in darker skin
- Hydration, weight, alertness and tone (a floppy jaundiced baby is an emergency)
- Hepatosplenomegaly, bruising, cephalhematoma, the colour of the stool in the nappy
- The older child: hepatomegaly, spleen, stigmata of chronic liver disease, Kayser-Fleischer rings
Red flags
- Jaundice in the first 24 hours
- Bilirubin approaching the phototherapy or exchange threshold for the hour of age
- Pale stools, dark urine, or jaundice beyond 14 days (21 in the preterm)
- Lethargy, poor feeding, hypothermia, a high-pitched cry, arching
- Coagulopathy or encephalopathy in the older child
Initial investigations
- Total and conjugated bilirubin; blood group and direct antiglobulin test; full count, film and reticulocytes if hemolysis is possible; G6PD
- Plot the level on the hour-specific nomogram against the risk category (gestation, hemolysis, illness)
- Prolonged jaundice: split bilirubin, thyroid function, urine culture, liver enzymes; an ultrasound and hepatology review if conjugated
- Older child: liver panel with pattern, INR, viral serology, acetaminophen level when relevant
How to interpret them
- A conjugated bilirubin above about 34 µmol/L, or above 20 percent of the total, is never normal
- Bilirubin rising faster than about 85 µmol/L per day suggests hemolysis
- The treatment threshold depends on the hour of age and the risk category, not on a single number
When the child is deteriorating
- Bilirubin at the exchange threshold or signs of acute bilirubin encephalopathy: intensive phototherapy, hydration, intravenous immunoglobulin for isoimmune hemolysis, exchange transfusion
- Suspected biliary atresia: hepatology and surgery the same week
The adult frame, for contrast