Pediatrics [NEONATAL JAUNDICE]

Introduction
Jaundice in a neonate has a wide range of implications. While Prehepatic
most of them are benign (such as physiologic jaundice) there are Hemolysis,
Hemorrhage
others that require extensive intervention (biliary atresia). The
dreaded complication of hyperbilirubinemia is kernicterus (more Intrahepatic
Crigler-Najjar
later) which we fortunately can prevent. Just like an adult, there
Dubin-Johnson
are prehepatic (hemolysis), intrahepatic (metabolic), and Posthepatic Gilbert
posthepatic (biliary obstruction) causes. In a neonate (especially Atresia Rotor
in a preemie), hepatic conjugation and excretion is far less than Sepsis Hepatitis
an adult, which is the basis behind physiologic jaundice. Obstruction Sepsis

UNCONJUGATED CONJUGATED
Types of Bilirubin
There are two types of bilirubin. Conjugated bilirubin is water Lipid Soluble Water Soluble
soluble so it can’t cross the blood brain barrier but can be Cross BBB Can’t Cross BBB
excreted in the urine. It can’t cause brain damage but is always Kernicterus Ø Kernicterus
pathologic as it indicative of problems with biliary excretion (or Ø Urine Excretion Urinary Excretion
of some other underlying cause such as metabolic or sepsis).
Conversely, unconjugated bilirubin is lipid-soluble so it can PHYSIOLOGIC PATHOLOGIC
cross blood brain barrier, potentially leading to kernicterus Onset 1-7 days Onset <24 hrs
(irreversible deposition in the basal ganglia and pons). It’s Bilirubin ↑ <5/day (slow) Bilibrubin ↑ >5/day (fast)
potentially fatal. Unconjugated bilirubin is either prehepatic D. Bili <10% Total D. Bili >1.5-2 or ≥20% Total
(hemolysis) or intrahepatic in adults, but can actually be Resolves by day 10 Lasts >2 weeks
physiologic in a neonate.
Baby is Yellow
Workup for Jaundice
If baby is yellow, start with a transcutaneous sensor. But the Unconjugated Conjugated
most important thing to do is draw a bilirubin level. Indirect Bilirubin
hyperbilirubinemia requires immediate therapy to prevent
kernicterus (usually occurring with a bili > 20-25). The goal Indirect Direct
should be to decide where the bilirubin is coming from using a
Coombs Test (isoimmunization), CBC, and a reticulocyte count HIDA Scan
Hepatic U/S
(pay particular attention to the tree to the right). These can all
Sepsis eval
overwhelm the liver with “too much bilirubin.” On the contrary, Metabolic eval
a direct hyperbilirubinemia is more dangerous. It requires a
Coombs
workup for sepsis (WBC, blood cultures), obstruction (HIDA
Coombs
scan), and almost any metabolic disease (Crigler-Najjar, Rotor, Isoimmunization
Test
Dubin-Johnson). Rh Disease
Coombs ABO Incapability
Treatment of Jaundice
The mainstay of therapy is placement under a blue light lamp
(phototherapy) which converts indirect bilirubin (again – not Hgb Blood Transfusion
High
water soluble) to water soluble metabolites that can be excreted Hgb Twin-Twin Transfusion
in the urine. Treatment of direct hyperbilirubinemia with Normal Maternal-Baby
phototherapy would turn the child bronze and not add any Hgb Delayed Cord Clamping
therapeutic value as direct bilirubin is already water soluble.
Children that are in really bad shape with severely high bilirubin
Retic Count Hemolysis Hemorrhage
levels or with symptoms of kernicterus require exchange
transfusion. Spherocytosis Hematoma
G6PD Disease Bleed
But when do we do these? The evidence isn’t conclusive, but the Pyruvate Kinase Def
American Academy of Pediatrics has a nomogram that will Reabsorption
provide cutoff levels for phototherapy and exchange
Hemorrhage
transfusion. There are no “general” numbers that can help guide
Breast Feeding Jaundice
therapy as the infant’s age and risk factors need to be taken into Breast Milk Jaundice
account.

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 Pediatrics [NEONATAL JAUNDICE]

Breast Feeding vs Breast Milk Jaundice

Breast feeding jaundice is a quantity issue in newborns ≤ 7 days
old. Without sufficient volume, the bowels don’t move fast
enough; the body reabsorbs bilirubin and bilirubin builds up. By
increasing the number of feeds the problem fixes itself. In order
to be reabsorbed from the gut the bilirubin must be unconjugated
so there will be an elevation in indirect bilirubinemia.

Breast milk jaundice (aka “human milk jaundice”) is a

“quality” issue that occurs at 6-14 days. The thought is that
breast milk inhibits glucuronyl transferase (the conjugation
enzyme). This typically does not cause kernicterus. Formula can
be temporarily substituted for breast feeding (preferred) or used
to supplement breast feeding.

Both of the above are exaggerations of physiologic jaundice –

they don’t involve direct hyperbilirubinemia. If direct
hyperbilirubinemia is present, alternative causes must be
explored.

Either way, it’s unconjugated bilirubin; consideration should be

given to phototherapy if the bilirubin is very high. Since it’s
physiologic, the need for phototherapy is unlikely.

Be careful using the "day of onset" to direct the diagnosis. Mom

usually comes in ~1 week after leaving the hospital (around day
10) with a baby that’s yellow; the timing does NOT help in most
circumstances.

Breast Feeding Jaundice Break Milk Jaundice

Quantity = Volume Quality = Enzymes
↓ gut motility ↓ 2,3 UDP-GT
↑ Reabsorption ↓ Conjugation
↑ Unconjugated ↑ Unconjugated
Day < 7 Day > 7

Tx: Feed baby more Tx: Feed baby formula

(formula supplementation) (formula replacement)

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