So let’s say we have this baby
and we know all these causes now
and we’re trying to figure
out how bad is this child.
Should we intervene or not?
The first is a clinical assessment.
We’re going to press on the skin a
little bit to assess the jaundice
and see whether it progresses
from head down to the limbs.
The problem is that this technique of
understanding that head jaundice happens first,
then trunk jaundice,
then leg jaundice,
may be underestimated on
infants with dark skin
or in preterm infants who may be worse than
they appear based on clinical suspicion.
It’s important if we see a
jaundiced baby and we’re concerned
and that takes a little bit of
experience to check the bilirubin
with either a transcutaneous
meter or a frank blood sample.
Most centers do blood samples.
Keep in mind the gestation of the baby.
We’re going to lower our treatment
threshold in preterm infants.
And keep in mind the age of the baby.
If an infant is less
than 24 hours old,
this is unlikely to be hemolysis and could
be potentially more serious like DIC.
If the infant is over two weeks
or maybe three weeks if preterm
and there’s persistent jaundice, there
may be something significant going on.
Either the child has conjugated
hyperbili and you’ve missed it before.
Or this could be unconjugated and
the patient has underlying syndrome
such as Crigler-Najjar
syndrome or Gilbert syndrome.
Next, we’re going to look at this baby.
Is this baby well or not?
If the baby is well-appearing,
that’s probably going to be physiologic
jaundice rather than sepsis.
But it’s important to check the
clinical evidence of sepsis
especially if the child’s dehydrated.
Next, we’re going to
check for risk factors.
Think about what the mom’s blood type
is and the baby’s blood type is.
Just like with Rh factor that
we went through carefully,
perhaps the mom is type A
and the baby is type B.
And mom had a type B baby before
and now she has anti-B antibodies
that have gone into that baby.
And that baby now has blood
causing the child to have
If they’re Mediterranean or
Afro-Caribbean, you might think of G6PD
and then also think about sepsis,
acidosis, low serum albumin, et cetera.
Lastly, we’re going to plot them.
We’re going to put them on a
graph and say how old they are
and how much hyperbili
do we tolerate.
We plot the bilirubin on a gestation’s
specific chart according age since birth,
in hours or days,
and then we plot the
change of the bilirubin
to identify whether these are
potentially high levels.
So if we plot them and we decide
it looks like they need therapy,
we’re going to do one
of two therapies.
First, we may light them or second, we may
do a full fledged exchange transfusion.
So who do we light?
Breastfed babies are a little
bit more likely to be lit up.
This is because the early
breast milk is colostrum
and it comes with a
very small volume,
and these infants do less
stooling early in life.
And remember stooling
is how we get it out.
Also, they may have breast milk jaundice
where the milk itself
is causing a jaundice,
although that’s usually later in
life around two weeks of age.
So if the child meet criteria
and fits on this graph,
then we will start phototherapy.
We’ll use the chart to calculate
when the light is needed
and when we can turn it off.
It’s basically when they
fall below the curve.
And we’ll recheck bilirubins periodically
to make sure the levels are coming down.
Some people like to get a rebound
level or once it comes down,
they turn off the light and they
check another level in six hours
to make sure that child
is still doing okay.
If it’s severely elevated and
they’re in the range of danger,
we may do an exchange transfusion
to prevent kernicterus.
That is extremely rare to do,
but it does happen sometimes.
So that’s my review of physiologic
jaundice and conjugated hyperbilirubinemia
in infants during the
Thanks for your time.