Management of neonatal jaundice (hyperbilirubinemia)
There is a long list of causes of neonatal jaundice, here in this article we are going to focus on management rather than causes of neonatal jaundice. When receiving a neonate with jaundice we have to take a good history, perform a thorough examination, send for investigations and treat accordingly.
Ask about time of developing jaundice (was it on first day, second day or…), gestational age, weight, feeding well or not, crying, active, has regular bowel motion? (to exclude possibility of sepsis, hypothyroidism…etc because in these diseases the neonate will be lethargic, has poor feeding and poor crying), ask about the color of stool (in case of biliary atresia stool color is acholic-whitish-. Ask about blood group and Rh of the mother (to know is there possibility of ABO or Rh incompatibility?), ask about history of jaundice, exchange transfusion and kernicterus in the siblings.
Perform complete examination of the neonate: uncover the neonate and look at the extent of yellowish discoloration on the body (is it only involving the face, trunk or whole body?), look at the color of jaundice; bright yellow or orange in case of indirect jaundice while color will be greenish or muddy yellow in case of direct -obstructive- jaundice, is neonate pale?. Do reflexes to know is neonate active or not? examine every system; CVS, Respiratory, Abdomen ( palpate abdomen: is it soft? examine for hepatosplenomegaly in case of hemolysis, congenital infections..), palpate anterior fontanel (if bulging may indicate Intra Ccranial Hemorrhage a cause of jaundice), examine skin thoroughly to see if there is any petechiae, echymosis (signs of congenital infection), weigh the neonate.
The history we took and examination we performed should direct us for which investigations the neonate is in need?
-TSB and PCV (for every neonate)
-BG, Rh of baby (if mother is Rh-ve (Rh incompatibility?), or if mother is O+ve or O-ve (ABO incompatibility?).
-CBP with blood film, retic count, coombs test and G6PD assay (if there is anemia and before exchange transfusion if required).
-Direct and indirect bilirubin level, Liver function test, abdominal US, virology screen (if you suspect direct hyperbilirubinemia).
-Septic screen (if you suspect infection).
-T4, T3 and TSH (if hypothyroidism suspected)
-Brain US (if you suspect ICH).
Again treatment changes according to the history, examination and investigations:
-Phototherapy (spiral phototherapy in case of near exchange levels).
-Hydrocortisone and/or Intravenous immunoglobulin IVIG (if there is immune mediated hemolytic anemia and bilirubin level continues to rise despite phototherapy, you will give these treatment to cease the hemolysis and prevent further rise in bilirubin and need of exchange transfusion)
-Exchange transfusion (in high levels)
-Treatment of underlying condition accordingly (e.g. treatment of sepsis, ICH, hypothyroidism, hepatitis…..if they are present).
**To know which treatment you choose, compare the bilirubin level with the below charts according to GA, Wt and presence of risk factors.
Click on the images to enlarge them.
**If neonate needed exchange transfusion, send for CBP with blood film, retic count, coombs test and G6PD assay and prepare fresh whole blood according to below table: