Jaundice in Children

Introduction

Jaundice refers to the yellowish discolouration of the sclera, skin and mucous membranes as a result of excessive accumulation of bilirubin
in the blood.
It is clinically visible at total  serum bilirubin (TSB) level of 5mg/dl (85μmol/L).
Close to 60% of term and 80% of preterm infants develop jaundice within the first week of life.
Jaundice can be physiologic or pathological.

Physiologic Jaundice

Physiologic jaundice is characterized by the following:

  1. Usually a diagnosis of exclusion,
  2. appears after 36 hours of life, peaks at the 5th day of life with total serum bilirubin (TSB) of 12mg/dl (205 umol/L) for term babies or
    15mg/dl (255 µmol/L) for preterm babies
  3. Conjugated bilirubin of >2mg/dl (34 µmol/L)
  4. Jaundice clears spontaneously by the 7th day of life for the term infants and between the 10th and 14th days for the preterm infants.

Pathological jaundice

Pathological jaundice is characterized by:

  1. Jaundice observed within the first 24hours of life
  2. Jaundice lasting more than 14 days in term infants and 21 days in the preterm infants (this is known as Prolonged Jaundice)
  3. Jaundice with TSB >12mg/dl (205 μmol/L)
  4. Jaundice with fever and other signs of sickness
  5. Conjugated bilirubin more than 2mg/dl (34 μmol/L) or deep yellow urine.

Clinical assessment

Clinical assessment of infants with jaundice:
Note should be taken of risk factors:

  • preterm birth,
  • history of jaundice in the siblings,
  • history of exclusive breastfeeding
  • small size <2.5kg at birth,
  • evidence of haemolysis,
  • sepsis.

Examine the baby close to the window or under very bright light.

  • Examine the sclera for yellowish discoloration.
  • Other examination sites include the gum, the tip of the nose, the upper chest wall, the lower abdominal wall, the palms and soles.
  • Using the tip of the finger, slight pressure is applied to these sites for up to 10 seconds and when the finger is lifted, the yellowish discolouration underneath the blanched skin becomes obvious.

Investigations

  • Serum bilirubin (only TSB is essential in the first week of life; split bilirubin -total, unconjugated and conjugated- is only required in cases of prolonged jaundice)
  • Trans-cutaneous Bilirubin (TcB)
    estimation is reliable as it correlates well with serum bilirubin except in severe cases of hyperbilirubinaemia. Therefore,
    this can be reliably used when serum TSB is not available.
  • Blood typing (for mother and baby)
  • Full Blood Count
  • Peripheral blood film examination
  • Coomb’s test
  • G6PD assay or screening
  • Thyroid Function Tests
  • Hepatobiliary scan

Management.

The goal of treatment is to rapidly reduce
serum bilirubin levels and prevent bilirubin encephalopathy.
Blue light phototherapy delivering
irradiance from a distance of 30cm from
the baby in a cot or incubator.
Important steps during phototherapy:

  1. infant should be nursed naked except for diaper
  2. infant must be blind-folded body
  3. temperature to be monitored 4 hourly
  4. turning of infant every 2-4 hours
  5. TSB must be monitored 12-hourly and at worst, on a daily basis.

Double-volume Exchange Blood
Transfusion (EBT) using 160-170ml/kg of
compatible fresh whole blood fresh.
This procedure should be carried out over at least 2 hours using a three-way valve.
Infants undergoing EBT should be
maintained on phototherapy to minimise
rebound hyperbilirubinaemia.
All babies with visible jaundice within the first 24 hours of life must have
phototherapy until a diagnosis is made.
Intensive phototherapy is achieved with
further reduction of the distance between baby and light source and increased irradiance from multiple directions.
The use of Bili-blanket serves this purpose well especially when it is combined with the conventional phototherapy.
Phototherapy should be continued until
Total Serum Bilirubin is 3-5mg/dl lower
than the threshold range for the age or
until the jaundice has cleared significantly.
Without obvious sepsis, antibiotics are
not indicated in the treatment of neonatal jaundice.
If fever is present, results of
relevant tests should guide treatment.
Note:

Ceftriaxone and sulphur
containing antibiotics or antimalarial drugs should be avoided because of the risk of displacement of bilirubin from albumin-binding sites.

Breastfeeding should be increased during care for jaundice.
If this is difficult, intravenous fluid should be administered with extra 10ml/kg added to the daily maintenance fluid requirement.
Both caloric intake and hydration enhance the excretion of bilirubin.
Phenobarbitone is not recommended
because it is slow-acting and not effective
for jaundice cases characterized by
rapidly rising TSB.