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Emergency physicians must be comfortable evaluating the neonate, and be able to manage, offer guidance to parents, and interpret and discuss bilirubin levels with pediatricians to prevent development of kernicterus
1 ) The key is the history, which allows you to risk stratify your patient; Risk factors for rising bilirubin levels include:
- isoimmune hemolytic disease
- G6PD deficiency
- Asphyxia
- Lethergy
- Sepsis
- Albumin < 3.0
- G6PD deficiency
- Asphyxia
- Lethergy
- Sepsis
- Albumin < 3.0
Always ask parents about;
- Time of birth (hours matter)
- Maternal and fetal blood type
- Birth hx: term or preterm, GBS, TORCH infections
- Fever
- Poor feeding/ feeding patterns, including whether mom feels engorged and if latching is successful
- Maternal and fetal blood type
- Birth hx: term or preterm, GBS, TORCH infections
- Fever
- Poor feeding/ feeding patterns, including whether mom feels engorged and if latching is successful
- Stool color (yellow, acholic)
- Timing of first stool
- Timing of jaundice (jaundice at Day 1 of life is not physiologic)
2) Determine direct and total bilirubin level (direct bilirubinemia is always pathologic, and may indicate biliary atresia or hepatitis)
3) Determine need for observation, phototherapy, or exchange transfusion- Plot total bilirubin level on bilirubin nomogram- Nomograms can be referenced online or in Harriet- Lane handbook (separate nomograms exist for guidelines regarding phototherapy and exchange transfusion)
4) If safe for discharge, arrange for followup, and if no follow up available, the patient should return to the ED for a repeat bilirubin check in 12-24 hrs
Bonus pearl: Types of Jaundice by Age
- < 24 hrs: hemolyis, TORCH, bruising from birth trauma (ie- cephalohematoma), acquired infection
- Day 2-3: Physiologic
- Day 3-7: infection, congenital diseases, TORCH
- >1 week: Breast Milk Jaundice, breast feeding jaundice, drug hemolysis, hypothyroidism, biliary atresia, hepatitis, red cell membrane disorders (SS, HS, G6PD deficiency)