What is the management approach for an infant with jaundice at 28 days?

Management of Jaundice in an Infant at 28 Days

For an infant with jaundice at 28 days of age, a measurement of total and direct (conjugated) bilirubin is essential to identify cholestasis, and the results of newborn thyroid and galactosemia screens should be checked to rule out these conditions. 1, 2

Initial Evaluation

Laboratory Assessment

1. Mandatory tests:

   • Total and direct (conjugated) bilirubin levels
   • Check results of newborn thyroid and galactosemia screens
   • Evaluate for signs or symptoms of hypothyroidism

2. If direct bilirubin is elevated:

   • Urinalysis and urine culture
   • Evaluate for sepsis if indicated by history and physical examination
   • Evaluate for causes of cholestasis

Clinical Assessment

• Assess for signs of acute bilirubin encephalopathy: lethargy, hypotonia, poor feeding, and irritability 2
• Evaluate feeding patterns (breastfeeding frequency, weight loss, wet diapers, stool pattern)
• Assess for hepatomegaly, splenomegaly, or other signs of liver disease

Management Algorithm Based on Bilirubin Type

If Predominantly Unconjugated Hyperbilirubinemia:

1. Breast Milk Jaundice

   • Continue breastfeeding
   • Monitor bilirubin levels
   • Consider supplementing with expressed breast milk if intake seems inadequate 2
   • Phototherapy if TSB exceeds 20 mg/dL after 72 hours of age 2

2. Hemolytic Disease

   • Complete blood count and blood smear
   • Consider G6PD testing, especially in African American infants (11-13% prevalence) 1
   • More aggressive management with phototherapy at lower thresholds

If Direct (Conjugated) Hyperbilirubinemia:

This indicates cholestasis and requires urgent evaluation for:

• Biliary atresia (time-sensitive diagnosis requiring intervention before 60 days)
• Metabolic disorders
• Infectious causes
• Genetic disorders

Treatment Considerations

1. Phototherapy Indications at 28 Days:

   • TSB exceeding 20 mg/dL 2
   • Lower thresholds if evidence of hemolysis

2. Monitoring During Treatment:

   • TSB levels should be monitored every 4-6 hours for TSB <20 mg/dL
   • More frequent monitoring (3-4 hours) for TSB 20-25 mg/dL 2

3. Breastfeeding Management:

   • Continue breastfeeding during phototherapy if possible
   • Ensure adequate intake (at least 8 feedings per day) 2
   • Avoid water or dextrose water supplementation as it will not decrease hyperbilirubinemia 2

Follow-up and Referral

• Regular monitoring of bilirubin levels until resolution
• Referral to pediatric gastroenterology if:
  • Direct hyperbilirubinemia is present
  • Jaundice persists beyond 4 weeks with no improvement
  • Signs of liver dysfunction are present

Important Caveats

• Jaundice at 28 days is considered prolonged and is not normal physiologic jaundice
• Visual estimation of jaundice severity is unreliable, particularly in darkly pigmented infants 1, 2
• Genetic factors, such as mutations in the UGT1A1 gene, should be considered in cases of prolonged breast milk jaundice 2
• Failure to identify and treat cholestasis can lead to permanent liver damage and poor outcomes

The American Academy of Pediatrics guidelines emphasize that jaundice persisting beyond 3 weeks requires evaluation for pathologic causes, particularly cholestasis, which can indicate serious underlying conditions requiring prompt intervention 1, 2.