What is the immediate management for a 5-day-old infant presenting with icteric (yellowish discoloration of the whites of the eyes) sclera?

Immediate Management of Icteric Sclera in a 5-Day-Old Infant

Immediately measure the total serum bilirubin (TSB) level and assess for pathologic jaundice, as this 5-day-old infant requires urgent evaluation to determine if phototherapy or exchange transfusion is needed to prevent kernicterus. 1, 2

Initial Assessment and Risk Stratification

Determine if Jaundice is Pathologic

The presence of icteric sclera at 5 days of age requires immediate laboratory evaluation because jaundice is considered pathologic if: 2

• TSB rises by more than 5 mg/dL (86 micromol/L) per day
• TSB is higher than 17 mg/dL (290 micromol/L)
• Infant shows signs of serious illness
• Conjugated bilirubin is elevated (>2 mg/dL or >20% of TSB)

Critical Historical Features to Obtain

Ask specifically about: 1, 2, 3

• Feeding adequacy (poor feeding increases jaundice risk)
• Stool and urine output (pale stools suggest conjugated hyperbilirubinemia/biliary obstruction)
• Birth history (prematurity, birth trauma, cephalohematoma)
• Family history (hemolytic disease, G6PD deficiency)
• Maternal blood type and antibody screen (ABO/Rh incompatibility)

Physical Examination Priorities

Focus on: 1, 3

• Degree of jaundice progression (head-to-toe assessment)
• Signs of hemolysis (pallor, hepatosplenomegaly)
• Neurologic status (lethargy, poor feeding, high-pitched cry, hypotonia—early signs of bilirubin neurotoxicity)
• Abdominal examination (distention could indicate biliary rupture, though rare) 4
• Hydration status (dehydration worsens hyperbilirubinemia)

Immediate Laboratory Workup

Order the following tests urgently: 1, 2

• Total and conjugated/direct bilirubin (to differentiate unconjugated vs conjugated hyperbilirubinemia)
• Complete blood count with reticulocyte count (to assess for hemolysis)
• Blood type and Coombs test (if not already done, to evaluate for immune-mediated hemolysis)
• G6PD level if indicated by ethnicity or family history

Interpretation of Conjugated Bilirubin

If conjugated bilirubin is >2 mg/dL or >20% of TSB, this indicates cholestasis and requires urgent evaluation for biliary atresia or other hepatobiliary pathology. 1 This is a surgical emergency if biliary atresia is confirmed, as outcomes are time-dependent.

Treatment Algorithm Based on TSB Level

For Unconjugated Hyperbilirubinemia

At 5 days of age (>72 hours old), initiate phototherapy when: 2

• TSB ≥20 mg/dL (342 micromol/L) in otherwise healthy term infants
• TSB ≥15-18 mg/dL if risk factors present (hemolysis, G6PD deficiency, sepsis)

Phototherapy is a simple and effective treatment that reduces bilirubin levels and prevents neurotoxicity. 1 The infant should be placed under phototherapy lights with maximum skin exposure, eye protection, and close monitoring of TSB levels every 4-6 hours initially.

When to Consider Exchange Transfusion

Exchange transfusion should be considered if: 2

• TSB approaches 25-30 mg/dL despite intensive phototherapy
• Rapid rise in TSB (>1 mg/dL per hour)
• Signs of acute bilirubin encephalopathy (lethargy, hypotonia, poor feeding, high-pitched cry)

This is a medical emergency requiring immediate transfer to a neonatal intensive care unit.

Management of Conjugated Hyperbilirubinemia

If conjugated bilirubin is elevated, do NOT use phototherapy (it is ineffective for conjugated hyperbilirubinemia) and immediately: 1

• Obtain abdominal ultrasound to evaluate biliary tree and liver
• Consult pediatric gastroenterology/hepatology urgently
• Measure conjugated bilirubin level to confirm cholestasis
• Evaluate for biliary atresia (requires surgical intervention ideally before 60 days of age for best outcomes)

Common Pitfalls to Avoid

Do not dismiss jaundice at 5 days as "physiological" without measuring TSB. 1, 2 While physiological jaundice peaks at 3-5 days in term infants, visible scleral icterus indicates significant hyperbilirubinemia requiring quantification.

Do not delay treatment while awaiting test results if the infant appears lethargic or has poor feeding. 2 These are early signs of bilirubin neurotoxicity and warrant immediate phototherapy initiation.

Always measure conjugated bilirubin in any infant with persistent jaundice beyond 2 weeks. 1 Missing biliary atresia has devastating consequences, and early surgical intervention (Kasai procedure) significantly improves outcomes.

Disposition

Hospitalize the infant if: 1, 2

• TSB requires phototherapy (≥20 mg/dL at this age)
• Conjugated hyperbilirubinemia is present
• Infant shows any signs of illness (poor feeding, lethargy, fever)
• Rapid rise in bilirubin levels
• Inadequate follow-up cannot be ensured

Outpatient management may be appropriate only if: 2

• TSB is <17 mg/dL and stable
• Infant is feeding well and well-hydrated
• No risk factors for severe hyperbilirubinemia
• Reliable follow-up within 24 hours is guaranteed