What is the approach to diagnosing and managing jaundice in children?

Approach to Jaundice in Children

Immediate Age-Based Triage

Jaundice in the first 24 hours of life is always pathologic and demands immediate measurement of total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) with urgent evaluation for hemolytic disease—never rely on visual assessment alone. 1

Newborns (0-2 weeks)

• Obtain objective bilirubin measurement immediately if jaundice appears in the first 24 hours, as this represents a high-risk category regardless of absolute level and requires active investigation for serious causes including isoimmune hemolytic disease, G6PD deficiency, sepsis, or significant bruising 1

• Monitor all infants routinely for jaundice development at least every 8-12 hours, assessing whenever vital signs are measured 2

• Use hour-specific nomograms (not day-based) to interpret all bilirubin levels and determine risk zones—this is critical for accurate risk stratification 1, 3

Infants Beyond 2 Weeks

• Any infant jaundiced at 2-3 weeks requires measurement of both total and direct (or conjugated) bilirubin to identify cholestasis, which may indicate biliary atresia or other serious hepatobiliary disease 2, 4

• Breastfed infants with otherwise normal history (no dark urine or light stools) and physical examination may be monitored until 3 weeks before measuring bilirubin if reliable follow-up is ensured 4

Essential Laboratory Workup

Initial Testing for All Jaundiced Infants

• Blood type and direct antibody test (Coombs' test) on infant's cord blood, particularly if mother is Rh-negative or blood group O 2, 1

• Complete blood count with peripheral smear and reticulocyte count to assess for hemolysis 1, 3

• Total and direct/conjugated bilirubin—interpret total bilirubin according to infant's age in hours using nomograms 1, 3

• G6PD level, especially in high-risk populations (East Asian, Mediterranean, African descent) 1, 3

Additional Testing When Indicated

• For rapidly rising bilirubin or jaundice crossing percentiles: investigate for isoimmune hemolytic disease (ABO/Rh incompatibility), G6PD deficiency, sepsis, or significant cephalohematoma 1

• For elevated direct/conjugated bilirubin or jaundice persisting beyond 3 weeks: evaluate for urinary tract infection, sepsis, and check newborn thyroid and galactosemia screening results 2, 3

Imaging Approach

Neonatal Period (Conjugated Hyperbilirubinemia)

• High-resolution ultrasound is the first-line imaging modality to differentiate obstructive from non-obstructive causes, particularly to identify biliary atresia, choledochal cyst, or inspissated bile 5

• Hepatic scintigraphy and percutaneous liver biopsy may be necessary when ultrasound shows diffusely coarse, hyperechoic hepatic echotexture (seen in hepatitis, biliary atresia, and choledochal cyst) to narrow the differential diagnosis 5

Older Children

• Ultrasound remains first-line to evaluate for biliary obstruction from gallstones, strictures, or masses 2, 5

• CT, MR cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) may be indicated based on ultrasound findings and clinical context 2

Treatment Decision-Making

Phototherapy Thresholds

• Use age-specific (hour-specific) and risk-stratified nomograms to determine phototherapy indication—infants with jaundice in first 24 hours have lower treatment thresholds 1

• Risk factors lowering treatment thresholds include: gestational age 35-37 weeks, hemolytic disease, G6PD deficiency, sepsis, acidosis, or albumin <3.0 g/dL 1, 3

• Never subtract direct bilirubin from total bilirubin when making phototherapy decisions—use the total bilirubin value 1, 3

Phototherapy Optimization

• Maximize exposed skin surface area by minimizing diapers, head covers, eye masks, and electrode patches 1

• Expect bilirubin decrease >2 mg/dL within 4-6 hours if phototherapy is effective 1

• Continue breastfeeding frequently if infant is clinically well—do not routinely supplement with water or dextrose water in non-dehydrated breastfed infants 1, 3

Monitoring and Follow-Up

• Timing of repeat TSB/TcB depends on initial risk zone and evolution of hyperbilirubinemia—for rapidly rising bilirubin or risk factors, recheck within 4-12 hours 1, 3

• Continue monitoring until bilirubin levels are clearly declining and below treatment thresholds 1

Critical Pitfalls to Avoid

• Visual estimation of bilirubin is dangerously unreliable, particularly in darkly pigmented infants—always obtain objective TSB or TcB measurements 2, 1, 3

• Never discharge an infant with jaundice in the first 24 hours without objective bilirubin measurement and clear follow-up plan 1

• Recognize that jaundice progresses caudally from face to trunk to extremities, but degree of jaundice does not reliably correlate with bilirubin level 2

• For cholestatic jaundice (elevated direct/conjugated bilirubin), early referral to pediatric gastroenterology is essential as timely diagnosis of conditions like biliary atresia is critical for successful surgical intervention 4