Jaundice resident survival guide (pediatrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Jaundice resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Biliary atresia
• Fulminant Liver failure

Common Causes

Causes of jaundice in children include:

• Unconjugated hyperbilirubinemia
  • Excessive hemolysis
  • Gilbert syndrome
  • Breast milk jaundice
  • Breast feeding failure jaundice
  • Crigler-Najjar syndrome
  • Hypothyroidism
  • Pyloric stenosis
  • Galactosemia

• Conjugated hyperbilirubinemia
  • Viral infections
    • Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis E
    • EBV
  • Sepsis
  • Urinary tract infection
  • Biliary atresia
  • Choledochal cyst
  • Breast milk jaundice
  • Metabolic disorders
  • Gallstone
  • Hepatotoxic drugs
    • Acetaminophen
    • Anticonvulsants
    • Anesthetics
    • Antituberculous drugs
    • Chemotherapeutic agents
    • Antibiotics
    • Oral contraceptives
  • Inspissated bile syndrome
  • Alagille syndrome
  • Wilson disease
  • Alpha-1-antitrypsin deficiency
  • Cystic fibrosis
  • Autoimmune hepatitis

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of jaundice in children.

Characterise jaundice ❑ Onset ❑ Duration (acute or chronic) ❑ Progression ❑ Location ❑ Precipitating events ❑ Dark urine ❑ Acholic stools

Ask about associated symptoms ❑ Abdominal pain ❑ Abdominal distension ❑ Nausea and Vomiting ❑ Dyspepsia ❑ Anorexia ❑ Weight gain or loss ❑ Fever and Chills ❑ Itching ❑ Steatorrhea ❑ Arthralgia ❑ Myalgia ❑ Urticaria ❑ Sore throat ❑ Rash ❑ Pale skin ❑ Fatigue ❑ Back pain ❑ Confusion ❑ Lethargy ❑ Poor feeding

Obtain a detailed history ❑ Age (causes of jaundice varies with age ❑ Race ❑ Past medical history ❑ Recurrent episodes of jaundice ❑ Hemolytic anemia ❑ Autoimmune disease ❑ Malignancy ❑ Past surgical history ❑ Family history ❑ Jaundice ❑ Liver disease ❑ Wilson disease ❑ Malignancy ❑ Anemia ❑ Autoimmune disease ❑ Travel history (poor sanitation) ❑ Medications or Herbal preparation ❑ Blood transfusion and Needle stick injury or unsterilized syringe use ❑ Sexual history ❑ Social history ❑ Smoking ❑ Alcohol ❑ Drug abuse ❑ Tattoo ❑ Occupational history ❑ Sewage worker (Leptospirosis) ❑ Health care worker (needle stick injury) ❑ Birth history (Neonatal jaundice) ❑ Maternal infection ❑ Maternal blood group ❑ Maternal Diabetes ❑ Medications during pregnancy ❑ Birth trauma ❑ Feeding history ❑ Breast milk ❑ Formula feeding ❑ Number of wet diapers per day

Examine the patient Check vitals ❑ Temperature ❑ Pulse ❑ Blood pressure ❑ Respiratory rate Perform a general physical exam ❑ HEENT examination ❑ Yellow sclera ❑ Cataract (TORCH infection) ❑ Hematoma (cephalhematoma) ❑ Lymphadenopathy ❑ Skin examination ❑ Yellow skin ❑ Pale skin ❑ Scratch mark (indicates pruritus) ❑ Bruise ❑ Spider nevi and palmar erythema (seen in liver disease) ❑ Abdominal examination ❑ Signs of previous surgery ❑ Right upper quadrant tenderness ❑ Murphy sign ❑ Courvoisier law ❑ Abdominal distension (hepatomegaly, enlarged gall bladder, splenomegaly, ascites, malignancy) ❑ CNS examination (Kernicterus) ❑ Altered mental status ❑ Hyoptonia ❑ Asterixis ❑ Lymph nodes (infection, malignancy) ❑ Extremities examination ❑ Lower limb edema (cirrhosis, malignancy) ❑ Dysmorphic features (Alagille syndrome)

Order serum bilirubin

Increased Indirect bilirubin

Increased Direct bilirubin

Pathological jaundice ❑ Breast milk jaundice ❑ Breast feeding jaundice ❑ Gilbert syndrome ❑ Crigler-Najjar syndrome ❑ Excessive hemolysis

Physiological jaundice

Features of hemolysis ❑ Pallor ❑ Fatigue ❑ Fever ❑ Chills ❑ Dark urine ❑ Splenomegaly ❑ Gallstone

Conjugated hyperbilirubinemia ❑ Viral Hepatitis ❑ EBV ❑ Biliary atresia ❑ Choledochal cyst ❑ Metabolic disorders ❑ Hepatotoxic drugs ❑ Wilson disease ❑ Autoimmune hepatitis

Present

Absent

Hemolytic anemia

❑ Breast milk jaundice ❑ Breastfeeding history ❑ Breast feeding jaundice ❑ Inadequate breastfeeding ❑ Gilbert syndrome ❑ Mild jaundice seen in neonates ❑ Positive family history ❑ History of exertion, stress, illness, fasting, infection ❑ No hemolysis ❑ Normal LFT ❑ Normal liver histology ❑ Crigler-Najjar syndrome ❑ Neonatal jaundice ❑ Positive family history ❑ No hemolysis ❑ Normal LFT ❑ Normal liver histology

Unconjugated hyperbilirubinemia ❑ Complete blood count with WBC and platelets ❑ Reticulocyte count ❑ Peripheral smear ❑ Direct and indirect Coombs test ❑ Serum haptoglobin ❑ Hemoglobin electrophoresis ❑ Serum lactate dehydrogenase

Conjugated hyperbilirubinemia ❑ Liver function test ❑ ALT and AST ❑ ALP ❑ GGT ❑ Prothrombin time ❑ Total protein and serum Albumin ❑ Hepatitis serology ❑ EBV serology and Monospot test ❑ ANA, ASMA, and [[anti-liverkidney- microsomal antibody]] ❑ Serum ceruloplasmin ❑ 24-hour urinary copper excretion ❑ USG abdomen

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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