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NeonatalJaundiceClinicalPresentation:History,PhysicalExamination

NeonatalJaundiceClinicalPresentation
Author:ThorWRHansen,MD,PhD,MHA,FAAPChiefEditor:TedRosenkrantz,MDmore...
Updated:Mar04,2016

History
Presentationanddurationofneonataljaundice
Notethefollowing:
Typically,neonataljaundicepresentsonthesecondorthirddayoflife.
Jaundicethatisvisibleduringthefirst24hoursoflifeislikelytobe
nonphysiologicfurtherevaluationissuggested.
Infantswhopresentwithjaundiceafter34daysoflifemayalsorequire
closerscrutinyandmonitoring.
Ininfantswithseverejaundiceorjaundicethatcontinuesbeyondthefirst12
weeksoflife,theresultsofthenewbornmetabolicscreenshouldbechecked
forgalactosemiaandcongenitalhypothyroidism,furtherfamilyhistoryshould
beexplored(seebelow),theinfant'sweightcurveshouldbeevaluated,the
mother'simpressionsasfarasadequacyofbreastfeedingshouldbeelicited,
andthestoolcolorshouldbeassessed.

Familyhistory
Obtainthefollowinginformation:
Previoussiblingwithjaundiceintheneonatalperiod,particularlyifthe
jaundicerequiredtreatment
OtherfamilymemberswithjaundiceorknownfamilyhistoryofGilbert
syndrome
Anemia,splenectomy,orbilestonesinfamilymembersorknownheredity
forhemolyticdisorders
Liverdiseaseinfamilymembers

Historyofpregnancyanddelivery
Ascertainthefollowinginformation:
Maternalillnesssuggestiveofviralorotherinfection
Maternaldrugintake,includingtheuseofherbalremedies
Delayedcordclamping
Birthtraumawithbruisingand/orfractures.

Postnatalhistory
Obtaindetailsofthefollowing:
Lossofstoolcolor
Breastfeeding
Useofdrugsandherbalremediesinthelactatingmother
Greaterthanaverageweightloss
Symptomsorsignsofhypothyroidism
Symptomsorsignsofmetabolicdisease(eg,galactosemia)
Exposuretototalparentalnutrition

PhysicalExamination
Neonataljaundicefirstbecomesvisibleinthefaceandforehead.Identificationis
aidedbypressureontheskin,sinceblanchingrevealstheunderlyingcolor.Jaundice
thengraduallybecomesvisibleonthetrunkandextremities.Thiscephalocaudal
progressioniswelldescribed,evenin19thcenturymedicaltexts.Jaundice
disappearsintheoppositedirection.Theexplanationforthisphenomenonisnot
wellunderstood,butbothchangesinbilirubinalbuminbindingrelatedtopHand
differencesinskintemperatureandbloodflowhavebeenproposed. [22,23]This
phenomenonisclaimedtobeclinicallyusefulbecause,independentofother
factors,visiblejaundiceinthelowerextremitiesstronglysuggeststheneedtocheck
thebilirubinlevel,eitherintheserumornoninvasivelyviatranscutaneous
bilirubinometry.
Recentworkintheauthorsgroup(Tllfsrudetal,unpublisheddata)wasnotable
toconfirmthissocalledcephalocaudalprogressionofjaundice.Thus,whendermal
jaundicewasmeasurednoninvasivelyontheforehead,sternum,andsymphysis,no
cephalocaudaltrendwasevident.
Inmostinfants,yellowcoloristheonlyfindingonphysicalexamination.More
intensejaundicemaybeassociatedwithdrowsiness.Brainstemauditoryevoked
potentialsperformedatthistimemayrevealprolongationoflatencies,decreased
amplitudes,orboth.
Overtneurologicfindings,suchaschangesinmuscletone,seizures,oralteredcry
characteristics,inasignificantlyjaundicedinfantaredangersignsandrequire
immediateattentiontopreventkernicterus.Inthepresenceofsuchsymptomsor
signs,effectivephototherapyshouldcommenceimmediatelywithoutwaitingforthe
laboratorytestresults(seeLaboratoryStudies).Thepotentialneedforexchange
transfusionshouldnotprecludetheimmediateinitiationofphototherapy. [24,25]

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Hepatosplenomegaly,petechiae,andmicrocephalymaybeassociated
withhemolyticanemia,sepsis,andcongenitalinfectionsandshouldtriggera
diagnosticevaluationdirectedtowardsthesediagnoses.Neonataljaundicemaybe
exacerbatedinthesesituations.
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
ThorWRHansen,MD,PhD,MHA,FAAPProfessor,DepartmentofNeonatology,WomenandChildren's
Division,DirectorofClinicalEthics,OsloUniversityHospitalHC,Rikshospitalet,DirectorofPediatricEducation,
FacultyofMedicine,UniversityofOslo,Norway
ThorWRHansen,MD,PhD,MHA,FAAPisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Pediatrics,AmericanPediatricSociety,SocietyforPediatricResearch,EuropeanSocietyforPaediatric
Research,PerinatalResearchSociety,AmericanAssociationfortheHistoryofMedicine,NewYorkAcademyof
Sciences
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
BrianSCarter,MD,FAAPProfessorofPediatrics,UniversityofMissouriKansasCitySchoolofMedicine
AttendingPhysician,DivisionofNeonatology,Children'sMercyHospitalandClinicsFaculty,Children'sMercy
BioethicsCenter
BrianSCarter,MD,FAAPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofHospiceandPalliativeMedicine,AmericanAcademyofPediatrics,AmericanPediatricSociety,
AmericanSocietyforBioethicsandHumanities,AmericanSocietyofLaw,Medicine&Ethics,Societyfor
PediatricResearch,NationalHospiceandPalliativeCareOrganization
Disclosure:Nothingtodisclose.
ChiefEditor
TedRosenkrantz,MDProfessor,DepartmentsofPediatricsandObstetrics/Gynecology,DivisionofNeonatal
PerinatalMedicine,UniversityofConnecticutSchoolofMedicine
TedRosenkrantz,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,
AmericanPediatricSociety,EasternSocietyforPediatricResearch,AmericanMedicalAssociation,Connecticut
StateMedicalSociety,SocietyforPediatricResearch
Disclosure:Nothingtodisclose.
AdditionalContributors
OussamaItani,MD,FAAP,FACNClinicalAssociateProfessorofPediatricsandHumanDevelopment,Michigan
StateUniversityMedicalDirector,DepartmentofNeonatology,BorgessMedicalCenter
OussamaItani,MD,FAAP,FACNisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Pediatrics,AmericanAssociationforPhysicianLeadership,AmericanHeartAssociation,AmericanCollegeof
Nutrition
Disclosure:Nothingtodisclose.

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