Conjugated bilirubin is reported as direct and is elevated because of obstructed excretion Goals of Treatment The goals of ED evaluation of the icteric infant include rapid diagnosis of the acutely treatable causes of icterus (sepsis, obstruction, metabolic disease), prevention of kernicterus and brain injury, and reassurance when the jaundice is physiologic Clinical Considerations Clinical Recognition In a child with true jaundice, the sclera will be yellow Jaundice in the first 24 hours of life of a term newborn is pathologic Full-term, well-appearing neonates over day of age often have physiologic or breast-milk jaundice Physiologic jaundice is benign Bilirubin levels spike close to day of life and then decrease Breast-feeding jaundice may present in the first few days, before sufficient milk production, or may present later, for unknown reasons Breast-fed infants may have prolonged unconjugated hyperbilirubinemia lasting up to several weeks, thought to be related to compounds in breast-milk Clinical Assessment Infants presenting with jaundice require a careful history, looking for timing of jaundice onset, stool and urine color, breast or bottle feeding, maternal and infant blood type, traumatic delivery, and maternal history of diabetes, hepatitis, and medications A careful examination should assess for cephalohematoma and signs of infection Acholic stools generally indicate biliary obstruction or severe hepatic failure CBC, total bilirubin level, and direct bilirubin level should be obtained A direct Coombs test should be obtained if maternal blood type in unknown, hemoglobin is low, or total bilirubin is at levels requiring intervention (see below) Consider blood typing mother and neonate for ABO and Rh factors if unknown Rh incompatibility is uncommon in mothers who have received prenatal care Infants presenting with elevated indirect bilirubin, direct bilirubin less than 15% of the total, and normal stool color have unconjugated hyperbilirubinemia Causes of unconjugated hyperbilirubinemia include physiologic jaundice, breastmilk jaundice, breast-feeding jaundice, hemolytic disease, blood group incompatibility, infection, dehydration, polycythemia, abnormalities in the conjugating enzyme (UDP-glucuronosyltransferase or UGT) as with Crigler– Najjar syndrome or Lucey–Driscoll syndrome, Gilbert syndrome, or hypothyroidism Infants with elevated direct bilirubin have conjugated hyperbilirubinemia, which is always pathologic Elevated direct bilirubin indicates obstructed excretion, or cholestasis, usually due to biliary obstruction, hepatocellular pathology, or metabolic disorder Hepatitis, and in particular, idiopathic neonatal hepatitis, is a common cause of conjugated hyperbilirubinemia This must be distinguished from infectious hepatitis, including hepatitis B, rubella, cytomegalovirus, toxoplasmosis, coxsackie virus, echovirus, HSV, syphilis, Listeria, and tuberculosis In addition, systemic infectious disease can also result in a toxic hepatitis, particularly systemic infections due to Escherichia coli, Pneumococcus, Proteus, and Salmonella Prolonged parenteral alimentation is another common cause of conjugated hyperbilirubinemia that can persist several months beyond the cessation of parenteral nutrition Metabolic disorders of the liver that can also result in conjugated hyperbilirubinemia include alpha 1antitrypsin deficiency, galactosemia, tyrosinemia, fructosemia, glycogen storage diseases, lipid storage diseases, cerebrohepatorenal syndrome, trisomy 18, cystic fibrosis, hemochromatosis, and idiopathic hypopituitarism Obtain CBC, blood culture, albumin, LFT’s PT/PTT, hepatitis serologies, urinalysis, urine culture, and urine-reducing substances Biliary atresia and neonatal hepatitis are the most common etiologies and patients with biliary atresia have better outcomes the earlier they are diagnosed Neonates presenting with elevated direct bilirubin with microcephaly, seizures, organomegaly, or petechiae should be evaluated for congenital TORCH (toxoplasmosis, other infections, rubella, CMV, herpes simplex) infections Management Determine if the infant has indirect or direct hyperbilirubinemia Infants with direct (conjugated) hyperbilirubinemia or acholic stools require admission for further diagnostic evaluation Treatment of neonatal hepatitis is supportive, with supplementation of the fat-soluble vitamins Prevention of hepatitis B infection requires early administration of HBIG and HBV vaccines to prevent chronic infection in exposed newborns Septic infants should be treated with broad-spectrum antibiotics, typically with rapid normalization of hyperbilirubinemia While some of the metabolic disorders (galactosemia, tyrosinemia, fructosemia, and the storage diseases) may be palliated with dietary restrictions, most progress to chronic cirrhosis and liver failure Indirect Hyperbilirubinemia Infants with physiologic jaundice can be discharged if they not meet criteria for phototherapy or exchange transfusion The Subcommittee on Hyperbilirubinemia of the AAP publishes guidelines for management of hyperbilirubinemia in healthy term infants according to total bilirubin levels and infants age (see Fig 40.1 ) Infants with breast-milk jaundice usually require increased breast-feedings, and close follow-up with pediatrician until adequate milk supply is insured Infants of diabetic mothers, infants with congenital hypothyroidism, or with resorption from large cephalohematomas may have higher levels of icterus than expected physiologically and may require serial bilirubin level checks Pallor CLINICAL PEARLS AND PITFALLS Anemia in the neonate is recognized as pallor most commonly when the hemoglobin falls below 10 g/dL Current Evidence True pallor in the neonate can be due to significant anemia, sepsis, shock, or severe chemical/electrolyte imbalance Clinical Recognition Anemia in the neonate is recognized as pallor most commonly when the hemoglobin falls below 10 g/dL Clinical Assessment ED evaluation of pallor should include a careful history and physical examination to distinguish between anemia, septic/cardiogenic shock, electrolyte imbalance, and genetically determined fair skin coloring Questions should be asked regarding perinatal history, the baby’s feeding, level of alertness, occurrence of vomiting or diarrhea, fever, and infant’s responsiveness Careful physical examination should include attention to vital signs, hydration status, and lethargy, and search for cephalohematoma and hepatosplenomegaly Consider obtaining a CBC Dermatologic Findings CLINICAL PEARLS AND PITFALLS As few as one to two vesicles on an erythematous base, most commonly on the scalp and face, may be the only presenting signs of HSV infection, which should be considered even in the absence of maternal signs or history of infection A tuft of coarse dark hair located in midline lumbosacral region may be associated with spina bifida occulta Benign Rashes Various papular rashes may be observed in the healthy newborn Characteristic body distribution patterns and age at appearance help differentiate these rashes from more worrisome conditions Diagnosis can be made by physical examination alone and not require further evaluation or specific treatment Parents should be reassured these are not worrisome conditions Milia are small 1- to 2-mm ivory or yellow papules located primarily on the forehead, nose, and cheeks of newborns Milia are keratin retention cysts They will spontaneously rupture and disappear during the first to weeks of life ( Fig 96.4 ) Miliaria, or neonatal prickly heat, is caused by sweat retention and is characterized by easily ruptured, 1- to 2-mm vesicles located primarily on the face chest and back Erythema toxicum is a more generalized eruption of small papules or pustules on an erythematous base that may occur anywhere on the body Usually presenting during the first to days of life, these lesions may be noted as late as weeks of age If the diagnosis is in question, a smear of the papular contents will show a predominance of eosinophils with no organisms and relative absence of neutrophils ( Fig 96.5 ) Neonatal acne is characterized by erythematous papules or pustules confined primarily to cheeks, chin, and forehead Lesions are caused by circulating maternal hormones, usually appear at to weeks of age and disappear within a few weeks ( Fig 96.6 ) Diaper rash is located on the skin covered by the diaper Irritants and contact dermatitis are often the initial precursor to the rash Candida infections are common and diagnosed if the rash is present in the intertriginous folds Candida infections are beefy red with well-demarcated borders and satellite papules and pustules Mostly a clinical diagnosis, candida can be confirmed if necessary by microscopic examination looking for budding yeasts and pseudohyphae ... Infants with breast-milk jaundice usually require increased breast-feedings, and close follow-up with pediatrician until adequate milk supply is insured Infants of diabetic mothers, infants with congenital