Pertinent family history includes the presence of a first-degree relative with history of jaundice or anemia, and racial or ethnic origin associated with a hematologic disorder Physical Examination The general appearance and vital signs of the patient will help guide the clinician as to the likelihood of a serious underlying condition such as bacterial sepsis Hydration status should be ascertained Hepatomegaly may indicate underlying liver dysfunction Splenomegaly may be found in hypersplenic states or patients with hemolytic anemia Neurologic examination should include evaluation for signs of ABE: hypotonia, irritability, retrocollis, opisthotonos, high-pitched cry, and coma Pallor may indicate concomitant anemia Presence of a cephalohematoma or large areas of ecchymosis may suggest extravascular hemolysis as the cause of hyperbilirubinemia Clinical examination of jaundice involves close inspection of the sclera and skin under adequate light, applying gentle pressure with one finger to facilitate examination of color In neonates, jaundice progresses in a cephalocaudal direction from the face to the trunk and extremities, and finally to the palms and soles In neonates, visual assessment of jaundice has been found to correlate poorly with serum bilirubin measurement, with great interobserver variability noted The acute neurologic manifestations of the neurotoxic effects of bilirubin are known as ABE, the term recommended by the American Academy of Pediatrics (AAP) ABE may be reversible if identified in the early phase, when clinical findings may be subtle and include sleepiness, hypotonia, and/or a high-pitched cry Later phases include lethargy, irritability, retrocollis, opisthotonos, seizures, apnea, and coma Death is typically due to respiratory failure or intractable seizures Additional Studies The total and fractionated (direct and indirect) serum bilirubin level should always be measured, as visual inspection alone is an unreliable indicator Many times, these are the only laboratory studies indicated in the ED evaluation of a child who presents with jaundice; indication for other laboratory studies will be reviewed here Occasionally, imaging studies are indicated in the evaluation of a child with jaundice or hyperbilirubinemia Laboratory Testing