0071643192.pdf

PEDIATRICS

■ Immune-mediated (Rh or ABO incompatibility)
■ Congenital RBC abnormalities (spherocytosis, G6PD, thalassemia)
■ Inborn errors of metabolism (Gilbert syndrome, galactosemia)
■ Increased enterohepatic circulation
■ Decreased ability to excrete conjugated bilirubin (biliary atresia, hepatitis)
■ Sepsis
■ Hypothyroidism

SYMPTOMS/EXAM

As serum bilirubin levels increase, jaundice will become more detectable, start-
ing at the infant’s head and progressing toward the feet (see Table 5.2). Estimates
of bilirubin levels based on physical examination, however, are unreliable.

Symptoms of bilirubin toxicity include:

■ Extensor rigidity
■ Tremor
■ Loss of suck reflex
■ Lethargy
■ Seizures

DIAGNOSIS/TREATMENT

Diagnosis and treatment options are based upon the serum bilirubin level.
Serum bilirubin levels should be interpreted relative to the infant’s age in
hours, not days. Hyperbilirubinemia is always abnormal if present in the
first 24 hours of life.

■ Additional lab studies that may be indicated include maternal and infant
blood types, Coomb’s test, infant CBC, reticulocyte count, and peripheral
blood smear.
■ Consider phototherapy if total bilirubin is > 5 ×the birth weight in kilo-
grams (usually 15–20 mg/dL).
■ Consider exchange transfusion if total bilirubin is > 10 ×the birth weight
in kilograms (usually 25–30 mg/dL)

COMPLICATIONS

Kernicterus

Diarrhea

Diarrhea is a nonspecific symptom most often caused by inflammation or
infection of the bowels (enteritis). In the United States, diarrheal diseases are
responsible for nearly 10% of all pediatric hospitalizations. Worldwide, diar-
rheal diseases continue to cause significant morbidity and mortality.

TABLE 5.2. Clinical Jaundice and Serum Bilirubin Levels

Face/eyes 7 – 8 mg/dL

Shoulder/torso 8 – 10 mg/dL

Lower body 10 – 12 mg/dL

Generalized >12 mg/dL

Unconjugated bilirubin =

indirect bilirubin.

Conjugated bilirubin = direct

bilirubin.

Total bilirubin = indirect

bilirubin + direct bilirubin.