HY lecture notes:
Pathologic jaundice in peds = must have at least one of the following:
- Any jaundice on the first day of life (first 24 hours of life), period = pathologic.
- Jaundice present after one week if term, or after two weeks if preterm = pathologic.
- Total bilirubin >15 mg/dL.
- Direct bilirubin >10% of total bilirubin, even if total bilirubin is <15 mg/dL.
- Rate of change of increase in bilirubin >0.5 mg/dL/hour.
Biliary atresia in neonates shows up on surgery shelves, as with the above student on one of the practice forms. In turn there is some overlap with pediatric shelf for this diagnosis and management.
The standard vignette is a neonate who has total bilirubin of, e.g., 14 mg/dL, with a conjugated (direct) bilirubin of 12 mg/dL.
So at first you’re like, “I don’t get it though. The total bilirubin is normal.” Yes, but the direct bilirubin is >10% of total, so it’s still pathologic jaundice.
Surg shelf wants “liver biopsy” as the next best step in management.
If they ask for treatment, go straight to “liver transplant.”
If neonate has pathologic jaundice (not due to biliary atresia) and they ask for treatment, choose “phototherapy” first, followed by “exchange transfusion” if they tell you they already tried phototherapy to no avail.
Breastmilk jaundice vs breastfeeding jaundice:
Breastmilk jaundice = due to beta-glucuronidase in breast milk, which leads to de-conjugation of intestinal bilirubin + increased enterohepatic circulation –> jaundice that starts on day 3-5 and peaks at 2-3 weeks –> Tx = stop breastfeeding for ~48 hours (and do bottle feeding), which leads to a rapid decrease in bilirubin; once breastfeeding is resumed, bilirubin might rise, but not back to pathologic levels.
Breastfeeding jaundice = insufficient feeding (e.g., failure of suckling, etc.) + decreased milk intake leads to reduced intestinal clearance of bilirubin –> increased enterohepatic circulation –> jaundice that peaks at 3-5 days –> Tx = formula feeding (fluid + caloric supplementation).
Physiologic jaundice is the answer if all bilirubin parameters are in the normal range. So they can say in the vignette that the neonate is slightly jaundiced and is attaching to the breast poorly during feeds, but if all of the bilirubin parameters are in the normal range, the answer is physiologic jaundice, not breastfeeding jaundice.
