Neonatal Jaundice Clinical Presentation

Updated: Mar 04, 2016
  • Author: Thor WR Hansen, MD, PhD, MHA, FAAP; Chief Editor: Ted Rosenkrantz, MD  more...
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Presentation

History

Presentation and duration of neonatal jaundice

Note the following:

  • Typically, neonatal jaundice presents on the second or third day of life.
  • Jaundice that is visible during the first 24 hours of life is likely to be nonphysiologic; further evaluation is suggested.
  • Infants who present with jaundice after 3-4 days of life may also require closer scrutiny and monitoring.
  • In infants with severe jaundice or jaundice that continues beyond the first 1-2 weeks of life, the results of the newborn metabolic screen should be checked for galactosemia and congenital hypothyroidism, further family history should be explored (see below), the infant's weight curve should be evaluated, the mother's impressions as far as adequacy of breastfeeding should be elicited, and the stool color should be assessed.

Family history

Obtain the following information:

  • Previous sibling with jaundice in the neonatal period, particularly if the jaundice required treatment
  • Other family members with jaundice or known family history of Gilbert syndrome
  • Anemia, splenectomy, or bile stones in family members or known heredity for hemolytic disorders
  • Liver disease in family members

History of pregnancy and delivery

Ascertain the following information:

  • Maternal illness suggestive of viral or other infection
  • Maternal drug intake, including the use of herbal remedies
  • Delayed cord clamping
  • Birth trauma with bruising and/or fractures.

Postnatal history

Obtain details of the following:

  • Loss of stool color
  • Breastfeeding
  • Use of drugs and herbal remedies in the lactating mother
  • Greater than average weight loss
  • Symptoms or signs of hypothyroidism
  • Symptoms or signs of metabolic disease (eg, galactosemia)
  • Exposure to total parental nutrition
Next:

Physical Examination

Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities. This cephalocaudal progression is well described, even in 19th-century medical texts. Jaundice disappears in the opposite direction. The explanation for this phenomenon is not well understood, but both changes in bilirubin-albumin binding related to pH and differences in skin temperature and blood flow have been proposed. [22, 23]  This phenomenon is claimed to be clinically useful because, independent of other factors, visible jaundice in the lower extremities strongly suggests the need to check the bilirubin level, either in the serum or noninvasively via transcutaneous bilirubinometry.

Recent work in the author’s group (Tølløfsrud et al, unpublished data) was not able to confirm this so-called cephalocaudal progression of jaundice. Thus, when dermal jaundice was measured noninvasively on the forehead, sternum, and symphysis, no cephalocaudal trend was evident.

In most infants, yellow color is the only finding on physical examination. More intense jaundice may be associated with drowsiness. Brainstem auditory-evoked potentials performed at this time may reveal prolongation of latencies, decreased amplitudes, or both.

Overt neurologic findings, such as changes in muscle tone, seizures, or altered cry characteristics, in a significantly jaundiced infant are danger signs and require immediate attention to prevent kernicterus. In the presence of such symptoms or signs, effective phototherapy should commence immediately without waiting for the laboratory test results (see Laboratory Studies). The potential need for exchange transfusion should not preclude the immediate initiation of phototherapy. [24, 25]

Hepatosplenomegaly, petechiae, and microcephaly may be associated with hemolytic anemiasepsis, and congenital infections and should trigger a diagnostic evaluation directed towards these diagnoses. Neonatal jaundice may be exacerbated in these situations.

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