DIFFERENTIAL DIAGNOSES
AND DISCUSSION OF THE CASE
Pediatrics Admission Conference
November 11, 2019
Senior Intern Martin Magadia
Jaundice
•
Characterized by yellow discoloration of sclera, skin, and mucus membrane
•
Increased bilirubin levels
•
Earliest and only sign of hepatic dysfunction
•
Observed in the 1st week of life in:
•
•
60% of term
80% of preterm
Approach to Jaundice in the Newborn
Jaundice
Physiologic
Nonphysiologic
Approach to Jaundice in the Newborn
Jaundice
>2 days to <2 weeks
Physiologic
Nonphysiologic
Approach to Jaundice in the Newborn
Jaundice
>2 days to <2 weeks
Physiologic
<2 days or >2 weeks
Nonphysiologic
Approach to Jaundice in the Newborn
Jaundice
Physiologic
Breastfeeding
jaundice
Nonphysiologic
Approach to Jaundice in the Newborn
Jaundice
Physiologic
Breastfeeding
jaundice
Breastmilk
jaundice
Nonphysiologic
Approach to Jaundice in the Newborn
Jaundice
Physiologic
Breastfeeding
jaundice
Breastmilk
jaundice
Nonphysiologic
Neonatal
Cholestasis
Approach to Jaundice in the Newborn
Jaundice
Physiologic
Nonphysiologic
Breastfeeding
jaundice
Neonatal
Cholestasis
Breastmilk
jaundice
Biliary Atresia
Approach to Jaundice in the Newborn
Jaundice
Physiologic
Nonphysiologic
Breastfeeding
jaundice
Neonatal
cholestasis
Breastmilk
jaundice
Biliary atresia
Hemolytic
disorders
Breastmilk Jaundice
More Likely
•
11th day of life
•
Avidly breastfeeding
•
Good suck and cry
•
Good activity
•
Adequate urine output and bowel
movements
•
Improving color of bowel movement
Less Likely
•
Exaggerated jaundice (icteric sclerae,
jaundiced mucosal membranes)
Breastfeeding Jaundice
More Likely
Less Likely
•
Good suck and cry
•
11th day of life
•
Good activity
•
Avidly breastfeeding
•
Adequate urine output and bowel
movements
•
Exaggerated jaundice (icteric sclerae,
jaundiced mucosal membranes)
•
Improving color of bowel movement
Hemolytic Disorders
More Likely
•
Exaggerated jaundice (icteric sclerae,
jaundiced mucosal membranes)
Less Likely
•
Jaundice started at 2nd day of life and
maximal at 5th day of life
•
No family history of hemolytic
disorders such as G6PD deficiency,
hereditary sphorecytosis,
thalassemia
•
ABO Blood type AB, Rh (D) positive
INITIAL IMPRESSION:
PHYSIOLOGIC JAUNDICE,
PROBABLY BREASTMILK
JAUNDICE
Rule out hemolytic disorders;
Normal nutritional status
Diagnosis
•
Indications for work up:
•
•
•
•
•
•
Jaundice appears before 24 hours
Fast increase of serum bilirubin >5mg/dL per 24 hours
Serum total bilirubin >12 mg/dL in term infants
>10-14 mg/dL in preterm
Prolonged jaundice more than 2 -3 weeks
Direct bilirubin >2mg/dL
Diagnosis
•
Indications for work up:
•
•
•
•
•
•
Jaundice appears before 24 hours
Fast increase of serum bilirubin >5mg/dL per 24 hours
Serum total bilirubin >12 mg/dL in term infants
Serum total bilirubin >10-14 mg/dL in preterm
Prolonged jaundice more than 2 -3 weeks
Direct bilirubin >2mg/dL
Diagnostic Panel
•
Bilirubin levels
•
CBC
•
Reticulocyte count
•
Coomb’s test
•
Blood type
•
Peripheral blood smear
Diagnostics done for the patient:
•
Total Bilirubin 21.91 mg/dL
•
Conjugated Bilirubin 1.72 mg/dL
•
Unconjugated Bilirubin 20.19 mg/dL
Bhutani
Nomogram
Phototherapy
Level
Bilirubin
Metabolism
Breastmilk Jaundice
•
Presence of glucuronidase in some breastmilk
•
2% of breastfed infants after the 7th day of life
•
May last until 2nd to 3rd week
Risk Factors
•
J
•
A
•
U
•
N
•
D
•
I
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
A
•
U
•
N
•
D
•
I
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
U
•
N
•
D
•
I
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
Unrecognized hemolysis
•
N
•
D
•
I
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
Unrecognized hemolysis
•
Non-optimal sucking or nursing
•
D
•
I
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
Unrecognized hemolysis
•
Non-optimal sucking or nursing
•
Deficient enzymes, Drugs, Dehydration
•
I
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
Unrecognized hemolysis
•
Non-optimal sucking or nursing
•
Deficient enzymes, Drugs, Dehydration
•
Infection
•
C
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
Unrecognized hemolysis
•
Non-optimal sucking or nursing
•
Deficient enzymes, Drugs, Dehydration
•
Infection
•
Cephalhematoma or bruising
•
E
Risk Factors
•
Jaundice in older siblings
•
Age and condition of mother, Asian, and altitude of living
•
Unrecognized hemolysis
•
Non-optimal sucking or nursing
•
Deficient enzymes, Drugs, Dehydration
•
Infection
•
Cephalhematoma or bruising
•
Early birth