Pediatric Jaundice Treatment in the Emergency Department
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Treatment Of Pediatric Patients With Jaundice In The ED

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Practice Recommendations (key points from the issue)
  3. Case Presentations
  4. Critical Appraisal Of The Literature
  5. Epidemiology
  6. Pathophysiology
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. Initial Stabilization
    2. History
    3. Physical Examination
      1. Hepatopulmonary Syndrome
  10. Physiologic Jaundice
  11. Pathologic Jaundice
    1. Unconjugated Hyperbilirubinemia
      1. Diagnosis
      2. Treatment
    2. Conjugated Hyperbilirubinemia
      1. Intrahepatic Cholestasis
        • Acute Liver Failure In The Pediatric Patient
        • Diagnosis
        • Treatment
        • Toxin- And Drug-Induced Liver Injury
        • Diagnosis And Treatment
        • αa1-Antitrypsin Deficiency
        • Cystic Fibrosis
        • Wilson’s Disease
        • Metabolic Disease
        • Autoimmune Hepatitis
        • Caroli Disease
        • Extrahepatic Cholestasis
        • Extrahepatic Biliary Atresia
        • Pancreatitis
      2. Choledochal Cyst
        • Cholelithiasis
        • Diagnosis
      3. Infectious Causes
        • Bacterial
        • Viral
      4. Hepatitis A
      5. Hepatitis B, C, D, And E
      6. Epstein-Barr Virus, Cytomegalovirus, Herpes Simplex Virus, Varicella-Zoster Virus
  12. Diagnostic Studies
    1. Bilirubin
    2. Urobilinogen
    3. Aminotransferases
      1. AST
      2. ALT
  13. Diagnostic Modalities
    1. Ultrasound
    2. Magnetic Resonance Cholangiopancreatography
    3. Endoscopic Retrograde Cholangiopancreatography
  14. Special Circumstances
  15. Disposition
  16. Time- And Cost-Effective Strategies
  17. Summary
  18. Risk Management Pitfalls For Pediatric Patients With Jaundice
  19. Case Conclusion
  20. Clinical Pathway For The Treatment Of Jaundice In 2- To 8-Week Old Infants
  21. Tables and Figures
    1. Table 1. Factors That Affect Bilirubin Levels
    2. Table 2. Differential Diagnosis Of Jaundice In Children
    3. Table 3. Worrisome Features Associated With Jaundice
    4. Table 4. Important Historical Questions And Implications
    5. Table 5. Important Physical Findings In Jaundice And Their Implications
    6. Table 6. Management Of Hyperbilirubinemia In The Healthy Term Newborn
    7. Table 7. Stages Of Hepatic Encephalopathy
    8. Table 8. Extrahepatic Complications Of Fulminant Hepatic Failure
    9. Table 9. Treatment Of Acute Liver Failure According To Etiology
    10. Table 10. Common Pediatric Drugs Associated With Cholestatic Injury
    11. Table 11. Common Metabolic Diseases Associated With Jaundice
    12. Table 12. Imaging Modalities For Diagnosis Of Extrahepatic Obstruction
    13. Table 13. Hepatitis Serologies
    14. Figure 1. Age And GenderRelated Changes In Bilirubin Levels
    15. Figure 2. Rumack Matthew Nomogram For Acetaminophen Toxicity
  22. References

Abstract

Jaundice, or icterus, is a yellow-green discoloration of the skin, eyes, mucous membranes, and body fluids that results from excessive bilirubin. Jaundice is apparent in infants with a total serum bilirubin (TSB) concentration greater than 5 mg/dL and in older children with a TSB concentration greater than 2 to 3 mg/dL.1 Total serum bilirubin reflects the sum of unconjugated (ie, indirect) and conjugated (ie, direct) fractions. Conjugated hyperbilirubinemia, also called cholestasis, is defined as a conjugated bilirubin concentration greater than 1 mg/dL or more than 20% of the TSB concentration; it is always pathologic.2 Early detection of cholestatic jaundice and a timely, accurate diagnosis are important for successful treatment and a favorable prognosis.

Although jaundice is a common finding in children, it also can be the presenting sign for a number of other disorders, hepatic as well as extrahepatic, reflecting either excessive bilirubin production or decreased excretion by the liver or biliary system. Binding to albumin prolongs the half-life of direct bilirubin, and even though the results of other liver tests may be normalizing, jaundice may be protracted. Jaundice itself is harmful only in newborns, in whom the accumulation of unconjugated bilirubin may lead to kernicterus in the immature brain.3 The differential diagnosis is age specific. Neonatal jaundice occurs in up to 60% of term infants in the first week of life. Approximately 2% of newborns reach TSB levels in excess of 20 mg/dL.4

The differentiation between nonpathologic and pathologic jaundice begins in the emergency department (ED). In recent years, a large body of evidence and updated guidelines have helped elucidate the pathophysiology of jaundice and outlined appropriate management options for children with cholestasis and related illnesses. This issue of Pediatric Emergency Medicine Practice provides the results of these evidencebased studies and the most up-to-date guidelines to assist the emergency clinician in caring for pediatric patients presenting with jaundice. These recommendations are general guidelines and are not intended as a substitute for clinical judgment or as a protocol for the care of all patients who present with jaundice.

Case Presentations

A 2-month-old infant presents to the emergency department with a chief complaint of jaundice. History reveals that the infant was full-term, had a normal birth, and was discharged from the nursery after 2 days. The infant is breastfed. During the last month, the parents have noticed progressive jaundice, and the infant’s stools seem lighter in color. The physical examination reveals a well-appearing, icteric infant without hepatosplenomegaly. The screening bilirubin test from the pediatrician’s office reveals that the infant’s total bilirubin level is elevated, but fractionation was not done. You have seen many jaundiced infants, especially among breastfed patients. Does this infant warrant further evaluation, or is this a case of physiologic/breast milk jaundice? Is there something in the history that suggests this jaundice is worrisome? Should you discharge the infant for follow-up with the primary physician, or should you proceed with emergency department evaluation? If so, what is the next step in examining this patient? Does this infant have acute liver failure that warrants admission to the intensive care unit? Does he have an obstruction of the biliary tree or other surgical emergency? Is this a case of infectious hepatitis, and can the patient be discharged home after proper hydration?

Critical Appraisal Of The Literature

All studies, review articles, and meta-analyses were identified via MEDLINE® and Ovid MEDLINE® (eg, the Cochrane Database of Systematic Reviews, the ACP Journal Club®, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials, the Cochrane Methodology Register, the Health Technology Assessment Database, and the National Health Service Economic Evaluation Database). Terms used in the search included jaundice, cholestasis, neonate, infant, pediatric, child, guideline, and emergency department/room. More than 200 articles published from January 1991 to July 2008 were analyzed, providing the background for further review.

Although most population-based data come from well-designed, large-sample studies of infants with jaundice, only a few studies have been prospective in nature. In addition, differences in interhospital bilirubin testing and frequency of identified jaundice are significant.5 This has led to the development of benchmarking models that adjust for race, feeding method, and gestational age in order to compare incidence of hyperbilirubinemia between hospitals.6 Guidelines have been issued by the American Academy of Pediatrics (AAP)7 and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)2 using the definitions for quality of evidence and balance of benefits and harm established by the AAP/NASPGHAN Steering Committee on Quality Improvement Management. These guidelines have undergone extensive peer review by committees, outside organizations, and experts in the field.

Risk Management Pitfalls For Pediatric Patients With Jaundice

  1. “This 2-month-old breastfed infant probably has breast milk jaundice.” Diagnosis of neonatal cholestasis must be done promptly, as patients with early diagnosis of biliary atresia (< 60 days of life) have a better prognosis following portoenterostomy. A missed diagnosis of biliary atresia leads to progressive liver disease and the need for liver transplantation.
  2. “The patient’s stools are pigmented; therefore, the diagnosis of biliary atresia can be excluded.” Although patients with biliary atresia classically have acholic stools, the presence of pigmented stools does not rule out biliary atresia.
  3. “TSB levels are sufficient to screen neonates with jaundice.” With neonatal jaundice, it is extremely valuable to differentiate between indirect hyperbilirubinemia, which may be benign, and direct hyperbilirubinemia, which is always pathologic and requires urgent workup.
  4. “This small, breastfed infant with jaundice has an elevated AST level. This finding is indicative of significant hepatocellular injury.” Although AST is present in large amounts in the liver, it is also present in heart and skeletal muscle, the kidney, the pancreas, and red blood cells. Thus, while elevated AST levels may be indicative of liver injury, they can also be elevated in situations such as acute rhabdomyolysis during a systemic viral illness.
  5. “This patient with new-onset jaundice and an INR of 2 can be discharged and seen as an outpatient.” Patients with jaundice and evidence of hepatic dysfunction (coagulopathy or hypoalbuminemia) have impending liver failure. These patients should be closely monitored in an intensive care setting. If liver dysfunction is progressive and unresponsive to vitamin K, the patient should be transferred promptly to a liver transplant center.
  6. “If a patient or family member states that no high-dose acetaminophen was ingested, an overdose is unlikely.” Many cold and pain medications contain acetaminophen, and unintentional overdosing may occur. Therefore, acetaminophen levels should be checked in any child presenting with liver failure, as early initiation of N-acetylcysteine may be lifesaving.
  7. “If a child seems alert, HE is unlikely.” Diagnosis of hepatic encephalopathy (HE) in young children may be very challenging, as evidence may be subtle. Patients in the early stages present with irritability, poor feeding, and a change in sleep rhythm.
  8. “The transaminase levels are trending downward; therefore, the patient is improving.” Patients with fulminant liver failure and massive hepatic necrosis may have transaminase levels that trend downward as a consequence of loss of hepatocytes and worsening liver function (ie, rise in bilirubin level and INR). These patients should be transferred immediately to a liver transplant center.
  9. “The patient’s albumin value is normal; therefore, the liver synthetic function is intact.” The half-life of albumin is 21 days, and in cases of fulminant liver failure, it can be less than 7 days.
  10. “All coagulopathy needs to be corrected with fresh frozen plasma.” Patients with cholestasis and coagulopathy may be vitamin K deficient and responsive to subcutaneous or intravenous administration of vitamin K. The INR is an important marker of the liver’s synthetic capability and is important for evaluation of disease progression and prognosis. Coagulopathy should be corrected with fresh frozen plasma (FFP), platelets, or factor VII in cases of active bleeding or prior to an invasive procedure such as a central line placement.
  11. “A serum sodium level of 120 mEq/L should be rapidly corrected with hypertonic saline.” Hyponatremia in patients with chronic liver disease is usually dilutional and not a reflection of sodium depletion. Therefore, fluid restriction is warranted. Parenteral infusion of calcium, phosphorous, and magnesium is often required.

Tables and Figures

Table 1. Factors That Affect Bilirubin Levels

Table 2. Differential Diagnosis Of Jaundice In Children

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

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Authors

Tamir Miloh; Keith J. Breglio; Jaime Chu

Publication Date

December 1, 2010

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