Hyperbilirubinemia/Jaundice — History and Physical — Clinical Pathway: All Settings

Neonates with Hyperbilirubinemia/Jaundice Clinical Pathway

History and Physical

Review the birth history and discharge sheet to identify the infant’s risk for significant hyperbilirubinemia.

Assess feeding, hydration and weight change, a minimum of 8 feedings a day are recommended.

Differential Diagnosis of Jaundice in the Newborn

Birth History
  • Infant History:
    • Date, time and place of birth
    • Gestational age
    • Birth weight, discharge weight
    • Delivery details (forceps, vacuum, etc.)
    • Jaundice in the first 24-28 hours
    • Phototherapy in the first 24-48 hours
    • Maternal diabetes
  • Maternal History:
    • Blood Type, Rh type and DAT results:
      • If the mother is O or Rh negative — Call the birth hospital for an antibody screen if results are unknown, RhIG given
      • If the mother’s antibody screen is positive or unknown — The infant needs blood type testing and DAT
  • Infant Can Be Treated as DAT Negative If:
    • Mother was RhD antibody negative prior to receiving RhIG during pregnancy
    • and
    • Infant is DAT positive to anti-RhD only
HPI
  • Feeding:
    • Breast, formula, formula supplementation
    • Duration and frequency feeds (ounces if formula fed)
      • Goal for at least 8 feeds/24 hrs
    • Intake in past 24 hours
  • Elimination:
    • Number of wet diapers
    • Pattern of stooling, stool transition
  • Other Symptoms:
    • Presence of fever, method of temperature measurement
    • Acetaminophen use
  • Signs of Bilirubin Encephalopathy:
    • Early:
      • Lethargy
      • Hypotonia
      • High-pitched cry
      • Poor feeding
    • Intermediate:
      • Irritability
      • Retrocollis
      • Opisthotonos
      • Fever
    • Advanced:
      • Apnea
      • Stupor
      • Coma
Pertinent Family History
  • Parent or sibling received phototherapy
  • Hematologic disorders
    • E.g., G6PD-deficiency, hereditary spherocytosis, known blood group incompatibility
  • Note:
    • Consider G6PD if jaundice in the first 24 hours
    • Infants of African, Middle Eastern, Arabian Peninsula and Southeast Asia descent with jaundice
    • Measurement of G6PD activity at the time of a hemolytic event can be inaccurate, consider Hematology Consult for further guidance
Physical Assessment
  • Vital signs, weight (naked) comparison with birth weight
  • General appearance
  • Hydration status
  • Abdominal Exam:
    • Hepatomegaly
    • Splenomegaly
  • Neurologic Exam:
    • Tone
    • Retrocollis
    • Opisthotonos
  • Skin Exam:
    • Bruising
    • Petechiae
    • Pallor
    • Scalp hematoma
  • Assess for Jaundice:
    • Cephalocaudal progression
    • Scleral icterus
    • Apply gentle pressure with one finger to reveal the color of the skin and subcutaneous tissue