Causes of hyperbilirubinemia in paediatric age group

Unconjugated hyperbilirubinemia

1) Increased production- hemolytic anemia (Hereditary spherocytosis, G6PD deficiency)
ineffective erythropoesis (Thalassemia, Pernicious anemia)
2) Reduced hepatic intake from bilirubin-albumin complex – drug induced
3) Impaired hepatic conjugation
a) Physiological – functionally immature liver
b) Breast milk jaundice - pregnendiol and FFA in breast milk interferes conjugation (in susceptible)
c) Genetic deficiency of UDPG transferase – Crigler-Najjar, Gilberts
d) Hepatocellular dysfunction- Viral or drug induced Hepatitis, Cirrhosis
e) Hypothyroidism
f) Cephalhematoma

Conjugated Hyperbilirubinemia

1) Impaired secretion of conjugated bilirubin into bile – Dubin-Johnson, Rotor’s
2) Impaired bile flow

a) Obstructive jaundice
b) Primary biliary cirrhosis
c) Neonatal cholestasis – extrahepatic biliary atresia/neonatal idiopathic hepatitis
Choledochal cyst,sclerosing cholangitis,Caroli’s disease
d) Metabolic- Tyrosinemia, Wolman disease, Niemann Pick, Galactosemia, Fructosemia

Appearance of Jaundice – Area of infant body to s.bilirubin levels

Head&neck — 5mg/dl
Upper trunk & proximal Upper limb — 10mg/dl
Lower trunk & thigh – 12mg/dl
Legs — 15mg/dl
Palms & sole – >15mg/dl

Causes of jaundice and time of onset

a) within 24 hours

  • Rh incompatibility (most common)
  • Concealed haemorrhage
  • Sepsis
  • Cong. Infections – CMV, Rubella, Syphillis, Toxoplasma
b) appears in 2nd to 3rd day
  • Physiological
  • Crigler najjar
  • Early onset breast milk jaundice
c) from 3rd day to 7th day
  • Bacterial sepsis
  • UTI
  • Polycythemia
  • Cong. Infections
d) after first week -All other caouses other than those mentioned above
Physiological Jaundice (unconjugated bilirubin)
  • After 24 hours
  • progressive rise in s.bilirubin- <5mg/dl per day (no sudden rise)
  • Peaks in 3-5 days, total not more than 15mg/dl
  • Clinical jaundice resolved by 1 week in term infants and 2 week in preterm
  • 2 phases – (phase 1 – lasts 5 days in term (12mg/dl) and 7 days in preterm (15mg/dl); phase 2 – gradual decline to 2mg/dl, which          lasts 2 weeks, before falling to adult values)
Breast milk Jaundice (unconjugated)
  • After 30 hrs, exclusively breast fed infants,
  • May continue way into 3rd month
  • bilirubin may reach 20mg/dl
  • Temprorary intererruption of breast feeding will dramatically bring down bilirubin levels, once within control values restart breast feed.
Crigler Najjar syndrome

Type 1

  • Inheritance –    autosomal recessive
  • LFT    –      normal
  • Liver histology  –    normal
  • Kernicterus –  yes
  • UDPG transferase – absent
  • response to  phenobarbitone-   no response
  • hemolysis –  absent

Type 2

  • inheritance – autosomal dominant
  • LFT –  normal
  • Liver histology- normal
  • Kernicterus-   rare
  • UDPG transferase- reduced
  • response to   phenobarbitone-  decreases bilirubin
  • hemolysis –   absent

Dubin Johnson Syndrome

  1. AR, conjugated hyperbilirubinemia becoz of mutation in canalicular multidrug resistance protein 2(MRP2)
  2. LFT normal; accumulation of black granular pigment in lysosomes of centrilobar hepatocytes
  3. Increased urinary coprophorphyrin but total coprophorphyrin is normal
  4. Gall bladder is not visualised on oral cholecystography

Rotor syndrome

  • AR, congenital conjugated hyperbilirubinemia. decreased biliary excreation
  • Liver is not pigmented, urine as well as total coprophorphyrin will be increased
  • Gall bladder will be visualized

This post was written by my friend Kim George, you can contact him @drkimgeorge@gmail.com

  1. awesome post! thanks

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