The Jaundiced Child

See separate section on neonatal jaundice. Remember the SEPTIC child may also be jaundiced.

Prehepatic (Haemolysis)	Hepatic Disease	Posthepatic (Obstructive)
Malaria incl. Tropical splenomegaly syndrome Sepsis Sickle cell disease G6PD deficiency Thalassaemia Hereditary spherocytosis	Infective Hepatitis Cirrhosis Drugs Malignancy Metabolic disease Schistosomiasis (late stage)	Biliary atresia Gallstones Choledochal cyst Worms (ascaris in common bile duct)

Important points in history

Family history of hereditary haemoglobinopathy, liver disease
Previous need for transfusion (transfusion = risk for contracting Hep B,C)
Drugs ingested: ART, anti TB meds or others suggesting G6PD deficiency
Anorexia, abdominal pain, pruritus
Colour of stool and urine - normal colour of stools suggests unconjugated jaundice and haemolysis, tea-coloured urine and pale stools suggests obstructive causes of jaundice

A full physical examination is necessary. Particular signs may point to a diagnosis, or may be important in different conditions.

Assess growth and nutritional state - poor in chronic liver disease
Pallor-suggests haemolysis if acute
Look for frontal bossing or maxillary overgrowth (sickle cell disease or thalassaemia)
Bruising, bleeding
Hepatosplenomegly (malaria, longstanding haemolysis)
Liver tenderness - suggestive of acute hepatitis
Look for signs of chronic liver disease (eg. spider naevi, clubbing, leukonychia, liver palms, scratches due to pruritis, ascites, distended abdominal veins)
Abdominal masses - malignancy, choledochal cyst

Conjugated bilirubin in liver disease or biliary obstruction
Unconjugated bilirubin in haemolysis or hepatitis
Transaminases raised in hepatitis
Abdominal ultrasound (shrunken liver in cirrhosis, large bright inflamed liver in hepatitis, tumours of liver, biliary atresia, choledochal cysts or gallstones)
Hepatitis B serology if hepatitis is considered.
VDRL

If there is ascites, a diagnostic/ therapeutic tap may be necessary.
If clotting screen is necessary - discuss with Johns Hopkins lab

Blood transfusion if PCV 12% or less Transfusions
Treat underlying cause of haemolysis including and malaria malaria
Treat with artesunate/LA for malaria even if malaria parasites are negative and the child has evidence of haemolysis (jaundice, low PCV), and fever
Sickle cell crisis
IV fluids - hyperhydration, oxygen, pain management, antibiotics
Stop any possible offending drugs

Blood sugar level - daily and more frequently if the child has a decreased conscious state - maintain RBS between 4-9 mmol/l.
Vitamin K: iv if bleeding actively - have a low threshold for its use if chronic liver disease (longstanding jaundice, bruising, signs of chronic liver disease).
Vitamin A - if chronic liver disease is suspected.
Diet: Low protein, high carbohydrate. Feed 2 hourly.
Fluid balance monitoring if encephalopathic- need approximately 2/3 maintenance fluid requirement. Monitor daily weight.
Antibiotics if febrile and jaundiced and MPS are negative.
Surgical review if varices and GI bleeding. Crossmatch blood.
In chronic liver disease consider prophylactic ranitidine, nystatin PO
Avoid Paracetamol. Use ibuprofen if required.

Haemolysis

Liver disease