Icterus in Pediatric Age

Introduction to Icterus in Children

Icterus, or jaundice, is a yellowing of the skin and sclera due to hyperbilirubinemia. In children, it can be a sign of various underlying conditions, ranging from benign to life-threatening. A thorough clinical examination is crucial for proper diagnosis and management.

Key points:

  • Icterus is visible when serum bilirubin exceeds 2-3 mg/dL
  • Can be physiological in newborns or pathological at any age
  • May indicate hepatobiliary dysfunction, hemolysis, or other systemic issues

History Taking in Icteric Children

A comprehensive history is essential for determining the cause of icterus:

  1. Age of onset: Neonatal vs. infantile vs. childhood jaundice
  2. Duration and progression: Acute, chronic, or fluctuating
  3. Associated symptoms:
    • Fever, abdominal pain, weight loss
    • Pruritus (suggestive of cholestasis)
    • Pale stools, dark urine
    • Bleeding tendencies
  4. Perinatal history: For neonates and infants
  5. Feeding history: Breastfeeding jaundice, malnutrition
  6. Medication history: Hepatotoxic drugs
  7. Family history: Hereditary conditions (e.g., Gilbert's syndrome)
  8. Travel history: Exposure to infectious agents

Physical Examination of Icteric Children

A systematic approach is crucial:

  1. General appearance:
    • Assess for signs of chronic illness or acute distress
    • Note the degree and distribution of jaundice
  2. Vital signs: Temperature, heart rate, respiratory rate, blood pressure
  3. Skin examination:
    • Assess jaundice in natural light
    • Look for petechiae, purpura, or bruising
    • Check for signs of pruritus
  4. Eye examination:
    • Scleral icterus
    • Kayser-Fleischer rings (Wilson's disease)
  5. Abdominal examination:
    • Hepatomegaly: Size, consistency, tenderness
    • Splenomegaly
    • Ascites
    • Abdominal masses
  6. Neurological examination:
    • Level of consciousness
    • Signs of encephalopathy
    • Kernicterus in severe neonatal jaundice

Special Considerations in Examining Icteric Children

Certain aspects require particular attention:

  • Neonatal jaundice:
    • Assess extent using Kramer's rule
    • Look for signs of hemolysis (pallor, tachycardia)
    • Check for signs of sepsis
  • Cholestatic jaundice:
    • Inspect stool and urine color
    • Look for xanthomas and scratch marks
  • Hepatocellular jaundice:
    • Assess for signs of liver failure (spider nevi, palmar erythema)
    • Look for caput medusae in portal hypertension

Differential Diagnosis of Icterus in Children

Based on the clinical examination, consider the following categories:

  1. Neonatal jaundice:
    • Physiological jaundice
    • Breastfeeding or breast milk jaundice
    • Hemolytic disease (ABO/Rh incompatibility)
    • Sepsis
    • Biliary atresia
  2. Hepatocellular causes:
    • Viral hepatitis (A, B, C, E)
    • Autoimmune hepatitis
    • Wilson's disease
    • Drug-induced liver injury
  3. Cholestatic causes:
    • Biliary obstruction
    • Progressive familial intrahepatic cholestasis
    • Alagille syndrome
  4. Hemolytic causes:
    • Hereditary spherocytosis
    • Glucose-6-phosphate dehydrogenase deficiency
    • Sickle cell disease

Investigations for Icteric Children

Based on the clinical examination, consider the following tests:

  1. Initial tests:
    • Total and direct bilirubin
    • Complete blood count
    • Liver function tests (ALT, AST, ALP, GGT, albumin)
    • Prothrombin time / INR
  2. Further investigations:
    • Viral hepatitis serology
    • Autoimmune markers
    • Ceruloplasmin and urinary copper (Wilson's disease)
    • Alpha-1 antitrypsin levels
    • Newborn metabolic screen results
  3. Imaging studies:
    • Abdominal ultrasound
    • Hepatobiliary scintigraphy (HIDA scan)
    • Magnetic resonance cholangiopancreatography (MRCP)
  4. Specialized tests:
    • Liver biopsy
    • Endoscopic retrograde cholangiopancreatography (ERCP)
    • Genetic testing for inherited disorders


Knowledge Check: Question and Answers for Medical Students & Professionals

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Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.





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