Icterus in Children
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:
- Age of onset: Neonatal vs. infantile vs. childhood jaundice
- Duration and progression: Acute, chronic, or fluctuating
- Associated symptoms:
- Fever, abdominal pain, weight loss
- Pruritus (suggestive of cholestasis)
- Pale stools, dark urine
- Bleeding tendencies
- Perinatal history: For neonates and infants
- Feeding history: Breastfeeding jaundice, malnutrition
- Medication history: Hepatotoxic drugs
- Family history: Hereditary conditions (e.g., Gilbert's syndrome)
- Travel history: Exposure to infectious agents
Physical Examination of Icteric Children
A systematic approach is crucial:
- General appearance:
- Assess for signs of chronic illness or acute distress
- Note the degree and distribution of jaundice
- Vital signs: Temperature, heart rate, respiratory rate, blood pressure
- Skin examination:
- Assess jaundice in natural light
- Look for petechiae, purpura, or bruising
- Check for signs of pruritus
- Eye examination:
- Scleral icterus
- Kayser-Fleischer rings (Wilson's disease)
- Abdominal examination:
- Hepatomegaly: Size, consistency, tenderness
- Splenomegaly
- Ascites
- Abdominal masses
- 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:
- Neonatal jaundice:
- Physiological jaundice
- Breastfeeding or breast milk jaundice
- Hemolytic disease (ABO/Rh incompatibility)
- Sepsis
- Biliary atresia
- Hepatocellular causes:
- Viral hepatitis (A, B, C, E)
- Autoimmune hepatitis
- Wilson's disease
- Drug-induced liver injury
- Cholestatic causes:
- Biliary obstruction
- Progressive familial intrahepatic cholestasis
- Alagille syndrome
- 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:
- Initial tests:
- Total and direct bilirubin
- Complete blood count
- Liver function tests (ALT, AST, ALP, GGT, albumin)
- Prothrombin time / INR
- Further investigations:
- Viral hepatitis serology
- Autoimmune markers
- Ceruloplasmin and urinary copper (Wilson's disease)
- Alpha-1 antitrypsin levels
- Newborn metabolic screen results
- Imaging studies:
- Abdominal ultrasound
- Hepatobiliary scintigraphy (HIDA scan)
- Magnetic resonance cholangiopancreatography (MRCP)
- Specialized tests:
- Liver biopsy
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Genetic testing for inherited disorders
