Written by Hannah Harp
Spoon Feed
PCPs should schedule a well-baby visit at age 2-4 weeks, and ALL newborns with jaundice/icterus, acholic stools, or prior elevated conjugated bilirubin should have direct/conjugated bilirubin drawn at this visit unless a prior level was normal.
Follow the yellow brick road…
Biliary atresia (BA) can be asymptomatic in the first two weeks of life, but referral to hepatology and surgery should occur before 30 days of life to optimize outcomes of Kasai hepatoportoenterostomy and prevent progression to liver transplant. An AAP Clinical Report provides an algorithm for identifying newborns with BA. Using a clinical strategy at the 2-4 week well-child visit, PCPs assess eye color, skin color, stool color, and prior bilirubin levels to determine the need for direct or conjugated bilirubin testing. If any of these are abnormal, a direct/conjugated bilirubin should be drawn. An urgent referral to pediatric gastroenterology should be placed if the level is >1 mg/dL at 2-4 weeks. Additional labs and ultrasound are not recommended in place of referral due to potential for falsely reassuring results. Exceptions to need for blood draw include a prior normal conjugated bilirubin level or levels that are <1 mg/dL and improving. The clinical report highlights the urgency of direct bilirubin levels ≥1 mg/dL, necessitating gastroenterology referral and potentially reducing liver transplant rates.
How will this change my practice?
Until now I have let seasoned parents decide if they would like to come for a 2 week visit or just wait until the 1 month visit to be seen. Not anymore! I’ve also added a prompt to my templates to confirm that a direct bilirubin was drawn in the hospital and to discuss the stool color card at the newborn and “by one month” visits. That being said, I will not have time to gather reference ranges and the source of their established lab values from all of our feeder hospitals – we can hardly get those initial bilirubin values to begin with!
Source
Guidance for the Primary Care Provider in Identifying Infants With Biliary Atresia by 2-4 Weeks of Life: Clinical Report. Pediatrics. 2025 Feb 18:e2024070077. doi: 10.1542/peds.2024-070077. Epub ahead of print. PMID: 39961332
