Persistent neonatal jaundice needs fractionated bilirubin before a breast milk jaundice explanation; chest pain ECGs and respiratory failure add urgent checks.
Jaundice beyond two weeks needs fractionated bilirubin, not reassurance.
A jaundiced three-week-old who feeds well can still have biliary atresia. The Cribsiders biliary atresia review is the place to begin: at two weeks, persistent jaundice needs fractionated bilirubin, and a direct bilirubin of 1 mg/dL or more should trigger urgent paediatric gastroenterology or hepatology input. Pale or acholic stools help, but normal stool recognition is unreliable, and normal early AST or ALT does not settle the case.
For adult acute care, the OMI journal club deserves attention next: a STEMI-negative ECG can still represent an occluded culprit artery when anterior ST depression is maximal in V1–V4. Respiratory failure follows with ABG-led separation of oxygenation and ventilatory failure. Order the fractionated bilirubin before calling persistent jaundice breast milk jaundice.
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Open this first because persistent neonatal jaundice is time-sensitive and easy to mislabel as breast milk jaundice. At the two-week review, check scleral jaundice and stool colour, then order fractionated bilirubin; direct bilirubin 1 mg/dL or more needs urgent specialist input.
Chest pain with a STEMI-negative ECG can still involve a culprit occlusion. Read anterior ST depression carefully: if maximal in V1–V4 without expected discordance, consider posterior or lateral OMI, add POCUS when skilled, and escalate with clear territory-based language.
Shortness of breath and low saturations need physiology before device choice. Use ABG, work of breathing and oxygen response to separate hypoxaemic from hypercapnic respiratory failure; true shunt, fatigue, intrinsic PEEP and haemodynamic effects change escalation.
An incidental carotid bruit or ultrasound stenosis should not automatically lead to surgery. Confirm the patient is truly asymptomatic, optimise antiplatelet, lipid, blood pressure, diabetes and smoking care, then discuss endarterectomy, transfemoral stenting or TCAR using absolute risks.
At the two-week baby review, look at sclerae and ask about stool colour rather than relying on feeding and weight gain. If jaundice persists, order fractionated bilirubin promptly. Treat an abnormal direct or conjugated result as same-week specialist referral, not a repeat-later result.
What should persistent jaundice after two weeks trigger?
Order a fractionated bilirubin promptly, including in breastfed infants. A direct bilirubin of 1 mg/dL or more after two weeks is abnormal and needs urgent evaluation.
Can good feeding and normal early transaminases exclude biliary atresia?
No. A reassuring examination, good feeding, normal growth and normal early AST or ALT do not rule out biliary atresia.
What ECG finding should change a STEMI-negative chest pain assessment?
Anterior ST depression maximal in V1–V4, without expected discordance, should prompt consideration of posterior or lateral OMI and early escalation language.
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