A 24-year-old mother is discharged from the hospital with her baby 24 hours after an uncomplicated labor and delivery. The baby was delivered at term and this is her first child. You receive a call from the mother the next day because she is concerned that the baby “looks a little orange”.
Which one of the following bilirubin levels would prompt phototherapy?
Correct Answer C:
Jaundice attributable to physiological immaturity usually appears between 24-72 hours of age, peaks by 4-5 days in term and 7th day in preterm neonates and disappears by 10-14 days of life. It is predominantly unconjugated and levels usually do not exceed 15 mg/dl. This pattern of physiological jaundice has been described in predominantly artificially fed babies. Based on recent recommendations of AAP, bilirubin levels up to 17-18 mg/dl may be accepted as normal in term healthy newborns. Safe bilirubin levels in preterms vary according to gestational age.
Anything out of this range is considered pathological jaundice.
A 37-year-old G2P2, has just given birth to a term baby at home, and did not have access to prenatal care during this pregnancy. The mother was taking levothyroxine during her pregnancy for her Hashimoto’s disease, but was at times forgetful. The baby showed signs of jaundice within the first 24 hours of birth. Two weeks later, the jaundice was still persistent, and the mother was complaining that new symptoms were starting to occur. There were times when the infant would start shaking, although the episode would be brief. Presently the infant is an abnormal posture, in which the back is severely arched and rigid.
What is the next step in management?
Correct Answer D:
This infant has pathological jaundice, and certainly hyperbilirubinemia as it has persisted for at least 2 weeks. The most feared complication of jaundice in a newborn is due to elevated indirect (unconjugated) bilirubin. We fear kernicterus in the newborn, as the bilirubin can deposit into the basal ganglia and brainstem nuclei. We must be aware of hypotonia, seizure-like activity, and opisthotonos. Opisthotonos is a condition in which the body is held in an abnormal posture, rigidity and severe arching of the back, with the head thrown backward. Other signs to be aware of is delayed motor skills, choreoathetosis, and sensorineural hearing loss. We manage these cases with immediate exchange transfusion (choice D).This is indicated in all children with bilirubin-induced neurologic dysfunction(BIND) or those who reach the threshold of >20 mg/dL (340 μmol/L) known as "vigintiphobia" because of its concerning association with neurological damage.
→ Look for ABO or Rh incompatibility (choice A) might certainly cause jaundice, but the most likely cause of jaundice in this child is congenital hypothyroidism.
→ Perform CBC, reticulocyte count, and blood smear (choice B) are useful in hemolytic anemia.
→ Initiate phototherapy when direct bilirubin >24mg/dL(choice C) is incorrect. Direct bilirubin is not a concern for causing BIND. For children with unconjugated bilirubinemia, levels >20 mg/dL should prompt exchange transfusion.
→ Urinalysis and urine culture, and assess for sepsis (choice E) is in likely to reveal the diagnosis of this child as it is most likely caused by congenital hypothyroidism.
A 36-hour-old male is noted to have jaundice extending to the abdomen. He is breastfeeding well, 10 times a day, and is voiding and passing meconium-stained stool. He was born by normal spontaneous vaginal delivery at 38 weeks gestation after an uncomplicated pregnancy. The mother’s blood type is A positive with a negative antibody screen. The infant’s total serum bilirubin is 222 µmol/L (13.0 mg/dL).
Which one of the following would be the most appropriate management of this infant’s jaundice?
Correct Answer B:
The current clinical practice guidelines on the management of hyperbilirubinemia in the newborn infant at 35 or more weeks gestation focus on frequent clinical assessment of jaundice, and treatment based on the total serum bilirubin level, the infant’s age in hours, and risk factors. Phototherapy should not be started based solely on the total serum bilirubin level. The guidelines encourage breastfeeding 8-12 times daily in the first few days of life to prevent dehydration. There is no evidence to support supplementation with water or dextrose in water in a non dehydrated breastfeeding infant. This infant is not dehydrated and is getting an adequate number of feedings, and there is no reason to discontinue breastfeeding at this time.
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