for http://www.dnbpediatrics.com/

1. Resident Teaching Sessions in
Neonatology
Case – The Jaundiced Infant
dnbpaediatrics.blogspot.in

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case
• Mother: 24 year old G2T0P0A1L0
Spontaneous labour at 38 weeks
• Delivery:Delayed 2nd stage
Forceps
• Infant: Male
Birthweight 3.8kg
Pale and floppy, given free flow oxygen
Apgars 61, 95 minutes

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case – Question 1
• Asked to see at 18 hours of age because of
jaundice and poor feeding
• What further details of the history may be
helpful?

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case – Answer 1
• Mother :
– Group B ß-hemolytic strept negative
– Rubella immune
– HBsAg negative, HIV negative
– Maternal blood group: O rhesus negative
– Caucasian, no family history of jaundice
• Healthy pregnancy, prenatal vitamins, no meds
• Rupture of membranes: 32 hours
• Breast feeding (unsuccessfully)

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case – Question 2
• What would you look for on examination of
the infant?

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case – Answer 2
• Looks well
• No dysmorphic features, no rash
• Jaundiced, pale
• Heart sounds normal, no murmur, cap refill 2 sec
• No hepatosplenomegaly
• Forceps marks and bruising to face, “boggy”
feeling to scalp
• HR 140/min, RR 40/min, BP 48/34(43), T 36.8

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case – Question 3
• What would be your first line of
investigations?

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case – Answer 3
• CBC, diff, film
• Bilirubin (unconjugated, conjugated)
• Glucose, lytes
• Blood culture
• Blood group and Coombs test

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case - Results
• Hb 110g/L, hct 0.31, WBC 27, NPL 10.9, plat 183
• Bilirubin: unconj 210 umol/L, conj 3 umol/L
• Glucose 3.2 mmol/L
• Na 138 mmol/L, K 4.5 mmol/L
• Infant blood group A rhesus positive
• Direct Coombs test strongly positive

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Coombs test
• Direct: detects antibodies on the patient’s
cells.
• Indirect: detects antibodies in the patient’s
serum

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case – Question 4
• What management would you institute
immediately?

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case – Answer 4
• Phototherapy
• Optimise fluid intake (oral/nasogastric/IV)
• Antibiotics
• Repeat bilirubin in 4 hours

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Phototherapy
• Isomerisation of water insoluble unconjugated
bilirubin to a more water soluble form (lumirubin).
• Most effective is blue light: wavelength 400-
500nm. White light often used.
• Side effects:
– Increased fluid losses (1ml/kg/hr extra required)
– Irritability
– Loose stools
– Temperature instability
– Maculo-papular rash
– Separation of infant from mother

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case – Question 5
• After 4 hours of phototherapy and IV fluids,
the bilirubin is now 260 umol/L
• What further management options would
you consider?

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case – Answer 5
• Exchange transfusion:
– “Double volume” 160 cc/kg, removes 80% of
red cells, 50% bilirubin
• Intravenous immunoglobulin

16. dnbpaediatrics.blogspot.in
case – Question 6
• After 6 days of phototherapy, the bilirubin
is measured at 140umol/L (unconjugated)
after 12 hours off phototherapy
• What complications would you look for,
and what would be your follow-up plan?

17. dnbpaediatrics.blogspot.in
case – Answer 6
• Complications
– Rebound hyperbilirubinemia
– Anemia
– Manifested as lethargy, poor feeding, poor
growth
• Hct prior to discharge, continue to monitor
bilirubin

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Causes of hyperbilirubinemia
• Unconjugated
– Hemolysis
• DAT positive (ABO incompatibility, rhesus incompatibility,
SLE, drugs)
• DAT negative (RBC enzyme deficiencies e.g. G6PD, pyruvate
kinase)
– No hemolysis (Physiologic, breast milk, Gilbert,
Crigler-Nijjar, hypothyroidism)
• Conjugated (obstructive, infection, drugs,
metabolic); usually late

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Benign unconjugated
hyperbilirubinemia
• Physiological jaundice
– Increased red blood cell mass, shortened RBC life span
and hepatic immaturity of ligandin and glucuronyl
transferase
• Breast milk jaundice
– Beta-glucoronidase in milk leads to deconjugated of
bilirubin in the bowel and increased enterohepatic
circulation
– Reassure and do not stop breast feeding

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Prolonged hyperbilirubinemia
• Unconjugated
– Hypothyroidism, urine tract infection,
hemolysis
• Conjugated
– Biliary atresia, TORCH infection, metabolic
disorder, alpha-1-antitrypsin deficiency, cystic
fibrosis, TPN cholestasis, idiopathic neonatal
hepatitis

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Learning Objectives
• Describe the management of the infant with
unconjugated hyperbilirubinemia
• List the common causes of unconjugated
and conjugated hyperbilirubinemia in the
newborn period