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 Case
Report
Jaundice
by
Caraciolo J. Fernandes, MD
A
5-day old, 3387-gram Hispanic male infant presented
to an outlying emergency room with a one-day history of irritability,
jaundice, skin rash, and poor breastfeeding. He was born vaginally
at 38 weeks’ gestation, weighing 3600 grams, to a 30-year-old
G3P1-2Ab1 woman after an uneventful pregnancy. Initial hospital
course was unremarkable; he was discharged home the third day
of life on breast feeds supplemented with an occasional bottle
of formula. The parents stated that the child’s sibling had a
normal early neonatal course without jaundice. Initial laboratory
studies were: mother’s blood group O+; baby’s blood group B+;
direct Coombs, negative; Hct, 45.2 gm%; reticulocyte count, 2.7%;
indirect bilirubin, 32.6 mg%; direct bilirubin, 0.8 mg%. Phototherapy
and IV fluids were started, and he was transferred to Texas Children’s
Hospital.
Physical
exam on admission at Texas Children’s an hour later showed a significantly
jaundiced infant with normal vital signs. He was mildly irritable
when examined but was otherwise neurologically normal. He had
no evidence of dehydration. Following the admitting evaluation,
laboratory studies were ordered including a type and crossmatch
for a possible exchange transfusion. Crystalloid IV fluids were
continued at 150 cc/kg/day, and intensive phototherapy was started.
Results of Texas Children’s laboratory studies demonstrated no
electrolyte abnormality and confirmed elevation of indirect bilirubin
(24 mg%).
Careful
evaluation of history, examination, and laboratory studies suggested
a diagnosis of breastfeeding jaundice. Following institution of
intensive phototherapy, the indirect bilirubin fell rapidly (from
28.4 to 21 mg%). Therefore, an exchange transfusion was not performed.
Ad libitum PO feeds were initiated; IV fluids, discontinued. The
third day following admission, phototherapy was discontinued when
indirect bilirubin was 11.6 mg%. At discharge, the following day,
the indirect bilirubin was 11.8 mg%; the infant weighed 3580 grams,
had a normal clinical exam, and was feeding well PO. Before discharge,
in view of the significant hyperbilirubinemia, AEBR hearing tests
were performed and developmental follow-up was scheduled.
Denouement:
Although neonatal jaundice is common and usually benign, hyperbilirubinemia
in the newborn period can have a potentially harmful, yet preventable,
outcome. Significant jaundice in a symptomatic infant (irritability,
poor suck, refusal to feed, abnormal cry/tone) should prompt use
of phototherapy and immediate diagnostic studies to determine
the degree and cause of jaundice. Many clues from the history
(maternal blood group, jaundice in siblings and its course/treatment,
adequacy or lack of breast-feeding, etc.) and clinical examination
(signs of dehydration, abnormal clinical exam) can help guide
therapy while awaiting the results of laboratory studies. While
an exchange transfusion, when indicated, usually is performed
in a tertiary care setting, intensive phototherapy (defined as
phototherapy that is directed to as much of the skin as possible,
eg, overhead and fiber optic blanket) may occasionally obviate
the need for an exchange transfusion and should be instituted
as soon as possible in infants with significant neonatal hyperbilirubinemia.
In this era of early hospital discharges, the likelihood increases
that early jaundice will go unrecognized until it is symptomatic,
placing greater emphasis on appropriate follow-up of these infants
(nurse phone calls/visits, early office visits) to identify and
prevent avoidable complications.
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