A 2-week-old girl is brought to the office because she looks "a bit yellow." She was born at 40 weeks gestation by normal spontaneous vaginal delivery to a mother whose blood type is AB+. Apgar scores were 9 (-1 color) and 9 (-1 color) at 1 and 5 minutes, respectively. Birth weight, length, and head circumference were at the 50th percentile. She was discharged home on the second day of life and has been breastfeeding every 2-3 hours for 15 minutes on each side. The infant has 6 wet diapers and 5-6 yellow seedy stools per day. She has regained her birth weight and has normal vital signs. Physical examination shows an active, crying infant with moist mucous membranes and jaundice of the face, neck, and chest. The remainder of the examination is normal. Total bilirubin is 10 mg/dL and direct bilirubin is 0.6 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Question

A 2-week-old girl is brought to the office because she looks "a bit yellow."  She was born at 40 weeks gestation by normal spontaneous vaginal delivery to a mother whose blood type is AB+.  Apgar scores were 9 (-1 color) and 9 (-1 color) at 1 and 5 minutes, respectively.  Birth weight, length, and head circumference were at the 50th percentile.  She was discharged home on the second day of life and has been breastfeeding every 2-3 hours for 15 minutes on each side.  The infant has 6 wet diapers and 5-6 yellow seedy stools per day.  She has regained her birth weight and has normal vital signs.  Physical examination shows an active, crying infant with moist mucous membranes and jaundice of the face, neck, and chest.  The remainder of the examination is normal.  Total bilirubin is 10 mg/dL and direct bilirubin is 0.6 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: The American Academy of Pediatrics recommends that infants with breast milk jaundice continue breastfeeding exclusively. Formula (Choice C) is not required if the mother's breast milk supply is adequate and the neonate is gaining weight and has a normal examination. Cessation of breastfeeding can accelerate the decline in serum bilirubin levels but has no clinical benefits as kernicterus from breast milk jaundice is very rare. Rather, discontinuing breastfeeding prevents the infant from receiving the benefits of breast milk, including maternal antibodies, mother-infant bonding, and immunity. Interrupting breastfeeding with bottles, especially during the first month, can decrease the mother's milk supply and the newborn's ability to latch and suck at the breast. All efforts should be made to promote and support breastfeeding. Parents should be reassured that the prognosis is good with spontaneous resolution by age 3 months. (Choice B) Oral rehydration solutions are used to treat dehydration. They are less nutritious than breast milk and are not indicated in this adequately hydrated neonate. (Choice D) The level of hyperbilirubinemia in this 2-week-old infant does not warrant phototherapy, but phototherapy can be considered if the level continues to rise. (Choice E) Conjugated hyperbilirubinemia is always pathologic and requires additional workup. If the direct bilirubin is elevated (>20% of total bilirubin), ultrasound of the hepatobiliary tree should be performed to evaluate for biliary atresia. Educational objective: Treatment of breast milk jaundice includes frequent follow-up and monitoring of the infant's hyperbilirubinemia. Exclusive breastfeeding should be continued and encouraged as the jaundice should resolve spontaneously by age 3 months. References: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. (http://www.ncbi.nlm.nih.gov/pubmed/15231951) Hyperbilirubinemia in the newborn infant > or =35 weeks' gestation: an update with clarifications. (http://www.ncbi.nlm.nih.gov/pubmed/19786452) Neonatal jaundice and human milk. (http://www.ncbi.nlm.nih.gov/pubmed/21942599)

A 2-Week-Old Girl Is Brought to the Office Because She