A 48-hour-old boy is evaluated in the newborn nursery on morning rounds. The infant has been breastfeeding exclusively with good latch. He passed meconium yesterday and has urinated several times, but the parents are concerned about his increasing yellow discoloration. He was born at 38 weeks gestation via normal spontaneous vaginal delivery. Review of prenatal records shows a maternal blood type of O+ and normal routine blood testing. Physical examination shows an alert, nondysmorphic boy with a strong suck and intact Moro reflex. He has icteric sclerae and appears jaundiced from head to feet. The abdomen is soft, nontender, and nondistended. The liver is palpable 1 cm below the right costal margin. The examination is otherwise unremarkable. The infant's blood is drawn at 49 hours of life; laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 48-hour-old boy is evaluated in the newborn nursery on morning rounds.  The infant has been breastfeeding exclusively with good latch.  He passed meconium yesterday and has urinated several times, but the parents are concerned about his increasing yellow discoloration.  He was born at 38 weeks gestation via normal spontaneous vaginal delivery.  Review of prenatal records shows a maternal blood type of O+ and normal routine blood testing.  Physical examination shows an alert, nondysmorphic boy with a strong suck and intact Moro reflex.  He has icteric sclerae and appears jaundiced from head to feet.  The abdomen is soft, nontender, and nondistended.  The liver is palpable 1 cm below the right costal margin.  The examination is otherwise unremarkable.  The infant's blood is drawn at 49 hours of life; laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf6d_b0e3_8f63_0bb3dd5e42ed_MD0005_00 This patient has pathologic unconjugated hyperbilirubinemia caused by ABO hemolytic disease, which typically occurs in infants with A+ or B+ blood type and mothers with O+ blood type. The mothers have antibodies against A and B antigens, causing a hemolytic reaction in the newborn when blood is mixed in the peripartum period. Hyperbilirubinemia from red blood cell destruction due to ABO hemolytic disease is often mild to moderate and can be treated with phototherapy. In cases of severe hyperbilirubinemia (bilirubin >20-25 mg/dL), patients require aggressive intervention with exchange transfusion. Exchange transfusion is a procedure in which bilirubin and circulating antibodies are removed and most of the infant's red blood cells are replaced with donor red blood cells. Additional indications for exchange transfusion include failed phototherapy with rapidly rising bilirubin levels and signs of bilirubin-induced neurologic dysfunction (eg, lethargy, hypotonia). The goal of therapy is to reduce bilirubin levels rapidly and prevent permanent brain damage from bilirubin toxicity (kernicterus). phototherapy (Choice A) A complete blood count, blood culture, and empiric antibiotic therapy are appropriate for concerns of sepsis. Although sepsis can cause hyperbilirubinemia, this patient has a clear cause (ABO hemolytic disease) and otherwise appears well. (Choice B) Breastfeeding jaundice is caused by insufficient fluid intake and may require formula supplementation to prevent significant jaundice and dehydration. Cessation of breastfeeding and total parenteral nutrition are not typically indicated in a neonate who can tolerate oral fluids. Treatment of severe hyperbilirubinemia requires aggressive treatment with exchange transfusion. (Choice D) The mother's normal routine prenatal blood test results suggest prior vaccination to hepatitis B, and the infant's abdominal examination (eg, liver edge 1 cm below costal margin) is normal for newborns. Therefore, active hepatitis B disease is unlikely, and serologies and immunoglobulin therapy are unnecessary. (Choice E) Although exposure to sunlight can decrease bilirubin levels, sunburn risk limits its use; in addition, this patient's bilirubin level requires aggressive treatment. Educational objective: Exchange transfusion, the removal of bilirubin and antibodies with replacement of red blood cells, is indicated for neonates with severe hyperbilirubinemia (>20-25 mg/dL), worsening hyperbilirubinemia on phototherapy, or signs of bilirubin-induced neurologic dysfunction. References: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. (http://www.ncbi.nlm.nih.gov/pubmed/15231951)

A 48-Hour-Old Boy Is Evaluated in the Newborn Nursery on Morning