A 60-hour-old boy is evaluated in the newborn nursery prior to anticipated discharge. He was born via vaginal delivery with vacuum assistance at 38 weeks gestation. Prenatal maternal group B streptococcus screen was positive, for which the mother received antibiotics during labor and delivery. Other prenatal laboratory studies were normal. Maternal blood type is A+. On day of life 1, the patient was noted to have a well-demarcated scalp swelling that has remained stable in size. He is breastfed exclusively and has had 3 wet diapers in the last 24 hours. Physical examination shows an alert and active boy with appropriate tone and a strong cry. He has icteric sclerae, jaundice from the face to the lower abdomen, and a 2 x 3 cm scalp swelling over the right parietal area. The remainder of the examination is unremarkable. Laboratory results are as follows: Phototherapy is initiated, and repeat total bilirubin 6 hours later is 17.1 mg/dL. The father says, "We really want to take our baby home. Can we supplement with formula and keep him by the window to get sunlight?" Which of the following is the best next step in management of this patient?

Question

A 60-hour-old boy is evaluated in the newborn nursery prior to anticipated discharge.  He was born via vaginal delivery with vacuum assistance at 38 weeks gestation.  Prenatal maternal group B streptococcus screen was positive, for which the mother received antibiotics during labor and delivery.  Other prenatal laboratory studies were normal.  Maternal blood type is A+.  On day of life 1, the patient was noted to have a well-demarcated scalp swelling that has remained stable in size.  He is breastfed exclusively and has had 3 wet diapers in the last 24 hours.  Physical examination shows an alert and active boy with appropriate tone and a strong cry.  He has icteric sclerae, jaundice from the face to the lower abdomen, and a 2 x 3 cm scalp swelling over the right parietal area.  The remainder of the examination is unremarkable.  Laboratory results are as follows:  Phototherapy is initiated, and repeat total bilirubin 6 hours later is 17.1 mg/dL.  The father says, "We really want to take our baby home.  Can we supplement with formula and keep him by the window to get sunlight?"  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c02f_c8b0_8f63_7f1b426cf3f8_MD0005_00 Bilirubin levels in newborns are physiologically elevated due to liver immaturity, lack of intestinal bacteria to break down bilirubin, and high hemoglobin turnover. This infant has pathologic unconjugated hyperbilirubinemia, likely caused by increased red blood cell turnover from a cephalohematoma. Additional risk factors in developing hyperbilirubinemia include prematurity (<37 weeks gestation), exclusive breastfeeding, sibling requiring phototherapy, and East Asian race. The danger of very high bilirubin levels (>20-25 mg/dL) is kernicterus, or bilirubin encephalopathy, which results in severe neurologic dysfunction (eg, movement disorder, sensorineural hearing loss). The above nomogram for full-term infants helps to determine the need for phototherapy based on bilirubin level at a given hour of life. Phototherapy converts bilirubin into a water-soluble form that can be readily excreted in the urine and stool. As bilirubin levels physiologically rise at this age of life, a stable bilirubin level under phototherapy is not immediately considered a failed intervention and phototherapy should continue with interval bilirubin monitoring. Although formula supplementation can improve hydration and hyperbilirubinemia, stopping therapy (Choices B and E) would be inappropriate as the bilirubin level is still above the level of threshold for treatment. Additionally, although direct sunlight can lower bilirubin levels, it is not recommended in place of phototherapy due to sunburn risk. Phototherapy (Choice C) A direct bilirubin level should be obtained prior to phototherapy to exclude conjugated hyperbilirubinemia, which is always pathologic and will not respond to phototherapy. A repeat level is not indicated in the setting of a stable bilirubin level. (Choice D) Exchange transfusion removes bilirubin and replaces the majority of an infant's red blood cells. It is indicated if phototherapy has been ineffective (eg, rapidly rising bilirubin) or if bilirubin levels are already at toxic levels. Educational objective: During treatment of unconjugated hyperbilirubinemia, phototherapy should continue until bilirubin declines to below threshold levels. Exchange transfusion should be considered if bilirubin is at toxic levels (>20-25 mg/dL). 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. (http://www.ncbi.nlm.nih.gov/pubmed/21807875)

A 60-Hour-Old Boy Is Evaluated in the Newborn Nursery Prior