Which of the following is the best next step in management of this patient?

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11ec25c8_d689_1e66_bc81_4f2320616105_MD0003_00 Treatment of breastfeeding jaundice in otherwise healthy, full-term newborns is to increase the frequency and duration of feeds to stimulate milk production, maintain adequate hydration, and promote bilirubin excretion. Neonates should breastfeed approximately 8-12 times a day (every 2-3 hours) for ≥10-20 minutes per breast during the first month of life. When bilirubin is eliminated as fecal urobilinogen, less bilirubin is reabsorbed and recycled in the enterohepatic circulation, thereby decreasing serum bilirubin levels. If bilirubin continues to rise despite efforts to optimize lactation, formula supplementation may be necessary (Choice E). However, discontinuing breastfeeding and switching to formula will further decrease the mother's milk supply and eliminates the benefits of breastfeeding, which include improved infant immunity and mother-infant bonding. Infants should be closely monitored to ensure that they are receiving adequate enteral intake and that their bilirubin level is decreasing. This is often accomplished with frequent outpatient visits; if the dehydration is severe, inpatient admission for intravenous fluids may be required. (Choice B) Because this infant is already showing signs of dehydration, feeding frequency should be increased and he should be reevaluated within 1-2 days. If breastfeeding difficulty continues, the infant is at high risk for severe hyperbilirubinemia, kernicterus, or severe dehydration; therefore, waiting a week is too long. (Choice C) Liver ultrasonography is indicated for infants with conjugated hyperbilirubinemia to evaluate for obstructive lesions, such as biliary atresia or choledochal cysts. Ultrasound is not part of the evaluation of breastfeeding jaundice. (Choice D) The threshold for phototherapy in a full-term, healthy, 4-day-old infant is a total bilirubin level ≥20 mg/dL. Exchange transfusion is reserved for infants with levels ≥25 mg/dL or those with bilirubin-induced neurologic dysfunction. (Choice F) Galactosemia is an absolute contraindication to breast milk or cow's milk-based formula, and soy formula should be fed to these patients. Soy formula is inappropriate for breastfeeding jaundice. Educational objective: If bilirubin levels are below the phototherapy threshold, breastfeeding jaundice can be managed by optimizing lactation and increasing breastfeeding frequency. If the mother's milk supply is inadequate, supplementation with cow's milk-based formula can be considered, but breastfeeding should not be discontinued. References: Evaluation and treatment of neonatal hyperbilirubinemia (http://www.ncbi.nlm.nih.gov/pubmed/25077393) Neonatal jaundice and human milk. (http://www.ncbi.nlm.nih.gov/pubmed/21942599)

Which of the Following Is the Best Next Step in Management