Arciaga, Frances Geline R.

May 17, 2021

2MD Pediatrics I

PEDIATRICS I SGD CASE ON NEONATAL JAUNDICE

CASE:

A 4 day old infant was brought to the OPD due to yellowish discoloration of the skin.

Birth History:

Patient is a full term Baby Girl, delivered at the District Hospital assisted by a physician,

appropriate for gestational age (AGA) to a 22 year old A+ primiparous woman with

gestational diabetes. She weighed 3.1 kg. The pregnancy was otherwise uneventful. Labor

was augmented with Oxytocin.

Patient was discharged home on the 2nd day of life at which time her weight was down 4%

from birth weight and she had mild facial jaundice.

Mother relates that while in the hospital, baby was breast fed every 3 hours and had 2 wet

diapers and one meconium stool over a 24 hour period. On day 3, her parents gave her

water on two occasions as she appeared hungry despite regular and frequent breast

feeding attempts. In addition, they noted an increase in the degree of yellowish

discoloration of the skin, but failed to address it after being reassured by family members
that it is common among newborns. They also had an appointment to see their pediatrician

the following day.

At the OPD, on day 4 of life, mother reports that she is breastfeeding the baby every three

hours and that there have been 2 wet diapers per day. The urine is described as dark

yellow in color and the stools appear dark green.

Exam:

VS: T = 37.8oC, P = 162/min, RR = 55/min, BP = 63/45.

Weight = 2.7 kg (25%ile), length = 50 cm (75%ile), head circumference = 34 cm (75%ile).

The infant is jaundiced and irritable. The anterior fontanel is slightly sunken, the oral

mucosa is tacky, and there is jaundice up to the lower extremities. No cephalohematoma or

bruising is present. The sclera of both eyes are icteric. Muscle tone and activity are normal.

The remainder of the physical exam is normal.

The total bilirubin is 20 mg% with a direct fraction of 0.7 mg%.

Guide questions:

1. What are the salient features of this case?

Silent Features

Modifiable Non-Modifiable

- Inadequate nursing, failure - 4 day old female infant delivered full

to observe signs of readiness term at the District Hospital assisted

to feed by a physician, appropriate for

- Breast feeding techniques gestational age (AGA) to a 22 year old

A+ primiparous woman with

gestational diabetes

- She weighed 3.1 kg at birth

- Patient was discharged home on the

2nd day of life at which time her

weight was down 4% from birth

weight and she had mild facial

jaundice.

- Baby was breast fed every 3 hours and

had 2 wet diapers and one meconium

stool over a 24 hour period

- On day 3, her parents gave her water

on two occasions as she appeared

 hungry despite regular and frequent

breast feeding attempts.

- In addition, they noted an increase in

the degree of yellowish discoloration

of the skin

- On day 4 of life, baby is breastfeeding

every three hours and that there have

been 2 wet diapers per day.

- The urine is described as dark yellow

in color and the stools appear dark

green.

- VS: T = 37.8oC, P = 162/min, RR =

55/min, BP = 63/45.

- Weight = 2.7 kg (25%ile), length = 50

cm (75%ile), head circumference = 34

cm (75%ile).

- The infant is jaundiced and irritable.

The anterior fontanel is slightly

sunken, the oral mucosa is tacky, and

there is jaundice up to the lower

extremities.

- The sclera of both eyes are icteric.

 Muscle tone and activity are normal.

The remainder of the physical exam is

normal.

- The total bilirubin is 20 mg% with a

direct fraction of 0.7 mg%.

2. Give your clinical impression and differential diagnosis. Discuss each.

Clinical Impression: Breastfeeding Jaundice

Differential Diagnosis

1. Breast milk Jaundice

- The cause of breast milk jaundice is linked to the substance (glucuronidase) that is

present in the breast milk that inhibits the liver’s ability to break down and process

bilirubin.

- This condition is a type of neonatal jaundice associated with breastfeeding that is

characterized by indirect hyperbilirubinemia in an otherwise healthy breastfed

newborn that develops after the first 4-7 days of life, persists longer than

physiologic jaundice, and has no other identifiable cause.

 2. Breastfeeding Jaundice

- This is a type of jaundice that is a result of the baby not receiving enough milk to

lower their bilirubin levels. This causes the bilirubin to be reabsorbed into the

intestines and keep the levels elevated which triggers jaundice.

- Inadequate milk intake also delays the passage of meconium, which contains large

amounts of bilirubin that is then transferred into the infant’s circulation. In most

cases breastfeeding can, and should, continue. More feedings can reduce the risk of

jaundice.

Breast milk Jaundice vs Breastfeeding Jaundice

Breast milk Jaundice Breastfeeding Jaundice

Most commonly presents in the 2nd week of Usually presents in the 1st week of life

life

Affected infants are thriving and weight gain Affected infants are often dehydrated

is adequate and have weight loss or poor weight gain

Breastfeeding is adequate Breastfeeding is not providing sufficient

nutrition

Treatment is not usually required Breastfeeding should be optimized or

supplemented

Spontaneous resolution usually occurs Spontaneous resolution usually occurs

within 12th weeks of life by the third week of life

 3. ABO Haemolytic Disease of the Newborn

- In ABO hemolytic disease of the newborn (also known as ABO HDN) maternal IgG

antibodies with specificity for the ABO blood group system pass through the

placenta to the fetal circulation where they can cause hemolysis of fetal red blood

cells which can lead to fetal anemia and HDN.

- The baby develops jaundice in the first day of life

Physiologic jaundice (Breast milk, Pathologic jaundice

Breastfeeding jaundice) (HDN, Liver disease)

Jaundice is visible only on the 2nd – 3rd day Jaundice appears on the first 24-36 hours of

of life life

Peaks at 5-6mg/dl on the 2nd – 4th day of life Serum Bilirubin is rising at a rate faster than

5mg/dl/24hrs

Decrease to below 2mg/dl between 5th – 7th Serum bilirubin >12mg/dl

day of life

Total bilirubin increases not more than Total bilirubin increases to >0.5mg/dl/hr

5mg/dl/day

Decline to adult levels by 10th – 14th day of Jaundice persists after 10-14 days

life
3. What are the diagnostic procedures needed to determine the cause of the

jaundice? Explain.

- A detailed history and physical examination showing that the infant is thriving and

that lactation is well established are key elements to diagnosis. Breastfed babies

should have 3-4 transitional stools and 6-7 wet diapers per day, and they should

have regained their birth weight by the end of the second week of life or

demonstrate a weight gain of 1 oz/day.

- Measure the total serum bilirubin concentration in neonates who have jaundice that

has progressed from the face to the chest, as well as in neonates who are at risk for

hemolytic disease of the newborn.

- A complete blood cell (CBC) coun will give you the blood picture of your patient

with reticulocyte count that will tell you the presence of hemolysis.. Findings may

include the following: Polycythemia (hematocrit level >65%) and Anemia

(hematocrit level <40%)

- Urine specific gravity can be useful in the assessment of hydration status.

If hemolysis is suspected, consider the following tests:

- Blood type of mother and infant to evaluate for ABO, Rh, or other blood group

incompatibility

- Coombs test, as well as an elution test for antibodies against A or B, to evaluate for

immune mediated hemolysis

- Peripheral smear to look for abnormally shaped RBCs (ovalocytes, acanthocytes,

spherocytes, schistocytes)
 4. How would you manage the patient?

Medication is not currently a component of care for breast feeding jaundice.

For healthy term infants with breast milk or breastfeeding jaundice who have bilirubin

levels of 12 mg/dL to 20 mg/dL, the following options are acceptable:

- Increase breastfeeding to 8-12 times per day, and recheck the serum bilirubin level

in 12-24 hours. Reassure the mother about the relatively benign nature of

breastfeeding jaundice . This recommendation assumes that effective breastfeeding

is occurring, including milk production, effective latching, and effective sucking with

resultant letdown of milk. Breastfeeding can also be supported with manual or

electric pumps and the pumped milk then given as a supplement to the baby.

- Continue breastfeeding and supplement with formula.

- Temporary interruption of breastfeeding is rarely needed and is not recommended

unless serum bilirubin levels reach more than 20 mg/dL (340 µmol/L).

If the infant is treated on an outpatient basis, measure serum bilirubin levels either daily in

the clinic until the bilirubin level is less than 15 mg/dL (260 µmol/L) and provides the

mother with excellent breastfeeding education.

For Diet

Continue breastfeeding, if possible, and increase the frequency of feeding to 8-12 times per

day. Depending on maternal preference, breastfeeding can be supplemented or replaced by

formula at the same frequency. Supplementation with dextrose solution is not

recommended, because it may decrease caloric intake and milk production and may

consequently delay the drop in serum bilirubin concentration. Breastfeeding can also be

supplemented by pumped breast milk.

For Activity

No activity restrictions are necessary. Encourage parents to remove the child from the

warmer or infant crib for feeding and bonding.

For some instance, sunlight helps to break down indicrect bilirubin so that a baby's liver

can process it more easily. You can advise to place the child in a well-lit window for 10

minutes twice a day is often all that is needed to help cure mild jaundice.

Reference/s:

What is the treatment options for breast milk jaundice in healthy term infants? (medscape.com)
Breastfeeding Jaundice and Breast Milk Jaundice (birthinjuryhelpcenter.org)
Hemolytic disease of the newborn (ABO)/Hemolytic disease of the newborn (ABO) -
Wanweipedia/wanweibaike
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