Case

HPI

• Newborn male vaginal delivery with vacuum assist at 39 weeks. Mother is O+, infant blood type is B+ with 2+ direct Coombs

• Maternal history: GBS neg, serologies neg, anemia during pregnancy

• Apgars 8 and 8• TCB at ~4.5 hrs of life is 5.2• Baby born after rounds, exam is normal per

nursing report by phone

Questions

1. What are this infants risk factors for hyperbilirubinemia?

2. What risk curve for phototherapy initiation would you put this infant on?

3. What labwork would you want to obtain at this point?

Labwork

• Total bilirubin 5.77 (direct 0.36) at 5.5 hrs of life

• CBC: 28.6 <13/40 > 100• Retic: 11.6%

1. What is your interpretation of the lab results?

2. What are your next steps in management of this newborn?

Case continued

• You decide to initiate phototherapy for indirect hyperbilirubinemia at threshold for light therapy

1. When do you want to check the next bilirubin?

2. Do you want to repeat any other labs?

3. How can you support this mother who would like to breastfeed her newborn?

Lab results

• Baby is almost 12 hrs old (6hrs since initiating phototherapy)

• Serum bili is 6.58• CBC: 18.5 <12.7/39.3>192• Retic: 14%

• At 24 hrs of life serum bili is 7.12• On rounds in the morning, physical exam is

notable for a moderate size cephalohematoma

Questions

1. What is a cephalohematoma?

2. What do you want to do with the phototherapy at this point? Stop or continue? And why?

3. Has your risk curve changed given the physical exam finding?

• At 48hrs of life serum bili is 7.03• Repeat CBC: 13.6 <12.7/38.8<221• Retic: 15%

1. Should you discontinue phototherapy at this point?

2. Do you want to check a rebound?

3. When should this infant be seen by the pediatrician for repeat bili?

Case continued

• Rebound bili after discontinuing phototherapy at 48hrs was 6.31 at 60 hrs of life

• Recommended mother take newborn to ED for bilicheck (not done)

• Seen in clinic at DOL 6. Serum bili 3.47m retic 3%

Learning points

• Selecting appropriate risk curve on bili nomogram

• Interpreting abnormal labs and making follow-up plans

• Managing a newborn under phototherapy• Supporting a breastfeeding mother• Follow-up following discontinuation of

phototherapy