Question

Sammy is a newborn boy at 32 hours of life. His birth weight was 8 pounds. He was born via normal spontaneous vaginal birth at 40 weeks of gestation to a 26-year-old G1. There were no maternal prenatal issues. Labor and delivery were complicated by a prolonged second stage of labor, which eventually progressed to spontaneous birth. The Apgar scores were 6 and 8, and the infant was taken to the nursery for an observation period; he received intravenous (IV) fluids but did well and so was discharged to the routine care in the mother’s room at 12 hours of life. Sammy was noted to have facial bruising and a cephalhematoma, which were attributed to the prolonged second stage of labor. All newborn blood work was normal. The group B streptococcal culture was negative. Maternal blood type is A positive. Exclusive breastfeeding was initiated at 12 hours of life. On physical examination, Sammy has some jaundice evident on the chest and torso.

1. What risk factors does Sammy have for hyperbilirubinemia?

2. The pediatrician orders a bilirubin level, and the total serum bilirubin level is 7 mg/dL. A repeat level is ordered in 8 hours. Does this result indicate a dangerous level of hyperbilirubinemia?

3. What are the risks to the newborn with elevated bilirubin levels?

4.Sammy’s repeat total serum bilirubin was 5 mg/dL at 40 hours of life, and the pediatrician has given discharge orders for this evening when Sammy will be 48 hours old. What education regarding jaundice is appropriate for Sammy’s parents at this time?

Answer 1

Introduction

Sammy is full term baby with adequate weight. Due to reduced APGAR score,and prolonged second stage of labour, hence was on observation for 12 hours. All labs are normal and is on breast feeding.

Bilirubin levels are also well within normal ranges. Due to few risk factors, Sammy might be at risk and needs observation.

Hyperbilirubinemia/Jaundice is one of the most common problems encountered in term newborns. Neonatal hyperbilirubinemia, defined as a total serum bilirubin level above 5 mg/dL.

1. Risk factors

Maternal risk factors

· ABO or Rh incompatibility

· Breastfeeding

· Drugs: diazepam (Valium), oxytocin (Pitocin)

· Ethnicity: Asian, Native American

· Maternal illness like gestational diabetes

Neonatal risk factors

· Birth trauma: cephalohematoma, cutaneous bruising, instrumental delivery

· Excessive weight loss after birth

· Infections: TORCH [ toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes (simplex) virus]

· Infrequent feedings

· Male gender

· Polycythemia

· Prematurity

· Previous sibling with hyperbilirubinemia

Sammy might have hyperbilirubinemia due to;

· Stress of birth as facial bruising and a cephalohematoma during second stage of labour. Which is the commonest neonatal risk factor.

· Visible jaundice anywhere on the body on day 1.

· Male gender might be also considered as a risk factor.

· ABO/Rh incompatibility may be considered if we know Sammy’s blood group.

2. Serum bilirubin level >12 mg/dl require intervention.

Day1 – Total bilirubin – 10-15mg/dl – repeat in 4-6 hours

Day 2 - Total bilirubin – 10-15mg/dl - repeat in 6-8 hours

In infants found clinically jaundiced during the first 2-3 days, it is helpful to document the rate of rise in the serum bilirubin level. A rise of >0.5 mg/dl per hour may indicate brisk hemolysis.

Clinical symptoms of jaundice

Yellowish discoloration noticeable first in the face, and then the chest, stomach area, arms, and then finally to the legs. However, in some babies, the head-to-toe progression of jaundice may not be seen, and the jaundice may appear over the entire body like a tan.

As Sammy has total serum bilirubin 7 mg/dL, there is low risk of developing hyperbilirubinemia. It can be stopped or interrupted with breast feeding.

3. Risk to newborn with elevated bilirubin levels

Early

· Lethargy

· Poor feeding

· High-pitched cry

· Hypotonia

Late

· Irritability

· Opisthotonos

· Seizures

· Apnea

· Hypertonia

· Fever

Chronic

· Kernicterus/ chronic bilirubin encephalopathy - High levels of bilirubin in blood which leads to irreversible brain damage.

· Reversible acute bilirubin encephalopathy

· High-frequency hearing loss

· Mild mental retardation

4. Heath teaching to parents

Serum bilirubin 5 mg/dL during discharge. There is mild risk. Hence routine discharge instructions are enough with add on to hyperbilirubinemia.

· Breast feeding - Breastfeed your baby q2h. Feed baby at least 8 to 12 times every 24 hours.

· Observe weight of baby.

· Observe for intake and output of baby.

· Provide basic routine hygienic care like bathing, nail care, diapering and sleep needs.

· Watch for signs of jaundice – Yellowish discoloration in skin or the whites of the eyes. If jaundice gets worse, the yellow color will spread from the eyes to face. Then it will move downwards to body toward the feet.

· Observe the early and late signs of newborn with elevated bilirubin levels: vomiting, lethargy, not feeding well, fever, having a high-pitched cry, dark urine or not enough wet or dirty diapers. If these signs persist, seek medical attention immediately.