You are asked to review a full-term baby on the postnatal ward who is 12 hours old. The midwife is concerned that the baby looks jaundiced. You go to see the baby who is jaundiced and has yellow sclera but is alert and has just completed a breast feed. You review his history including the history of the recent pregnancy.
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(a) What information do you need to know about the mother and the pregnancy?
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This is early-onset jaundice ( < 24 h) and is therefore pathological and has to be taken seriously. You need to establish whether there are any risk factors for infection such as prolonged rupture of membranes or known maternal infection (high CRP, positive urine or HVS culture). It is also important to know the mother’s blood group as this may be haemolytic disease of the newborn.
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(b) What immediate tests should you perform on the baby?
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You should take blood to measure the serum bilirubin level and the babies blood group. A direct Coomb’s test will establish whether there is maternal IgG antibody attached to the baby’s red blood cells. A full blood count may show signs of anaemia and haemolysis and may show a leucocytosis if there is infection. CRP and blood culture should be performed.
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(c) What will you do with the bilirubin result?
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The bilirubin result should be plotted on a graph (NICE treatment threshold graphs for term babies) against the time the sample was taken, in this case 12 hours of age. This shows that the bilirubin is well above the treatment line and on the exchange transfusion line.
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(d) What treatment is mandatory?
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As the bilirubin is 200 μmol/L at 12 h it is mandatory to start aggressive phototherapy with a high-luminescence device. The baby should be nursed naked (in an incubator if necessary) and with an open nappy to expose as much skin as possible to the light. A "biliblanket" can be used to treat the underside of the baby simultaneously.
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(e) What other treatment might you consider? What would influence your decision?
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Serious consideration should be given to performing an exchange transfusion. This is particularly likely to be required if the Coomb's test is strongly positive, the newborn is already anaemic (due to in-utero haemolysis) or the bilirubin is rising rapidly (>8.5 μmol/L per hour). The transfusion lab should be alerted to prepare blood urgently. You may consider giving intravenous immunoglobulin to block antibody binding sites and slow the rate of haemolysis, while preparing for an exchange transfusion.
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(f) The serum bilirubin peaked at 450 μmol/L on day 4 of life but the child recovers well after appropriate therapy. You arrange to see them in the outpatient clinic at 2–3 weeks of age. What tests might this child need as an outpatient?
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This child needs a formal BSER hearing test (due to the high peak bilirubin which is ototoxic) and should also be assessed for anaemia, since ongoing haemolysis can continue despite the jaundice resolving. This can lead to significant anaemia in the first 6 weeks of life. Folic acid supplements will help with erythropoesis.
