What’s Your Diagnosis? Neonatal Hyperbilirubinemia

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last Pediatric Electrical Injuries in the Emergency Department right.

Case Presentation: Neonatal Hyperbilirubinemia: Recommendations for Diagnosis and Management in the Emergency Department 

A 4-day-old boy born at 39 weeks’ gestation presents for evaluation of jaundice…  

The jaundice was first noticed 2 days ago. The birth was unremarkable, with a birth weight of 2.4 kg. The baby has been exclusively breast-fed and has 2 wet diapers/day. On examination, the patient has scleral icterus and generalized jaundice. His vital signs reveal a temperature of 37.2°C and a heart rate of 168 beats/min. You consider the diagnosis of neonatal hyperbilirubinemia, but how do you differentiate nonpathologic from pathologic causes of hyperbilirubinemia? Based on the visual diagnosis of jaundice, should you start treatment immediately with phototherapy? What additional laboratory testing is needed to determine the need for treatment and the disposition for this neonate? 

Case Conclusion

Given the age of the patient (98 hours) and that the patient was breastfeeding exclusively, you suspected breastfeeding jaundice. You obtained a TcB, and the level was 16.5 mg/dL. You ordered a TSB and conjugated bilirubin level. The TSB was 17.2 mg/dL, with a conjugated bilirubin of 0.9 mg/dL. Based on the hour-specific nomogram, the neonate plotted in the high intermediate-risk zone. You proceeded to plot the TSB on the phototherapy nomogram and determined that the neonate had no known neurotoxicity risk factors. The results of the phototherapy nomogram indicated no need for phototherapy. You decided the neonate should be discharged. You reviewed the hyperbilirubinemia risk factors and, based on the exclusive breastfeeding, you discharged the patient home and advised the parents to follow up within 24 hours. 

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Last Updated on January 26, 2022

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