Neonatal jaundice: unconjugated hyperbilirubinaemia: Case

This late-preterm infant has severe unconjugated hyperbilirubinaemia at 48 hours with multiple compounding risk factors: gestational age of 36 weeks, exclusive breastfeeding with 10 per cent weight loss, jaundice onset before 24 hours, and maternal blood group O. The TSB of 340 micromol per litre is dangerously elevated for a 36-week infant and likely exceeds the phototherapy threshold for a higher-risk infant. The conjugated fraction of 15 micromol per litre is reassuring, ruling out conjugated hyperbilirubinaemia. [1]

Clinical findings

The key findings are early-onset jaundice (before 24 hours), rapid progression, significant weight loss from inadequate intake, and a bilirubin level in the high-risk zone. The differential diagnosis includes ABO incompatibility (mother O, infant likely A or B), breastfeeding jaundice from inadequate intake, G6PD deficiency (if at-risk heritage), and hereditary spherocytosis. The initial investigations should include a DAT, blood group, full blood count with reticulocyte count, peripheral film, and G6PD assay if at-risk heritage. [3]

The examination should assess for pallor (haemolysis), cephalohaematoma or bruising (enclosed haemorrhage), hepatosplenomegaly (haemolysis or infection), and the infant's general wellness. The cephalocaudal progression of jaundice should be documented, though it is an imprecise tool. The feeding assessment should evaluate latch, milk transfer, urine and stool output, and weight loss trajectory. [1]

Management

Initiate intensive phototherapy immediately. Use high-intensity blue LED light at 430 to 490 nm with an irradiance above 30 microwatts per square centimetre per nanometre and maximal skin surface exposure (80 to 90 per cent). Protect the eyes with opaque patches and monitor temperature. A repeat TSB should be obtained at 4 to 6 hours to confirm response. [1]

Feeding support is critical. Continue breastfeeding and ensure adequate intake, supplementing with expressed breast milk or formula if needed. This infant's 10 per cent weight loss and exclusive breastfeeding status indicate inadequate caloric intake contributing to increased enterohepatic circulation. Consider lactation support and a feeding assessment. Do not stop breastfeeding. [1]

If the haemolytic workup confirms immune-mediated haemolysis (positive DAT, spherocytes on film) and the bilirubin continues to rise despite intensive phototherapy, administer intravenous immunoglobulin at 0.5 to 1 g per kg over 2 hours. If the bilirubin approaches the exchange transfusion threshold for a 36-week higher-risk infant, prepare for double-volume exchange transfusion using blood cross-matched against both mother and infant. [2]

Follow-up and counselling

Once the bilirubin has fallen below the gestational-age-specific discontinuation threshold, phototherapy can be stopped. A rebound bilirubin check should be obtained 12 to 24 hours after cessation. The infant should be feeding effectively, gaining weight, and clinically well before discharge. [1]

A documented follow-up plan is essential before discharge, with a bilirubin check within 24 to 72 hours depending on the risk assessment. Parents should be educated about the warning signs of worsening jaundice, the importance of adequate feeding, and when to seek medical review. If G6PD deficiency is confirmed, provide specific education about avoiding oxidative triggers including fava beans, naphthalene, henna, and certain medications. [3]

The prognosis for this infant is excellent if the bilirubin is brought under control promptly. Infants treated with phototherapy alone who respond appropriately and have no neurological signs recover completely without sequelae. However, kernicterus prevention depends on timely recognition, appropriate treatment, and reliable follow-up. [2]