The parents of a full-term (38 3/7 weeks) baby boy born three days ago bring him to the ED because he “looks yellow”; the family was to see the baby’s pediatrician today for a recheck, but was unable due to the office’s schedule.  The child has been doing well at home, with normal urine output and without fever or difficulty with feeds; this is their first child.  Mother began to breastfeed in hospital, but was discouraged by her family members when she arrived home; the child has been formula-fed for the past day.

In the ED, you see a well appearing African-American baby boy with normal vital signs and a normal head-to-toe newborn exam; he has yellow palms.  There is no family history of metabolic syndrome or blood dyscrasia.

You decide to check his total bilirubin level, which results at 11 mg/dL.  The parents are concerned, especially the father, who recently had routine blood tests with a total bilirubin of 0.8 mg/dL –“my son has a level 10 times higher than me – and he’s so little!”.  Regarding the management of your patient, which of the following is the single BEST answer:

A.      Observe the child in the ED and recheck his total bilirubin in 2-4 hours

B.      Give IV fluids and consider phototherapy

C.      Ask the mother what time of the day the child was born

D.      Admit the child for further workup

  In the meantime, a quote:   "An observant parent's evidence may be disproved but should never be ignored." --Anonymous   Lancet 1:688, 1951


Dr. M
08/20/2012 8:44am

C. To plot this child on the nomogram, need to know the number of hours the child has been alive as well as risk factors to know which line the child will fall on as far as need for phototherapy.

I heart:

BTW - Might consider screening for G6PD if this bili level ends up being elevated. Higher risk in African Americans, x-linked recessive...

08/20/2012 11:31am

I choose A. At 3 days out with a level of 11 mg/dl, this child falls into the low risk category. We can assume that there was a somewhat elevated bili or jaundice in the immediate postnatal period because the child was scheduled for a recheck, but this is the recheck and the level is OK now. If it is stable or falling at the recheck in the ED, I would discharge home, with close PCP followup of course.

tall guy
08/21/2012 11:01am

C. I'd like to be able to plug the child's data into a nomogram and graph out where they lie. If the child was not close to phototherapeutic levels, I would reassure and educate the parents. If they were still troubled by this problem, we could do option A and get a rate of rise for the bilirubin. Then we would extrapolate the bilirubin's expected rise over the next 24 hours. This would aid in educating the parents and ensuring that the child wouldn't need phototherapy prior to follow at PCP the next day

08/21/2012 3:13pm

Given the age (even if off by 24hrs), limited risk factors, and levels, I think one may need to broaden the DDX beyond “routine” neonatal hyperbilirubinemia. May not be super kosher but I’m going with D – work up for something else. Is this the classic Gilbert’s presentation (?)… I’d probably fractionate it and hunt a bit more.

Dr. Craig
08/21/2012 3:50pm

My one word answer is “”.

Sean Fox link
08/22/2012 10:15am

I concur with the utility of love that site. Remember to as when the hour of birth was... that is important!


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