Pediatrics · Year 3 · from Pediatrics
Case 1: Physiologic Jaundice of the Newborn
Patient Demographics
- Age: 3-day-old male
- Sex: Male
Chief Complaint
"The baby looks yellow."
History of Present Illness
A 3-day-old male newborn is brought to the pediatrician's office for a routine post-discharge visit. Parents report the baby has developed yellow discoloration of the skin noticed this morning. He was born at 39 weeks via spontaneous vaginal delivery with no complications. Birth weight was 3.4 kg. He is exclusively breastfeeding, feeding every 2-3 hours for 15-20 minutes per breast, with 4-5 wet diapers and 3 yellow seedy stools per day. He is alert and active. No fever, vomiting, or lethargy has been noted. Mother is blood type O positive, baby is A positive. Direct Coombs test at birth was negative.
Growth Parameters
- Birth weight: 3.4 kg (50th percentile)
- Current weight: 3.2 kg (6% weight loss - acceptable)
- Length: 50 cm (50th percentile)
- Head circumference: 34 cm (50th percentile)
Physical Examination
- General: Alert, active newborn with jaundice visible on face, chest, and abdomen to the level of the umbilicus
- HEENT: Anterior fontanelle soft and flat, scleral icterus present, no cephalohematoma
- Cardiovascular: Regular rate and rhythm, no murmurs
- Respiratory: Clear breath sounds, no distress
- Abdomen: Soft, umbilical stump drying, no hepatosplenomegaly
- Skin: Jaundice extending to mid-abdomen (Kramer zone 3), no bruising, no pallor
- Neurologic: Normal tone, strong suck, symmetric Moro reflex
Workup
- Transcutaneous bilirubin: 14.2 mg/dL
- Total serum bilirubin: 13.8 mg/dL
- Direct bilirubin: 0.4 mg/dL (normal)
- Blood type: Baby A+, Mother O+
- Direct Coombs: Negative
- Reticulocyte count: 4.2% (normal for age)
- Hematocrit: 52% (normal)
- G6PD screen: Pending (if indicated by ethnicity)
Diagnosis
Physiologic jaundice of the newborn
Clinical Reasoning
The timing of jaundice onset (day 3), indirect hyperbilirubinemia, negative direct Coombs test, absence of hemolysis markers, normal weight loss, and good feeding all support physiologic jaundice. The bilirubin level of 13.8 mg/dL at 72 hours of life falls in the low-intermediate risk zone on the Bhutani nomogram, below the phototherapy threshold for a low-risk infant. There is no evidence of pathologic jaundice (onset <24 hours, rapid rise, direct hyperbilirubinemia, or hemolysis).
Management
- Continue breastfeeding: Encourage frequent feeding (8-12 times/day) to promote bilirubin excretion
- No phototherapy indicated: Bilirubin below phototherapy threshold for age and risk category
- Follow-up: Recheck bilirubin in 24 hours to ensure downward trend
- Parent education: Signs of worsening jaundice, feeding cues, when to seek care
- Anticipatory guidance: Expect jaundice to improve by day 5-7, may persist longer in breastfed infants
Clinical Image
Image Description: Clinical photograph demonstrating neonatal jaundice with visible yellow discoloration of the skin and scleral icterus.
Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:Jaundice_in_newborn.jpg License: CC BY 2.0