# Clinical Cases: Newborn Care

## 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
1. **Continue breastfeeding:** Encourage frequent feeding (8-12 times/day) to promote bilirubin excretion
2. **No phototherapy indicated:** Bilirubin below phototherapy threshold for age and risk category
3. **Follow-up:** Recheck bilirubin in 24 hours to ensure downward trend
4. **Parent education:** Signs of worsening jaundice, feeding cues, when to seek care
5. **Anticipatory guidance:** Expect jaundice to improve by day 5-7, may persist longer in breastfed infants

### Clinical Image
![Jaundiced newborn with scleral icterus](case_01_image.jpg)

**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

---

## Case 2: Hypoxic-Ischemic Encephalopathy

### Patient Demographics
- **Age:** 6-hour-old male
- **Sex:** Male

### Chief Complaint
Newborn with poor respiratory effort and decreased tone after difficult delivery.

### History of Present Illness
A male infant was born at 40 weeks gestation after a prolonged labor complicated by category III fetal heart rate tracing with recurrent late decelerations and absent variability. Emergency cesarean section was performed. At delivery, the infant was limp with no respiratory effort and heart rate of 40 bpm. Bag-mask ventilation was initiated, and after 2 minutes of positive pressure ventilation, heart rate increased to 80 bpm. The infant required intubation at 3 minutes of life due to continued poor respiratory effort. APGAR scores were 1 at 1 minute, 3 at 5 minutes, and 5 at 10 minutes. Cord blood gas showed pH 6.85 with base deficit of -18 mEq/L.

### Growth Parameters
- **Birth weight:** 3.6 kg (60th percentile)
- **Length:** 51 cm (55th percentile)
- **Head circumference:** 35 cm (50th percentile)

### Physical Examination (at 6 hours of life)
- **General:** Intubated, lethargic infant on mechanical ventilation
- **HEENT:** Anterior fontanelle full but not bulging, pupils 4mm bilaterally with sluggish reaction to light
- **Cardiovascular:** Bradycardia (HR 90), weak peripheral pulses, capillary refill 4 seconds
- **Respiratory:** Intubated, minimal respiratory effort over ventilator
- **Abdomen:** Soft, decreased bowel sounds
- **Neurologic:**
  - Level of consciousness: Lethargy/stupor
  - Tone: Marked hypotonia (floppy)
  - Reflexes: Weak suck, incomplete Moro
  - Posture: Decerebrate posturing with stimulation
  - Seizures: None observed clinically
- **Sarnat staging:** Stage II (moderate) HIE

### Workup
- **Umbilical cord arterial blood gas:** pH 6.85, pCO2 75, pO2 18, BE -18
- **Initial labs:**
  - Lactate 12 mmol/L (elevated)
  - Glucose 45 mg/dL
  - Creatinine 1.4 mg/dL (elevated)
  - AST 320 U/L, ALT 180 U/L (elevated)
  - Troponin elevated
- **CBC:** Normal
- **aEEG (amplitude-integrated EEG):** Moderately abnormal background with reduced amplitude
- **Head ultrasound:** No hemorrhage, increased echogenicity of basal ganglia bilaterally

### Diagnosis
**Moderate hypoxic-ischemic encephalopathy (Sarnat Stage II)**

### Clinical Reasoning
The diagnosis of HIE is supported by: evidence of intrapartum hypoxia (category III FHR tracing), metabolic acidosis with pH <7.0 and base deficit >-12, 10-minute APGAR <5, need for continued resuscitation at 10 minutes, and clinical signs of moderate encephalopathy (lethargy, hypotonia, autonomic dysfunction). The infant meets criteria for therapeutic hypothermia based on gestational age >=36 weeks, age <=6 hours, and evidence of moderate-severe encephalopathy.

### Management
1. **Therapeutic hypothermia:** Initiate whole-body cooling to target temperature 33.5C for 72 hours
2. **Continuous EEG monitoring:** Monitor for subclinical seizures, treat if identified
3. **Supportive care:**
   - Maintain normoglycemia (50-150 mg/dL)
   - Fluid restriction (60 mL/kg/day) for potential SIADH
   - NPO, parenteral nutrition
   - Blood pressure support as needed (dopamine if MAP <40)
4. **Avoid hyperthermia, hyperoxia, hypocapnia** (worsen injury)
5. **MRI at day 5-7:** Assess extent of injury after rewarming
6. **Neurology consultation:** Prognostication, follow-up planning
7. **Family support:** Honest communication about prognosis and potential outcomes

### Clinical Image
![MRI showing HIE injury pattern](case_02_image.jpg)

**Image Description:** Brain MRI demonstrating bilateral basal ganglia and thalamic injury pattern typical of acute profound hypoxic-ischemic encephalopathy.

**Source:** Radiopaedia
**URL:** https://radiopaedia.org/cases/hypoxic-ischaemic-encephalopathy-term-infant
**License:** CC BY-NC-SA 3.0

---

## Case 3: Neonatal Sepsis

### Patient Demographics
- **Age:** 18-hour-old female
- **Sex:** Female

### Chief Complaint
Newborn with temperature instability and poor feeding.

### History of Present Illness
An 18-hour-old female newborn develops temperature instability with a rectal temperature of 38.2C noted on routine vital signs in the newborn nursery. The infant had been feeding well initially but has become increasingly lethargic and refused the last two feeds. The mother had prolonged rupture of membranes for 26 hours prior to delivery and received only one dose of ampicillin (4 hours before delivery) as GBS prophylaxis. Mother was GBS positive on prenatal screening. Delivery was at 38 weeks via vaginal delivery. Birth weight was appropriate for gestational age. APGAR scores were 8 and 9. The infant initially appeared well but nursery staff noted mottled skin color and tachypnea on most recent assessment.

### Growth Parameters
- **Birth weight:** 3.1 kg (35th percentile)
- **Length:** 49 cm (35th percentile)
- **Head circumference:** 33.5 cm (35th percentile)

### Physical Examination
- **General:** Ill-appearing, lethargic newborn with mottled skin
- **Vital signs:** T 38.2C rectal, HR 185, RR 68, BP 52/30, SpO2 94% on room air
- **HEENT:** Anterior fontanelle soft, flat
- **Cardiovascular:** Tachycardia, weak peripheral pulses, capillary refill 4 seconds
- **Respiratory:** Tachypnea, mild subcostal retractions, grunting, clear breath sounds
- **Abdomen:** Mildly distended, decreased bowel sounds
- **Skin:** Mottled, delayed capillary refill
- **Neurologic:** Hypotonic, weak cry, poor suck

### Workup
- **CBC:** WBC 3,200/mcL (low), neutrophils 1,100/mcL, bands 24%, I:T ratio 0.35 (elevated), platelets 98,000/mcL
- **CRP:** 45 mg/L (elevated)
- **Blood culture:** Pending (obtained before antibiotics)
- **CSF (lumbar puncture):**
  - WBC 85/mcL (75% neutrophils)
  - Protein 180 mg/dL (elevated)
  - Glucose 22 mg/dL (low; serum glucose 75)
  - Gram stain: Gram-positive cocci in chains
  - Culture: Pending
- **Urinalysis and culture:** Obtained
- **Chest X-ray:** Bilateral hazy infiltrates
- **Blood gas:** pH 7.28, pCO2 38, HCO3 17 (metabolic acidosis)
- **Lactate:** 5.8 mmol/L (elevated)

### Diagnosis
**Early-onset neonatal sepsis with meningitis, presumed Group B Streptococcus**

### Clinical Reasoning
This infant has multiple risk factors for early-onset sepsis: maternal GBS colonization with inadequate intrapartum prophylaxis (<4 hours before delivery) and prolonged rupture of membranes >18 hours. The clinical presentation of fever, lethargy, respiratory distress, poor perfusion, and laboratory findings of leukopenia with left shift, thrombocytopenia, elevated CRP, and abnormal CSF with gram-positive cocci strongly suggest GBS sepsis with meningitis. The presentation within 24 hours of birth is classic for early-onset sepsis.

### Management
1. **Empiric antibiotics:** Ampicillin 150 mg/kg IV q8h + Gentamicin 4 mg/kg IV q24h (meningitis dosing)
2. **Fluid resuscitation:** 20 mL/kg NS bolus, repeat as needed for perfusion
3. **Respiratory support:** Supplemental oxygen, escalate to CPAP or mechanical ventilation if needed
4. **NPO and IV fluids:** TPN if prolonged course anticipated
5. **Supportive care:**
   - Monitor glucose closely
   - Correct metabolic acidosis
   - Blood pressure support with dopamine if fluid refractory
6. **Repeat lumbar puncture:** In 24-48 hours to document sterilization
7. **Duration of antibiotics:**
   - If cultures confirm GBS meningitis: 14-21 days
   - Repeat CSF at end of therapy
8. **Hearing screen:** Before discharge (GBS meningitis associated with hearing loss)
9. **Neurodevelopmental follow-up:** Long-term monitoring for sequelae

### Clinical Image
![Gram stain showing GBS](case_03_image.jpg)

**Image Description:** Gram stain of cerebrospinal fluid demonstrating gram-positive cocci in chains consistent with Group B Streptococcus.

**Source:** CDC Public Health Image Library
**URL:** https://phil.cdc.gov/Details.aspx?pid=2471
**License:** Public Domain