Case 1: Severe Jaundice in a 2-day-old Term Neonate

Presentation

A 2-day-old, 2.68-kg term male neonate is brought to the emergency department with lethargy, poor feeding, and significant generalized jaundice. He was born via spontaneous vaginal delivery at home to a gravida 4, para 3 Amish woman under the supervision of a midwife, at an estimated gestational age of 39 weeks after an uncomplicated pregnancy with scant prenatal care. Jaundice was noticed 7 hours after birth. The neonate has only breastfed 5 to 6 times since birth, and passed a normal-colored stool at home. Prenatal laboratory findings are unavailable because of limited prenatal care. The mother’s blood type is AB, Rh negative. The mother’s obstetric history includes a previous miscarriage (4 years earlier), a previous stillbirth at 30 weeks’ gestation (3 years earlier), and a term pregnancy (2 years earlier). She had received Rh_o(D) immune globulin 3 weeks after the miscarriage, 2 weeks after the stillbirth delivery, and 2 weeks after the most recent pregnancy. The mother, father, and 2-year-old brother are reportedly healthy.

Review of systems at admission is significant for decreased activity, poor feeding, and generalized, intense yellow discoloration of the skin. The infant has no fever, vomiting, diarrhea, constipation, bloody stools, seizures, or hypertonia. Physical examination reveals a weak cry, lethargy, scleral icterus, soft liver edge 3 cm below the right costal margin, and significant generalized jaundice of the entire body. No dysmorphic features are appreciated.

Case Progression

Initial evaluation revealed a total serum bilirubin (TB) of 49.4 mg/dL (845 μmol/L), conjugated bilirubin of 42 mg/dL (718 μmol/L), unconjugated bilirubin of 10.7 mg/dL (183 μmol/L), reticulocyte count greater than 23, and hemoglobin of 12.6 g/dL (126 g/L). Urinalysis demonstrated dark brown urine. Serum aspartate aminotransferase (AST) was elevated at 239 U/L (4 μkat/L), serum alanine …