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Case 3: Early Severe Jaundice in a Term Infant

An appropriate-for–gestational age (AGA) African American female infant is born at term via elective, repeat cesarean section at 39 weeks’ gestation to a gravida 2, para 2 woman. The mother’s pregnancy had been complicated only by gestational hypertension, and maternal antenatal testing results were unremarkable. Maternal blood type is O positive with a negative antibody screen during pregnancy. Meconium fluid is noted at delivery; however, the infant is vigorous with a strong cry and requires only routine resuscitation with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. After resuscitation, the infant makes a transition to routine couplet care with an anticipated 48-hour stay.

A cord blood sample is sent for blood type and direct antiglobulin test (DAT) per hospital protocol secondary to infant blood type finding of B-negative type with a negative DAT result. Her first 24 hours are uneventful with direct breastfeeding every 2 to 3 hours, 2 documented voids, 3 stools, and minimal weight loss. All documented vital signs and examination results are normal for a term newborn. At 24 hours after birth, a transcutaneous bilirubin test is attempted per standard newborn care plan, with the resulting value too high to detect. Serum total and direct bilirubin concentrations are found to be 21.7 mg/dL (360 μmol/L) and 0.6 mg/dL (10 μmol/L), respectively. The infant is transported directly to the NICU for continued management and preparation for possible exchange transfusion.

With any case of hyperbilirubinemia, especially with early-onset or rapidly increasing levels, it is important to keep a broad differential to avoid missing benign versus more severe causes of jaundice. Categorizing by time of onset into 3 categories can be useful in establishing a differential diagnosis. These categories are based on newborn age: less than 24 hours after birth, between 24 and 72 hours after …