Case Presentation

Neonate with Jaundice

General Data
• Name of the Mother: Aya Santos

• Contact Number: 09546828453

• Baby’s Name: AZ Santos

• Born: 7 days old (Oct.8, 2021), Male

• Lahug, Cebu City

• Filipino

• Roman Catholic
Chief Complaint
General Jaundice
History of Present Illness
1 week pta, New born is presented with yellow tinted skin around 24
hours after birth.

Today, eyes started to exhibit same yellow tint, no factors seem to

alleviate the symptom, the baby presents to be irritable while crying,
there is no complication upon feeding and no further associated
symptoms
Prenatal History
Ms. Aya santos 30/f, G1P1
Has prenatal check-ups regularly, for a total number of 5 times
Lab tests include: CBC, UA, UZ, HIV screening and Hepatitis B (RESULT:
NORMAL)
No illnesses during pregnancy
Drugs taken during pregnancy were Ferrous sulfate, multivitamins &
calcium
No pertinent history of smoking or alcohol intake
Postnatal History
Upon Deliver the newborn was 38 weeks AOG
Uncomplicated Vaginal Deliver attended by the OBGYNE resident in
charge along other medical staff in Vicente Sotto Memorial Hospital
No other complications were noted
Newborn birth weight: 3500G
Duration of confinement: 2days
Feeding History
Newborn is breastfed, milk has constant consistency, newborn was fed
8 times for the last 24hours, voided and excreted 5 times for the past
24 hours, infant noted to be always hungry
Developmental History
Recent weight: 3400grams or 3.4 kls,
Length: 49cm
Head Circumference: 32cm
Chest Circumference: 30cm
Neonate was show to be active after his birth
Immunization History
BCG, hepa. B, & vit. D
Past Medical History
The patient has shown general jaundice and is exposed to sunlight for
one hour everyday from 7am-8am. Newborn has no other past medical
history
Family History
Child has no siblings being ,first born. parents no history jaundice or
other haptobiliary diseases, there was also no known heredofamiliary
diseases, congenitial abnormalities, and no psychiatric disorders
Personal Social History
Both parents are nurses an live 1 bedrom apartment in lahug
environement i decent and adequate for child growth, and both are at
30 years of age, there is no known alchohol, smoking history or use of
illicit drugs
Review of Systeams
CONSTITUTIONAL: No fever, physiologic weight loss of 100g. Mother
reported increased irritability.
Skin: yellowish discoloration according to the mother
EYES: yellowish discoloration on the mucous membranes and sclera with
same organ being the first to turn yellow according to the mother.
EARS, NOSE, MOUTH/THROAT: No otorrhea, no congestion,
CARDIOVASCULAR: No history of heart murmur, no cyanosis.
PULMONARY: No cough or increased work of breathing
GI: mother stated that infant is breastfed and no trouble when feeding
but is usually very hungry and eats a lot
Physical Examination
General survey
Patient is well developed, well-nourished, not in cardiorespiratory
distress
Vital Signs
Temperature: 36.3’C
Oxygen Saturation: 99%
RR: 42bpm
BP: not recorded
Growth parameters:
Weight:3.4kg
Height:49cm
Head Circumference: 32cm
Chest Circumference: 30cm
Skin
Neither warm nor cold to touch presents with normal turgor but has
yellow discoloration
HEENT
Head: Normocephalic, atraumatic. Anterior fontanelle is soft and flat
with normal pulsations. Posterior fontanelle is fingertip.

Eyes: Pupils equal, round and reactive to light. Extraocular muscles

appear intact but patient too young to cooperate with exam. Mucous
membranes and sclera are yellowish but there are no No discharge,
conjunctivitis or scleral icterus. No ptosis.. Fundi-unable to visualize.
Positive red reflexes bilaterally
HEENT
Ears: Clear external auditory canals. Pinnae normal is shape and
contour. No pre-auricular pits or skin tags. TM’s grey bilaterally. No
erythema or bulging.
Nose: Normal pink mucosa, no discharge or blood visible. Normal
midline septum.
Mouth: moist mucous membranes. No evidence of a cleft on palpation
of roof.
HEENT
Pharynx: Unable to visualize tonsils. Pharynx shows no erythema or
ulcerations. Normal movement of soft palate.
Neck: Grossly non-swollen. No tracheal deviation. No decrease in ROM.
No lymphadenopathy, goiter or masses detected.
Chest
No increase of accessory muscles, no evidence of increased work of
breathing. Lungs are clear to auscultation bilaterally. No stridor,
wheezes, crackles, or rubs. Good air movement
Cardiovascular
Quiet precordium, no right ventricular heave, no thrills. PMI in left mid-
clavicular line in 6th intercostal space. Regular rate and rhythm. Normal
S1 with normally split S2 on respiration. No murmurs, gallops or rubs.
2+ pulses in all extremities including strong bilateral femoral pulses.
Capillary refill less than 2 sec
Abdomen
Soft, non-tender, non-distended. Bowel signs present. Liver edge
palpable below costal margin by 1-2 cm. No noted splenomegaly. No
masses. Umbilicus healing well – no erythema, discharge or foul smell
Genitalia, Extremities and back
Genitalia: normally placed urethral meatus. Bilaterally descended testes
measuring 1.5cm bilaterally, GU Tanner I, Pubic Hair Tanner I; no
hernias, no hydroceles
Extremities: Warm, no clubbing, cyanosis or edema. No gross
deformities. Good skin turgor with no tenting. Negative Barlow and
Ortolani signs – no hip clunks.
Back: straight, no lordosis, no kyphosis. Symmetrical Gallant reflex
present. No sacral dimple, no hair tuft.
Neurological
Moves all extremities symmetrically, appropriate tone
Head Circumference: 32cm
CN I deferred
CN II can focus on face briefly, PERRL
CN III, IV, VII unable to tell if eyes move in all directions
CN V corneal reflex deferred CN VII symmetrical facial expression,
closes eyes forcefully CN VIII startles to clap CN VII, IX, X, XII positive
gag, symmetrical soft palate movement, normal swallow and cry CN XI
deferre
Neurological
CN VII symmetrical facial expression, closes eyes forcefully
CN VIII startles to clap
CN VII, IX, X, XII positive gag, symmetrical soft palate movement,
normal swallow and cry
CN XI deferred
Labs
Newborn Screening: Pending still after 1 month
Differential Diagnosis
Breast milk Jaundice
Abo Compatibility
Cholestasis
Breast Feeding Jaundice
This condition is a type of neonatal jaundice associated with
breastfeeding that is characterized by indirect hyperbilirubinemia in an
otherwise healthy breastfed newborn that develops after the first 4-7
days of life
Pathophysiology
Breast milk jaundice is a common cause of indirect hyperbilirubinemia.
The etiology of breast milk jaundice is not clearly understood, but a
combination of genetic and environmental factors may play a role. 
Etiology
Replacement of  breastfeeding with oral glucose solution does not
appear to decrease the prevalence or degree of jaundice. 
Epidemiology
Jaundice occurs in 50-70% of newborns. Excess physiologic jaundice
(bilirubin level >12 mg/dL) develops in 4% of bottle-fed newborns,
compared to 14% of breastfed newborns
Clinical Manifestation
Clinical jaundice is usually first noticed in the sclera and the face
Labs
• detailed history and physical examination
• total serum bilirubin 
• complete blood cell (CBC) count
Labs
• detailed history and physical examination
• total serum bilirubin 
• complete blood cell (CBC) count
Treatment
(1) assessment of risk for severe hyperbilirubinemia before hospital
discharge,
(2) breastfeeding support
(3) care coordination between the nursery and primary care
Treatment
(1) assessment of risk for severe hyperbilirubinemia before hospital
discharge,
(2) breastfeeding support
(3) care coordination between the nursery and primary care
Management
Weight monitoring
Diet
No activity restriction
ABO INCOMPATIBILITY
 Epidemiology

• The most common cause of HDFN

• 20% of live births are at risk for immune-mediated hemolysis due to ABO mismatch
• Mother is often group O and infant either group A or B
• Most often happen during 1st pregnancy
 Pathogenesis

• Group O mothers will produce IgG antibodies against blood group A or B antigens
• These antibodies will cross the placenta and can cause immune-mediated hemolysis
 Lab Tests

• Direct Coombs Test

 Manifestations

•Most cases are mild

•Jaundice  being  the  only  clinical  manifestation
•Jaundice usually during first 24 hours of life
•Mild hepatosplenomegaly
•The infant is not generally affected at birth.
•(-) Pallor
•Rare Hydrops fetalis
•Rarely, it may become severe, and symptoms and signs of
kernicterus develop rapidly.
 Treatment

•Phototherapy  may  be  effective  in  lowering  serum  bilirubin

 levels.
•In  severe  cases,  IVIG  administration  can  reduce  the rate
 of hemolysis  and  the  need  for  exchange  transfusion.
•Some  infants  with  ABO  hemolytic  disease  may  require
 transfusion of  packed  RBCs  at  several  weeks  of  age
 because  of  slowly  progressive anemia.
•Postdischarge  monitoring  of  hemoglobin  or  hematocrit
 is essential  in  newborns  with  ABO  hemolytic  disease.
Neonatal Cholestasis
EPIDEMIOLOGY

1 in every 2,500 infants

 Idiopathic neonatal hepatitis (1: 4,800 to
1: 9,000 in neonates)
 Biliary atresia (25%–35%)
 Genetic disorders (25%)
 Metabolic diseases (20%)
 a1-antitrypsin deficiency (10%).
•N e o n a t a l c h o l e s t a s i s i s j a u n d i c e s e c o n d a r y t o e l e va t e d
conjugated bilirubin levels in the newborn period.

•Ty p i c a l l y, i n f a n t s a r e n o t j a u n d i c e d a t b i r t h b u t d e v e l o p
c h o l e s t a s i s w i t h i n d a y s t o w e e k s o f l i f e . I n u t e r o, t h e p l a c e n t a
and maternal liver perform the necessary hepatic functions for
the infant. The liver slowly matures throughout the 1st year of
life to reach full hepatic metabolism potential.

•N e o n a t a l c h o l e s t a s i s c a n b e c a u s e d b y a va r i e t y o f m e c h a n i s m s
o f h e p a t o b i l i a r y d y s f u n c t i o n t h a t r e s u l t s i n p o o r b i l e fl o w o r
e x c r e t i o n . I n a d d i t i o n , t h e r e i s i n e ffi c i e n t e n t e r o h e p a t i c
circulation in the newborn period, which contributes to bilirubin
accumulation.
MANIFESTATION
Affected infants may have:
• Jaundice
• Cirrhosis
• Pruritus
• Hepatomegaly
• Acholic stool
• Dark urine
• Poor weight gain
Disorders resulting in Neonatal Cholestasis
Biliary Atresia
is an idiopathic fibrosing cholangiopathy of unknown etiology that leads to complete obstruction of the extrahepatic bile duct during the first
few month after birth.
Aside from jaundice, these infants do not initially appear ill.

Neonatal hepatitis
Characterized by ill-appearing infant with an enlarged liver and jaundice.

Alpha 1- antitrypsin deficiency

Presents with clinical findings indistinguishable from neonatal hepatitis. It most common inherited cause of neonatal cholestasis, and the
leading metabolic disorder requiring liver transplantation.

Alagile syndrome
A multisystem disorder characterized by chronic cholestasis with unique liver biopsy finding of paucity of bile ducts in the portal triads.
LAB TEST

• Total and direct bilirubin

• Liver tests
• Tests for metabolic, infectious, and genetic causes
• Liver ultrasonography
• Hepatobiliary scan
• Occasionally biopsy of liver, operative cholangiography, or genetic testing
TREATMENT

 Careful attention to nutritional needs and diet are essential for infants with this disorder. Special
supplements (i.e., fat-soluble vitamins), formulas, and/or dietary restrictions may be suggested by the
physician. Special infant formulas may be prescribed.
 There is no specific treatment available for infants with neonatal cholestasis. Treatment is directed toward
the specific symptoms that are apparent in each individual.
 If itching (pruritus) becomes a problem, a drug that has been used to treat itching associated with liver
disease is ursodeoxycholic acid.
 A surgical choice of last resort for infants who develop end-stage liver disease is a liver transplantation.