What is the appropriate management for a 7-day-old infant with severe jaundice, born at 37+3 weeks gestation to a GBS (Group B Streptococcus) positive mother?

Management of Severe Jaundice in a 7-Day-Old Infant

For a 7-day-old infant with severe jaundice (TcB >340), immediate phototherapy should be initiated to prevent bilirubin encephalopathy, with consideration for exchange transfusion if phototherapy fails to reduce bilirubin levels adequately. 1

Initial Assessment Questions

History

• Feeding pattern: How many times per day is the infant breastfeeding? Is feeding adequate? 1
• Stooling and voiding pattern: How many wet diapers and bowel movements per day? 1
• Weight change: Current weight and percentage change from birth weight? 1
• Maternal factors: Blood type, Rh status, and GBS status? 1
• Family history: Previous siblings with jaundice or who required phototherapy? 1

Physical Examination

• Vital signs: Temperature, heart rate, respiratory rate 1
• Hydration status: Assessment of fontanelle (noted as slightly sunken), mucous membranes, skin turgor 1
• Extent of jaundice: Distribution (face, trunk, extremities) 1
• Neurological status: Alertness, tone, reflexes (to assess for signs of bilirubin encephalopathy) 1
• Signs of hemolysis: Hepatosplenomegaly, bruising, cephalohematoma 1

Laboratory Evaluation

• Total serum bilirubin (TSB) level (TcB >340 indicates need for confirmatory TSB) 1
• Direct/conjugated bilirubin level 1
• Blood type and Coombs' test for both mother and infant 1, 2
• Complete blood count with peripheral smear 1
• Consider G6PD testing, especially if infant is of African, Mediterranean, or Asian descent 1, 3

Management Plan

Immediate Interventions

• Initiate intensive phototherapy immediately with special blue fluorescent tubes or LED lights that deliver irradiance of >30 mW/cm²/nm 1
• Position lights at optimal distance (10-15 cm above infant) to maximize irradiance 1
• Maximize skin exposure by removing clothing except for diaper and eye protection 1, 4
• Ensure proper eye protection to prevent retinal damage 4
• Monitor vital signs and temperature every 2-4 hours 4

Hydration and Feeding

• Assess hydration status (slightly sunken fontanelle suggests mild dehydration) 1
• Support breastfeeding with 8-12 feedings per day 1
• Do not supplement with water or dextrose water as this does not reduce bilirubin levels 1
• Consider supplemental fluids (IV) if dehydration is present or oral intake is inadequate 1

Monitoring

• Repeat TSB measurement within 4-24 hours depending on initial level and response to therapy 1
• Plot TSB results on hour-specific nomogram to assess risk and response to treatment 1
• Monitor for signs of acute bilirubin encephalopathy: lethargy, poor feeding, high-pitched cry, hypertonia, arching 1
• Continue phototherapy until TSB falls below treatment threshold based on infant's age and risk factors 1

Escalation of Care

• Consider exchange transfusion if TSB approaches or exceeds exchange levels despite intensive phototherapy 1
• For a 7-day-old term infant without hemolysis, exchange transfusion threshold is approximately 25 mg/dL (428 μmol/L) 2
• If hemolysis is present, exchange transfusion should be considered at lower levels (20-25 mg/dL) 1

Special Considerations

• GBS-positive mother: Although the infant was born to a GBS-positive mother, this does not directly affect jaundice management but may increase risk of sepsis, which can worsen jaundice 1
• Mild jaundice at birth: Early onset jaundice (within first 24 hours) is a risk factor for severe hyperbilirubinemia and suggests hemolytic disease 1
• Breastfeeding jaundice: Ensure adequate breastfeeding frequency and technique to minimize risk 1
• Late preterm status (37+3 weeks): Late preterm infants are at higher risk for developing severe hyperbilirubinemia 1

Follow-up Plan

• After discharge, follow-up within 24-48 hours to reassess bilirubin levels 1
• Continue monitoring until bilirubin levels show a consistent downward trend 1
• Educate parents about signs of worsening jaundice and when to seek immediate medical attention 1
• Consider outpatient phototherapy if TSB levels remain elevated but below exchange transfusion threshold 1

Common Pitfalls to Avoid

• Underestimating severity: Visual assessment of jaundice is unreliable, especially in darker-skinned infants; always confirm with TSB measurement 1
• Delayed treatment: Severe hyperbilirubinemia requires prompt intervention to prevent kernicterus 1
• Inadequate phototherapy: Ensure proper irradiance, spectrum, and skin exposure for maximum effectiveness 1, 4
• Neglecting underlying causes: Investigate for hemolysis, G6PD deficiency, or other causes of severe jaundice 1, 3
• Overlooking dehydration: Ensure adequate hydration as dehydration can worsen hyperbilirubinemia 1