What is the management plan for a 6-day-old girl with significant weight loss and high unconjugated bilirubin (BR) levels, who is at risk for dehydration?

Key Questions for Progress Note: 6-Day-Old with 13% Weight Loss and Elevated Unconjugated Bilirubin

Feeding Assessment (Critical Priority)

The 13% weight loss by day 6 significantly exceeds the expected maximum of 6.1% ± 2.5% by day 3, indicating inadequate intake that requires immediate intervention. 1

Specific feeding questions to document:

• Frequency of feeds: How many times in 24 hours? (Target: every 2-3 hours, 8-12 feeds/day) 2

• Duration at breast (if breastfeeding): How many minutes per side? Is infant actively sucking and swallowing? 1

• Volume intake (if formula supplementing): How many ounces per feed? Total daily intake? 1

• Wet diapers: How many thoroughly wet diapers in the last 24 hours? (Adequate: 4-6 per day by day 4) 1

• Stool output: How many stools in last 24 hours? What color? (Adequate: 3-4 mustard-yellow stools per day by day 4; concerning if still meconium) 1

• Feeding difficulties: Any choking, gagging, falling asleep at breast, or difficulty latching? 1

Hydration Status Assessment

• Signs of dehydration: Sunken fontanelle, decreased skin turgor, dry mucous membranes, lethargy? 1

• Urine concentration: Are diapers heavily saturated or just damp? Dark or light colored urine? 1

• Activity level: Is infant alert and responsive between feeds or increasingly lethargic? 2

Bilirubin Trajectory and Risk Factors

• Current bilirubin level: What is today's total serum bilirubin (TSB)? Is it rising, stable, or declining? 1, 2

• Rate of rise: Compare yesterday's level to today's—what is the hourly rate of increase? 1

• Risk factors for severe hyperbilirubinemia:

  • Blood type incompatibility (ABO or Rh)? 3
  • Family history of G6PD deficiency or sibling with phototherapy? 1, 3
  • Cephalohematoma or significant bruising? 3
  • East Asian ethnicity? 3

Neurological Assessment for Bilirubin Toxicity

• Feeding behavior changes: Any decreased interest in feeding, weak suck, or difficulty arousing for feeds? 2

• Tone abnormalities: Any increased stiffness (hypertonia), floppiness (hypotonia), or arching of neck/back? 1, 2

• Cry pattern: High-pitched or shrill cry? 1, 2

• Alertness: Appropriate responsiveness or increasing lethargy/stupor? 1

Discharge Readiness Criteria

For safe discharge, this infant must demonstrate:

• Weight stabilization or gain: Document today's weight and trend over last 24 hours 1, 4

• Adequate oral intake: Consistent feeding every 2-3 hours with appropriate volume/duration 1, 2

• Bilirubin declining: TSB trending downward and well below phototherapy threshold for age 2

• Normal output: 4-6 wet diapers and 3-4 yellow stools in 24 hours 1

Supplementation Decision

Given the excessive 13% weight loss, supplementation with formula is indicated to correct dehydration and inhibit enterohepatic circulation of bilirubin. 1, 2 Document:

• Current supplementation plan: Is infant receiving formula supplements? How much per feed? 2

• Parental understanding: Do parents understand the need for supplementation and proper feeding technique? 2

Follow-up Planning

• Post-discharge bilirubin check: Schedule TSB or transcutaneous bilirubin measurement within 24 hours of discharge 2

• Weight check: Arrange follow-up weight assessment within 24-48 hours 1, 2

• Lactation support (if breastfeeding): Referral to lactation consultant for feeding optimization 1

Critical Pitfall to Avoid

Do not discharge without confirming adequate hydration and declining bilirubin, as the combination of 13% weight loss and elevated unconjugated bilirubin places this infant at high risk for both dehydration complications and progression to severe hyperbilirubinemia requiring readmission. 1, 2, 4