Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Age: [Baby’s Age in Days]
Gestational Age: [Weeks]
Birth Weight: [Grams]
Chief Complaint:
Jaundice (yellowing of the skin and sclerae)
History of Present Illness:
Onset of jaundice (hours or days after birth).
Intensity of jaundice (mild, moderate, severe).
Feeding history (breastfeeding, formula feeding, frequency, and amount).
Urine and stool output (frequency and color).
Maternal history (blood type, Rh status, GBS status, diabetes).
Family history of jaundice in siblings or parents.
Physical Exam:
General examination: Assess for lethargy, poor feeding, or other signs of illness.
Vital signs: Temperature, heart rate, respiratory rate.
Jaundice: Assess the degree of icterus (yellowing) using a standardized assessment tool (e.g., Bhutani nomogram). Evaluate scleral icterus (yellowing of the whites of the eyes).
Abdominal examination: Assess for hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen).
Laboratory Tests:
Total serum bilirubin (TSB): Measure the total amount of bilirubin in the blood.
Conjugated bilirubin: Differentiates between conjugated (indirect) and unconjugated (direct) bilirubin. Unconjugated bilirubin is the major concern in neonatal hyperbilirubinemia.
Complete blood count (CBC): May be done to rule out other causes of jaundice (e.g., sepsis).
Blood type and direct antiglobulin test (DAT) (Coombs’ test): Performed on the newborn and mother to identify blood group incompatibility as a potential cause.
Assessment:
Neonatal hyperbilirubinemia: Confirmed by elevated total serum bilirubin levels.
Degree of hyperbilirubinemia: Classified based on the TSB level and gestational age using a standardized nomogram.
Etiology (suspected cause):
Physiological jaundice (most common): Occurs due to the newborn’s immature liver function and breakdown of red blood cells.
Breastfeeding jaundice: May cause a temporary rise in TSB levels due to decreased beta-glucuronidase activity in breastmilk.
Pathological jaundice: Caused by underlying medical conditions (e.g., blood group incompatibility, G6PD deficiency, sepsis).
Plan:
The plan will depend on the severity of hyperbilirubinemia and the suspected cause. Possible elements include:
Monitoring: Frequent bilirubin level checks and clinical assessment for signs of worsening jaundice or bilirubin encephalopathy (kernicterus).
Increased feeding frequency: Encourage more frequent breastfeeding or formula feedings to promote stooling and bilirubin elimination.
Phototherapy: Exposure to a specific wavelength of light helps convert unconjugated bilirubin into a form that can be excreted in the stool. Different types of phototherapy (traditional, intensive) may be used depending on the severity.
Intravenous immunoglobulin (IVIg) therapy: May be used in cases of severe blood group incompatibility (Rh incompatibility).
Exchange transfusion: Removal of some of the baby’s blood and replacement with donor blood – a last resort for severe cases.
Consultations: Consider referral to a neonatologist for complex cases or those not responding to initial treatment.
Disposition:
Discharge home with close monitoring and follow-up appointments if jaundice is mild and improving.
Admit to the nursery for further monitoring and potential phototherapy if jaundice is moderate or worsening.
Admit to the neonatal intensive care unit (NICU) for intensive phototherapy, exchange transfusion, or management of underlying medical conditions in severe cases.
Education:
Educate parents about jaundice, its causes, and the importance of monitoring their baby for signs of worsening jaundice.
Provide guidance on feeding practices (increased frequency) to help eliminate bilirubin.
Discuss the benefits of breastfeeding and the transient nature of breastfeeding jaundice in most cases.