Approach to jaundice (newborn and infant) Quiz: Ace Your Exams

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A 72-hour-old female neonate born at 39 weeks is brought to the emergency department for yellowing skin, lethargy, and poor feeding. This is the mother’s second delivery, and she was born via spontaneous vaginal delivery at home after an uncomplicated pregnancy. The parents prefer holistic medicine and refused all recommended shots during the pregnancy. The mother’s blood type is AB, Rhesus (Rh) negative. The neonate has breastfed since birth and passed black-colored stools within 24 hours of delivery. Over the last 24 hours, she has been lethargic and not latching on well. There have only been two minimally wet diapers in the last 24 hours. She has not experienced vomiting, diarrhea, bloody stools, or seizures. Temperature is 37° C (98.6° F), pulse is 170/min, respirations are 35/min, blood pressure is 69/36 mm Hg, and oxygen saturation is 98% on room air. Physical examination is significant for a sleepy but arousable neonate with a high-pitched cry. The anterior fontanelle is open and flat. Lips are slightly dry. Scleral icterus, generalized jaundice, and cephalohematoma are present. No dysmorphic features are appreciated. Cardiopulmonary exam is normal. There is mild hypotonia. Labs are shown below. Access is obtained and phototherapy is initiated. Which of the following is the best next step in management?    
 Laboratory value     Results     
 Total bilirubin     31 mg/dL    
 Conjugated bilirubin      1 mg/dL    
 Reticulocyte count      8%    
 Neonates blood type     AB, Rh positive    
 Direct antiglobulin test (DAT)     Positive     
  

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