1. Case

2. HPI Newborn male vaginal delivery with vacuum assist at 39 weeks. Mother is O+, infant blood type is B+ with 2+ direct Coombs Maternal history: GBS neg, serologies neg, anemia during pregnancy Apgars 8 and 8 TCB at ~4.5 hrs of life is 5.2 Baby born after rounds, exam is normal per nursing report by phone

3. Questions 1.What are this infants risk factors for hyperbilirubinemia? 2.What risk curve for phototherapy initiation would you put this infant on? 3.What labwork would you want to obtain at this point?

4. Labwork Total bilirubin 5.77 (direct 0.36) at 5.5 hrs of life CBC: 28.6 100 Retic: 11.6%

5. 1.What is your interpretation of the lab results? 2. What are your next steps in management of this newborn?

6. Case continued You decide to initiate phototherapy for indirect hyperbilirubinemia at threshold for light therapy

7. 1.When do you want to check the next bilirubin? 2.Do you want to repeat any other labs? 3. How can you support this mother who would like to breastfeed her newborn?

8. Lab results Baby is almost 12 hrs old (6hrs since initiating phototherapy) Serum bili is 6.58 CBC: 18.5 192 Retic: 14%

9. At 24 hrs of life serum bili is 7.12 On rounds in the morning, physical exam is notable for a moderate size cephalohematoma

10. Questions 1.What is a cephalohematoma? 2. What do you want to do with the phototherapy at this point? Stop or continue? And why? 3. Has your risk curve changed given the physical exam finding?

11. At 48hrs of life serum bili is 7.03 Repeat CBC: 13.6 <12.7/38.8<221 Retic: 15%

12. 1.Should you discontinue phototherapy at this point? 2. Do you want to check a rebound? 3. When should this infant be seen by the pediatrician for repeat bili?

13. Case continued Rebound bili after discontinuing phototherapy at 48hrs was 6.31 at 60 hrs of life Recommended mother take newborn to ED for bilicheck (not done) Seen in clinic at DOL 6. Serum bili 3.47m retic 3%

14. Learning points Selecting appropriate risk curve on bili nomogram Interpreting abnormal labs and making follow- up plans Managing a newborn under phototherapy Supporting a breastfeeding mother Follow-up following discontinuation of phototherapy