Pediatric Problem Based Learning
Case Trigger: Neonatal Jaundice (My baby has yellow eyes)
Case trigger
Ali is an 18-hour full-term baby, noticed by the nurse in the postnatal ward to have yellow
eyes. His mother stated that this yellow color started few hours after birth.
History of present illness
18-hour old baby born by spontaneous vaginal delivery to a 23-year-old
gravida 2, para 1, blood type O-negative mother.
Uncomplicated pregnancy, no medications nor special events happened
during pregnancy.
Rupture of membranes 7 hours prior to delivery with clear fluid.
APGARs 7 and 9 at 1 and 5 minutes respectively.
The mother states that breast feeding is a struggle, her baby has poor latch
and is easily frustrated. The mother has sore nipples.
The mother’s first baby did not have similar problem.
No hematological disorders in the family.
The baby passed meconium and urine immediately after birth
Phototherapy started.
Family History: Parents are consanguineous and healthy. They have one older
child, a 3-year-old female who is healthy as well. There is no family history of
infant death, metabolic or haematological diseases.
Social History: The mother is a 25-year-old, works as a schoolteacher. The father
is 28-year-old and works as an engineer. They have one older healthy daughter,
and they live in a small apartment. There are no pets at home and no recent travel.
Systemic review: unremarkable
Physical Examination :
Growth Parameters:
Weight: 3.4 kg
Length: 53 cm
Head circumference: 37cm
General Slightly lethargic, crying with exam, flexed posture,
visible jaundice
Vital signs T: 37.3C, HR: 144/m, RR: 48/m
HEENT “head, Normocephalic, fontanelle slightly depressed, eyes
eyes, ears, nose, and ears normal set/shape, sclera yellow, palate
and throat.” intact, tongue normal with Epstein pearls on the
mucous membranes,
Cardio/respiratory No murmur, pulses normally felt bilaterally and no
brachial-femoral delay, breath sounds clear,
Gastrointestinal/ Soft, non-distended, liver palpable, umbilical stump
intact/clamped; passed one meconium stool, voided
genitourinary
one time since birth
Musculoskeletal Hips stable bilaterally, all within normal
Investigations
Lab Results Reference range
Total bilirubin 16 mg/dL <5.2 mg/dL within 24 hours of birth
Direct bilirubin 0.5 mg/dl 0.3-1.0 mg/dl
Blood group B -ve
Direct Positive Negative
antiglobulin test
Hematocrit 39% Males: 42-52%; Females: 35-47%
Hemoglobin 12 g/L Males: 13-18 g/dL; Females:12-16
g/dL
WBC 15 7-14 x 109
Platelets 218 210-340 x109
CRP 2 0-8 mg/dl
Glucose 4.5 3.3-5.6 mmol/L
LFt Normal
RFT Normal
Sodium 140 135-145mmml/L
Potassium 5.1 3.5-5.2 mmol/L
Urine culture -ve
Blood culture -v
Differential diagnosis
Hemolytic diseases: Rh incompatibility, ABO incompatibility, G6PD
deficiency, Spherocytosis, Autoimmune hemolytic anemia
Physiological jaundice
Infection: TORCH, Sepsis, UTI
Endocrine: Hypothyroidism, Hypopituitarism
Trauma (birth): Cephalhematoma, subgaleal hemorrhage
Breast milk jaundice
Liver related problems:
o Obstructive causes: Extra-hepatic biliary atresia, Gallblader stones,
Cholydochal cyst, neonatal sclerosing cholangitis Syndromes:
Allagile’s syndrome,
o Malignancy: Liver tumors (hepatoblastoma), Metastases
o Idiopathic neonatal hepatitis (undefined etiology)
Metabolic problems: Cystic fibrosis, Inborn errors of metabolism
(Galactosemia, Fructosemia, Tyrosinemia), Storage disorders (Lipid storage
disorders), Alpha-1-antitrypsin deficiency
Familial conditions: Crigler Najjar syndrome, Progressive familial
intrahepatic obstruction
Learning objectives:
1. Physiological jaundice
2. Breast milk and Breast-feeding jaundice
3. Pathological Causes of Jaundice in a newborn?
4. Hemolytic disorders in the newborn.
5. What are the clinical manifestations of jaundice in a baby?
6. What is the management of jaundice in infants?
7. Complications of unconjugated hyperbilirubinemia in infants (Kernicterus).
8. What are the Causes of obstructive Jaundice in infants and children, how do
they present?
9. Extra-hepatic biliary atresia, significance of early diagnosis and management
10.Complications of conjugated hyperbilirubinemia in infants
