4 day old breastfed neonate, otherwise well, term neonate presented with jaundice, on testing the bilirubin level was found to be 18 mg/dl. Which of the following is the best step of management?
Sta phototherapy and continue breast feeding
Sta iv fluids and given phototherapy
Initiate exchange transfusion
Stop breast feeding and do phototherapy
Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin. Risk factors = isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, Temperature instability, sepsis, acidosis, or albumin <3.0 g/d (if measured) For well infants 35-47 6/7 wk can adjust TSB levels for intervention around the medium risk line. It is an option to intervene at lower TSB levels for infatns closer to 35 weeks and at higher TSB levels for those closer to 37 6/7 wk. It is an option to provide conventional phototherapy in hospital or at home at TSB levels 2-3 mg/dL (35 - 50 mmol/L) below those shown but home phototherapy should not be used in any infant with risk factors. Cut off for phototherapy in 4-day old neonate is 19-20 mg/dl The dashed lines for the first 24 hours indicate unceainly due to a wide range of clinical circumstances and a range of responses to phototherapy. Immediate exchange transfusion is recommended if infant shows signs of acute bilirubin encephalopathy (hypeonia, arching, retrocollis, opisthotonos, fever, high pitched cry) or IF TSB is > 5 mg/dL (85mmol/L) abvoe these lines. Risk factors - isoimmune hemolytic disease, GPD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis. Measure serum albumin and calculate B/A ratio (see legend) Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin. It infant is well and 36-37 6/7 wk (median risk) can individualize TSB levels for exchange based on actual gestational age. Cut off for exchange transfusion in 4-day old neonate is 25mg/dl For otherwise well term neonate- Age Phototherapy cut off Exchange transfusion cut off 24 to 48 hrs. >15 mg/dl >20 mg/dl 48 to 72 hrs. >18 mg/dl >25mg/dl >72 hrs. >20mg/dl >25mg/dl