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Old 06-03-2016
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Default Clinical Mastery series Peds Form 2

a 36 hour old boy remains in the hospital because of jaundice that developed 12 hours after birth. He has received phototherapy for the past 24 hours. He as born at term following uncomplicated pregnancy. Mother is O RH pos, Infant is A RH pos, APGAR was 7-9 respectively. Exam today shows jaundice below the knees, spleen tip is 1cm below the costal margin. The remainder of the exam shows no abnormalities.
HCT 12hr = 45 , indirect bili 12hr = 11.8
HCT 24hr =39 , indirect bili 24 hr = 17.5
HCT 36hr = 30 , indirect bili 36 hr = 22.2

Direct bili pretty much normal!
Direct Coombs test is positive!
whats the most appropriate management at this time?

Observation
cont phototherapy
exchange transfusion - wrong answer
IV Fluids
Splenectomy

thank you in advance.

Im stumped. I'm leaning toward splenectomy because the anemia and increasing indirect bili which seems to points to hemolysis and possibly spherocytosis or something related.
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Old 06-04-2016
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This is a tricky question. I got this right from my med school lecture. Answer is continue phototherapy.
The type of intervention for jaundice is based on risk stratification. For neonates with low risk factors (term, no evidence of neurological dysfunction) exchange transfusion is done if total bili (almost =indirect bili in this case) is greater than 20 at 24 hours of life. This is time dependent, meaning at 48 hours of life, the indication for exchange transfusion will not be 20 but greater (more than 22). This kid has 22 at 36 hours, so there is still a lag time to try phototherapy. If at 48 hrs, his bili was more than 22, exchange transfusion will be indicated. Also irrespective of bili level, if there is neurologic involvement at any stage, exchange transfion is the answer.
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Old 06-04-2016
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I agree. I ruminated over this question for a while and realized that the best choice was to continue phototherapy. Your answer, which is much appreciated, gave me the reasoning I was missing.

Thank you.
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