OSCE Stem: Part A

You are an enthusiastic HMO with the lovely paediatric team. You receive a page stating
“day 3 baby in room X needs review”. Because you are both considerate and time-
constrained, you call back the nurse who paged you to let them know that you have
received the message and will get onto it as soon as you can.

A few hours later, you are able to arrive at room X, perform hand hygiene, and introduce
yourself to the new mum. She’s very tired and wants to know when she can go home and
show off baby Bellissima on Instagram. However, the nurse who came in before told her
that Bellissima was starting to look a little yellow, and this is upsetting as it will throw off the
first few insta outfits she had planned. You also learn that Bellissima was born at term via
normal vaginal delivery, has been establishing feeds, and has received vitamin K and hep
injections.

You perform an appropriate examination of Bellissima, starting with hand hygiene and
proceeding to adequate exposure of the patient. You note yellowing of the sclera when
Bellissima takes a breath to stop crying and opens her eyes. As you undress her, you
appreciate the distinct yellowness of jaundice extending to cover the whole body. Adhering
to the ‘Jaundice - Transcutaneous Bilirubinometry” guide from the women’s hospital, you
obtain a TCB reading of 350. You’re paeds protocol brain kicks in and away you go!
Q1. What is the most appropriate next step in management?

- Obtain blood sample (usually heelprick) for measurement of total serum bilirubin
(SBR)

- Plot this result on age-appropriate chart, and note whether it is above or below the
phototherapy line for age in days

- If above phototherapy line, start treatment with light therapy (protect baby’s eyes
with adorable wrap-around blindfolds)

- NOTE only unconjugated hyperbilirubinaemia can be treated with phototherapy;

conjugated levels of >15% need to address underlying cause

Q2. What are some of the common types of neonatal jaundice?

- Jaundice can be divided into time of onset, so:

o Within 24hrs of life = pathological

 Haemolysis due to ABO incompatibility, Rhesus disease of newborn,

hereditary spherocytosis

 Sepsis due to TORCH infections of mum’s GU tract, or the amniotic

fluid

o Between days 2-14 = physiological or breastfeeding

 Can be physiological, due to high rate of foetal Hb break down (foetal

Hb has shorter lifespan than adults) and the neonate’s liver can’t
handle all of this bilirubin at once, so it builds up in blood = jaundice

o After day 14 = prolonged jaundice

 Congenital hypothyroidism (but should have been picked up on the

Guthrie heel prick test; suspect if maternal hx of thyroid disease)

 Biliary atresia (rare; get high concentration of conjugated bilirubin,

pale or ‘chalky white’ stool, need US and corrective surgery)

Q3. What are the key risk factors for developing neonatal jaundice?

- Maternal factors

o ABO or Rh incompatibility

o Maternal illness e.g. GDM

 o Breastfeeding (common; is an exaggerated early-onset jaundice that is due to
the relative caloric deficiency as mum’s milk starts to come in)

o Breastmilk (rare; later onset at approx. day 4-7 of life, peaks at week 2-3 of
life, self resolves; occurs bc breastmilk contains glucuronyl transferase, which
is needed to convert bilirubin to a form that can be excreted from body;
baby’s liver just needs some time to kick in)

o Maternal smoking

o Drugs (diazepam, oxytocin)

- Neonatal factors

o Large for gestation

o Prematurity (in term baby = onset day2-3 and resolves by day7; premature =
earlier onset and longer duration)

o TORCH infections

o Birth trauma resulting in cephalohematoma, cutaneous bruising (e.g. via

instrumental delivery; as the haematoma resolves and blood is digested to
produce bilirubin)

o Weight loss >10% of birthweight

o Polycythaemia (in utero baby needs to be polycythaemic bc is in a relatively

hypoxic intrauterine environment, but no longer needs all of thes red cells
once out of the womb)

o Infrequent feeding (e.g. waiting for mum’s milk to come in, so they get a little
dehydrated)

o Drugs (in utero exposure to chloramphenicol, erythromycin)

Q4. What are the red flags for neonatal jaundice?

- Jaundice in the first 24hours of life

- Jaundice extending for >2weeks

- Signs and symptoms of kernicterus