Persistent hyperbilirubinemia in a 1-week-old male

An 8-day-old male infant presented with jaundice and poor feeding after an elevated transcutaneous bilirubin.He was born at 37 1/7 weeks via vacuum-assisted vaginal delivery after an uncomplicated pregnancy.Apgar scores were 5 and 9. Cord gases (arterial pH 7.23/base excess-2, venous pH 7.35/base excess-5) and newborn screen were normal.Birth weight was 3230 g (78.3 percentile).After discharge on day 7 of life, he presented to the emergency department for increased jaundice, abdominal distension, and not waking for feeds.He was afebrile with stable vitals.Jaundice was noted, but no bruising or cephalohematoma.His abdomen was soft with no palpable masses.Investigations revealed a normal complete blood count, C-reactive protein, procalcitonin, and electrolytes.Serum bilirubin was 398 mmol/L (indirect 390 mmol/L).His blood type was A+ and direct antiglobulin test (DAT) negative, with reticulocytes 62 10 9 /L.Lactate dehydrogenase (LDH) was 2016 U/L (range 225 to 600 U/L).He received intravenous fluids and intensive phototherapy.His bilirubin trended down but rebounded as fluids were weaned.Hematology consultation for the persistent hyperbilirubinemia and elevated LDH recommended testing for bleeding diathesis and an abdominal ultrasound.The latter showed a normal liver and spleen, but did reveal the cause of the patient's presentation.