Transcript Outpatient Care of the PostPartum Woman and her baby

OUTPATIENT CARE OF THE
POSTPARTUM WOMAN
AND HER BABY
Sarah Gopman, MD
Associate Professor
Dept. of Family and Community Medicine
University of New Mexico
July 1, 2015
Learning/Practice Objectives
• Screen for and treat postpartum depression
• Evaluate and treat postpartum thromboembolic
disease
• Recognize and treat endomyometritis, c-section
wound infections, and perineal wound complications
• Manage breastfeeding difficulties
• Evaluate and manage newborn hyperbilirubinemia
Screening for and Treatment of
Postpartum Depression
A postpartum patient at risk for
depression…
• Josie is a 25 y/o woman cared for by you since
she was 19
• H/o major depressive d/o, including
hospitalization for suicide attempt age 17
• Intermittently on SSRI, stopped two months prior
planned pregnancy, did well with cognitive
behavioral therapy during pregnancy
• Had a term NSVD of a healthy baby and is
breastfeeding
What type of mood disorders occur in the
postpartum period?
• Postpartum/baby “blues”
• ~40-80% of women affected
• Feeling overwhelmed
• Irritability
• Tearfulness
• Exhaustion
• Trouble falling or staying asleep
• Usually resolves by two weeks postpartum
• Increased risk of developing full postpartum
depression
What type of mood disorders occur in the
postpartum period?
• Postpartum depression
• 10-20% of women affected
• Greatest risk is first 12 weeks after delivery, but
risk persists for one year
• Symptoms last more than 14 days
What are postpartum depression
symptoms?
• Tearfulness, sad or flat affect, irritability, mood instability
• Feeling inadequate, guilty, overwhelmed
• Sleep and appetite disturbance
• Intense worries or obsessive thoughts re. harm to the
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baby
Difficulty concentrating or making decisions
Lack of interest in the baby, family or activities
Poor bonding
Thoughts of death or suicide
Somatic symptoms: HA, CP, palpitations, numbness,
hyperventilation
How is postpartum psychosis
characterized?
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1-2 in 1000 women affected
Agitation and anger
Anxiety/Paranoia
Insomnia/Delirium/Confusion
Mania (hyperactivity, elated mood)
Suicidal or homicidal thoughts
Auditory hallucinations (about the baby, of a religious
nature)
• Visual hallucinations (seeing or feeling “a presence” or
“darkness”)
• Delusions and commands to harm the infant (not just an
obsessive thought)
EMERGENCY: PSYCHIATRIC HOSPITALIZATION NECESSARY
What is the risk of suicide in the
postpartum period?
• “Suicides account for up to 20% of all
postpartum deaths and represent one
of the leading causes of peripartum
mortality.” (2005 in Archives of Women’s Mental Health)
What is different about postpartum depression
versus depression at other times of life?
• Sleep deprivation is the norm postpartum
• Strong societal expectations about maternal
happiness postpartum
• 50% of postpartum depression goes undiagnosed
• Postpartum depression affects mothers, children,
partners, and families
How does maternal depression relate to
pregnancy outcomes?
• Maternal effects
• Low weight gain
• Increased use of cigarettes, alcohol, other substances
• Ambivalence regarding the pregnancy
• Neonatal/infant effects
• Increased preterm birth
• Low birth weight
• Higher cortisol levels (sustained through adolescence)
How does postpartum depression affect
maternal behavior?
• Mothers who are depressed show
• Less affectionate behavior and impaired bonding
• Less response to infant cues
• More hostile/intrusive interactions with their infants
• Decreased rates of infant safety practices
What are the risks to children when
postpartum depression goes untreated?
• Children of mothers with untreated depression exhibit
• More fussiness and colic
• Impaired emotional development: fewer positive facial
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expressions
Poorer language development: less vocalization
Difficulties with attention
Decreased cognitive skills
Increased risk for long-term behavioral problems
• Remission of maternal depression improves children’s
mental and behavioral disorders
• Consider depression during pregnancy and
postpartum as an exposure with associated risks for
the infant!
When should you screen your patient for
postpartum depression?
• Any routine infant or maternal postpartum visit
• Special visits scheduled for following up on hx
of depression
• Example
• First newborn check at 2 or 3 days after d/c
• 2 weeks postpartum
• 4-6 weeks postpartum
What method will you use to screen her?
• Postpartum Depression Screening Scale
• 35-item Likert response scale (“Strongly Disagree” to
“Strongly Agree”)
• Third grade reading level
• Completed by patient in ~10 minutes
• Addresses seven areas
• Sleeping/Eating Disturbances
• Anxiety/Insecurity
• Emotional Lability
• Cognitive Impairment
• Loss of Self
• Guilt/Shame
• Contemplating Harming Oneself
What method will you use to screen her?
• Edinburgh Postnatal Depression Scale
• 10-item self-report scale (“Yes, most of the time” to “No, not at all”)
• Each item scores 0-3 points, max score 30, >10 is cutoff for
depression
• Available in several languages
• Intended for use at 6-8 weeks postpartum, but validated for use at
other times
• Completed by patient in ~5 minutes
• Addresses symptoms of
• Inability to laugh
• Inability to look forward to things with enjoyment
• Blaming oneself unnecessarily
• Feeling anxious or worried
• Feeling scared or panicky
• Feeling that “things have been getting on top of me”
• Difficulty sleeping because of unhappiness
• Feeling sad or miserable
• Crying
• Thoughts of harming oneself
How do the two screening methods
compare?
• Postpartum Depression Screening Scale
• For combined major and minor postpartum depression
• sensitivity 91%
• specificity 72%
• Edinburgh Postnatal Depression Scale
• For combined major and minor postpartum depression
• Sensitivity 68-80%
• Specificity 77%
Which antidepressants can be used while
breastfeeding?
• Sertraline (Zoloft) currently favored SSRI during
breastfeeding
• Short half-life
• Low or undetectable infant plasma levels
• More follow-up data on infant development
• Paroxetine (Paxil) and fluvoxamine (Luvox) also show low
infant plasma levels
• Use following with caution in patients w/ prior good effect
• Fluoxetine (Prozac)--long half-life
• Citalopram (Celexa)--high breast milk concentration
What else do we know about
antidepressant use while breastfeeding?
• Omega-3 fatty acids showed significant response
rate in one open-label study
• Medication exposure to fetus via placental
transfer is almost always greater than to the
newborn via breastfeeding
• Most national guidelines recommend six months
of treatment once depression is in remission
What are non-pharmacological options for
treatment of postpartum depression?
• Cochrane Review: any psychosocial or
psychological intervention, compared to usual
postpartum care, is associated with reduction in
risk of continued postpartum depression
• Breastfeeding may be somewhat protective
against postpartum depression (oxytocin
release?)
What are non-pharmacological options for
treatment of postpartum depression?
• Cognitive Behavioral Therapy
• Good results w/ group approach
• 10-40% fail to complete full treatment (similar to
pharmacotherapy)
• May have enduring effects not seen w/
pharmacotherapy (up to two years)
• Six sessions of non-directive counseling w/ child
health nurses was more effective than routine
primary care in Sweden
• Telephone-based peer support out-performed
care as usual (five 30-minute conversations)
Back to your patient…
• You see Josie frequently in clinic in the early postpartum period
(newborn checkups and her own visit)
• At two weeks postpartum
• She describes low energy, worrying that she is not a good mom,
difficulty sleeping, prolonged episodes of crying
• Denies SI/HI, hallucinations, etc.
• Is able to care for her baby but not enjoying it much
• You review options for treatment of postpartum depression,
including risks of no treatment
• She elects to start medication
• Used sertraline with good effect previously, so you rx 50mg daily
• You see her in f/u in 2 weeks
• Feeling better, no mania, bonding with baby, but some sx’s persist
• You increase sertraline to 100mg daily and schedule her back in 2
weeks
How can her partner
and family members help?
• Mothers without social support twice as
likely to develop postpartum
depression
• Among Latina women, those satisfied
with marital/partner relationships
showed lower risk of depressive sx’s
postpartum
• Among high risk women, better social
support  quicker improvement in
depressive sx’s
• Educate partner about signs of
mania/hypomania: can be uncovered
w/ use of SSRI. Also educate about
the importance of treatment!
Evaluation and Treatment of
Postpartum Thromboembolic Disease
How do patients with thromboembolic disease
present in the postpartum period?
• Silvia is a 37 y/o G5P5 at 9 days s/p repeat c/s
performed at 37 wks for pre-eclampsia
• She has a BMI of 43
• She presents w/ increasing left leg pain and
swelling for 2 days
• On exam, you note the left calf is 4cm larger in
circumference than the right and is tender to
palpation and slightly erythematous
• She has no dyspnea, tachypnea, or hypoxia
What are the risk factors for thromboembolic disease
in the postpartum period?
• Age > 35
• BMI > 30
• Grand multiparity
• Fam hx of VTE/thrombophilia
• Bed rest
• Immobility for > 4 days
• Pre-eclampsia
• Severe varicose veins
Virtualmedicalcentre.com
• Cesarean delivery (OR 13.3, 95% CI 3.4-51.4)
What is the incidence of VTE in
postpartum women?
• 0.5-3.0 per 1000 pregnancies
• Equal incidence in each trimester and postpartum
• 90% of DVTs in pregnancy are in the left leg
• PE is more frequent in the postpartum period
than during pregnancy (RR 15.0, 95% CI 5.143.9)
How is VTE diagnosed in the
postpartum period?
• Venous compression ultrasonography is the
preferred test for dx of DVT
• 89-96% sensitive and 94-99% specific for
symptomatic proximal LE DVT in non-pregnant
patients
• Current spiral CT technology is comparable to
pulmonary angiography in positive and negative
predictive values for PE
• CT delivers more radiation to the breast than V/Q
scan, which may be preferred in those w/ family
hx of breast cancer
How is VTE treated in the postpartum
period?
• Warfarin can be started at the same time as low molecular
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weight heparin or unfractionated heparin
LMWH (1 mg/kg SC bid) or UFH (80 units/kg loading dose
iv, then continuous iv infusion of 18 units/hour, or 17,500
units SC q12h)
aPTT goal is 1.5-2.0 X upper limits of normal
Continue LMWH or UFH until INR is 2.0-3.0 for 2
consecutive days
Treat until 3-6 months post-diagnosis and for at least 6
weeks postpartum
Back to your patient…
• Her risk factors are: age, c/s, pre-e, obesity
• Her LE doppler confirms left DVT
• She is appropriate for outpatient treatment
• Given LMWH 100mg SC in OBT
• Rx for bid LMWH is phoned to her pharmacy and emergency prior
authorization is approved
• She also starts warfarin and is given a f/u appt in the Coumadin
Clinic
• Is that okay for breastfeeding moms?Yes
• Should she be given prophylaxis in a subsequent
pregnancy?
• Yes: She falls under the criteria of “no known thrombophilia with
previous single episode of VTE associated with transient risk factor
that was pregnancy- or estrogen-related.”
Endomyometritis, C-section Wound
Infections, and Perineal Wound
Complications
A postpartum woman with fever…
• Delia is a 32 y/o G1P1, 7 days s/p c/s for failure
to progress following induction for GDMA2
• Complains of onset of fever and chills yesterday
evening, resolved w/ ibuprofen overnight,
recurrent this morning with temp 102 at home
• Reports her VB has increased slightly in the last
24h, notes a foul vaginal odor and some vague
abdominal pain
How does postpartum endomyometritis present
and what are the pathogens involved?
• Temp > 38.0 (100.4), chills
• Uterine tenderness
• Foul lochia
• Lower abdominal pain
• Fundus soft instead of firm, sub-involuted (above umbilicus,
excessive VB)
• Microbiology
• Usually mixture of 2-3 aerobes and anaerobes, including gram pos
and neg; rarely GC/CT
• Rare but potentially lethal bacteria: clostridium sordellii, clostridium
perfringens, strep or staph toxic shock
What are risk factors for postpartum
endomyometritis?
• C/s = most important
• Prolonged labor or ROM
• Lots of cervical exams
• Internal monitors in labor
• Manual placenta extraction
• Maternal DM or severe anemia
• BV or GBS colonization
How is postpartum endomyometritis
evaluated and diagnosed?
• Physical exam
• Fever, tachycardia
• Uterine tenderness on abdominal or bimanual exam
• Look for findings associated with other causes of fever, such as
surgical site infection, pelvic abscess, mastitis, UTI/pyelo, DVT/PE
• Rising neutrophil count w/ increased bands (WBCs commonly
elevated in labor, but should not continue to rise postpartum)
• Blood cx
• GC/CT if not done prior, positive earlier in pregnancy, or patient
at increased risk
• Imaging usually not indicated unless fever is persistent after
48-72h of abx or VB is heavy (fluid/debris/gas in uterus can be
normal)
How is postpartum endomyometritis
treated?
• Clindamycin 900mg iv q8h plus gentamicin 5mg/kg q24h (or
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1.5mg/kg iv q8h), w/ 90-97% cure rate
Treat until clinically improved and afebrile X 24-48h; further oral
tx not required unless bacteremia present based on positive
blood cx
If fever persistent, add ampicillin, vs. change to
ampicillin/sulbactam (Unasyn)1.5g iv q6h, which can also be
used first-line
Uterine suction currettage occasionally required to remove
POCs shown on U/S (if not improving or bleeding heavy)
In late postpartum endomyometritis (1-6 weeks postpartum and
usually milder sx’s, 15% of all disease), amoxicillin-clavulanate
875mg po bid X 7 days is acceptable
What if your patient presented with no fever, but
increased pain at her c/s incision site?
• Risk factors for c/s wound infection similar to endomyometritis
• Wound appears erythematous and induration can be palpated
• Evaluate for seroma, hematoma, or abscess, including probing
down to the fascia w/ a sterile cotton-tipped applicator if the
wound opens
• Wound aspirate (rather than swab) for cx
• After drainage of an abcess/opening the wound, irrigate and
pack w/ sterile gauze, w/ healing by secondary intention
• Antibiotics
• Cephalexin 500mg po qid X 7 days
• Clindamycin if MRSA suspected
• Both are fine for breastfeeding
• Close follow up is important
amamasblog.com
How do postpartum patients with perineal
laceration complications present?
• Tanya is a 20 y/o G1P1 s/p vacuum-assisted vaginal
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delivery for failure to descend and fetal intolerance of
labor
She had a second degree perineal laceration repaired
She presents 3 days postpartum with perineal pain
She reports a subjective fever at home, but is afebrile in
your office, with no recent antipyretic use
On perineal exam, no erythema, sutures appear intact, no
foul-smelling discharge, external anal sphincter and
rectovaginal septum intact, but a hematoma is noted of
the left labia
What is the differential diagnosis and treatment
for perineal pain postpartum?
• Labial/vaginal hematoma: incise, evacuate, and ligate the
bleeding vessel(s) if continues to expand or appears
infected; if stable and not large, may resorb
spontaneously
Williams Obstetrics, 23 Ed.
What is the differential diagnosis and
treatment for perineal pain postpartum?
• Perineal infection
• Open any organized abscess (imaging may be required to assess
for tracking of the abscess into deep tissues)
• Consider removing suture material
• Verify that a third or fourth degree laceration has not been
overlooked
• Antibiotics (may require admission)
• Look for hemorrhoids and anal fissures, treat accordingly
• Discuss in private whether pressured/forced to have sex
before completely healed
Back to your patient…
• Delia has endomyometritis by hx and exam
• Admitted for iv gent and clinda
• Becomes afebrile after 18 hours of abx
• Tx’d until afebrile for 24h and no fundal tenderness, then abx d/c’d
and observed for 24h off abx, remained afebrile
• Tanya has a 3 X 3 cm labial hematoma
• She states “that lump has been there since a few hours after the
delivery” and “it’s the same size as yesterday”
• Vitals are normal
• There is no surrounding erythema or induration
• You elect conservative management, give precautions, and bring
her back in 48h for re-examination
Management of
Breastfeeding Difficulties
What types of breastfeeding
difficulties do women
encounter postpartum?
• Cassandra is a 28 y/o G1P1, 10 days s/p term NSVD
• Exclusively breastfeeding, 3 days of breast pain
• Nipple pain starts at latch and lasts entire feeding, plus
shooting pains that radiate from nipple back into breast
occurring w/ letdown and feeding
• No fevers, chills, or body aches
• Nipples and areolae are bright pink; cracks and fissures
on both nipples; no other erythema, warmth, induration or
fluctuance
• Baby appears to have oral thrush
How is breast candidiasis evaluated?
• Pain from intraductal yeast infections is often described as
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shooting and radiates from nipple to chest wall, and is out of
proportion to the clinical exam
Nipple/areola may appear shiny or flaky
Skin scraping for microscopy
Positive breast milk culture
Often associated w/ other yeast infections in the infant, such as
thrush or diaper area dermatitis
There is not universal agreement among clinicians and
researchers regarding the existence of this clinical entity
How is breast candidiasis
treated?
Blisstree.com
• Infant and mother treated
• Topical nystatin or gentian violet for infant
• Topical nystatin, miconazole, or ketoconazole for mother if
infection seems to be cutaneous only (not intraductal)
• Another option is oral fluconazole (Diflucan) for mom, +/baby (not FDA approved, but used frequently for moms)
• Mother: 400mg po on day one, then 200mg po daily X
at least 10 days
• Infant: 6-12mg/kg po on day one, then 3-6mg/kg po
daily X at least 10 days
What are the risk factors for mastitis?
• Most common in 2nd and 3rd weeks postpartum (75-95%
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occurring before infant is 3 mos of age)
Poor breastfeeding technique
Infant cleft lip/palate or short frenulum
Cracked nipples
Missed feeding(s)
Nipple piercing
Poor maternal nutrition
Plastic-backed breast pads, tight bra
Yeast infection
Manual pump use
Breastfeedingbasics.com
What interventions can decrease the risk
of mastitis?
• Improve breastfeeding technique and latch
• Apply expressed breast milk or lanolin to nipples
and areolae
• Treat yeast infections
• Consider frenotomy
How is mastitis diagnosed and treated?
• Localized, unilateral breast tenderness and erythema
• Fever, malaise, fatigue, body aches, headache
• Breast milk cultures rarely indicated, unless infection fails
to respond to tx
• Most common organism is S. aureus
• Treat with antibiotics and improving breastfeeding
technique
• Complete emptying of the breast is key, and breastfeeding
should continue; this decreases risk of abscess
How is mastitis diagnosed and treated?
• Antibiotic choices
• Amox/clav 875 mg po bid
• Cephalexin 500 mg po qid
• Clindamycin 300 mg po qid
• Dicloxacillin 500 mg po qid
• TMP/SMX 160/800 mg po bid (avoid in mothers of infants < 2mos
or sick infants of any age)
• Duration of tx usually 10-14 days
• Abscess should undergo I&D or needle
aspiration, w/ fluid sent for culture, and
breastfeeding can usually continue
Another patient with breastfeeding difficulties…
• Noemi is a 24 y/o G2P2 s/p NSVD at 36 weeks following
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spontaneous preterm labor
Mother and infant discharged home at 2 days postpartum,
w/ LATCH score of 7-8
Followed closely in clinic for infant weight gain
Infant is now 6 weeks old, and mom returned to work 2
weeks ago
Having a hard time pumping at work, and thinks milk
supply is decreasing
Baby’s grandma has been giving an ounce or two of
formula, along w/ EMB, while mom at work
Why should we promote exclusive
breastfeeding?
Human milk provides
• Nutrients and energy for rapid growth and development
• Protective factors against infection
• Otitis media, diarrheal illness, upper respiratory infection
• Decreases pain and suffering
• Reduces lost work time for parents
• Chronic disease prevention
• Diabetes mellitus
• Celiac disease
• Childhood cancers
• Atopic disease
• Multiple sclerosis
• Inflammatory bowel disease
What are the costs of suboptimal
breastfeeding in the U.S.?
• 2010 study by Bartlick and Reinhold, published in the
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journal Pediatrics
Looked only at costs of pediatric diseases
Used “2007 dollars”
If 90% of US families breastfed exclusively for 6 months,
the U.S. would save $13 billion and prevent 911 deaths
At 80% compliance, savings would be $10.5 billion and
741 deaths
What are current breastfeeding
recommendations?
• American Academy of Pediatrics and American
Academy of Family Physicians
• 4-6 months exclusively
• Continue for at least 1 year
• World Health Organization
• 4-6 months exclusively
• Continue for at least two years
How can we help women maintain/increase
breast milk production?
• Avoid introduction of formula
• Pump q 3h when away from baby
• Pump immediately after each feed
• Adequate rest, nutrition, and hydration for
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mother
Have a “nurse-in”
Natural products: mother’s milk tea,
oatmeal, etc.
Metoclopromide course for mom: 10 mg
po tid X 10 days (or other regimens/drugs)
Advocate for breastfeeding-friendly
policies in your own workplace and
community!
Evaluation and Management of
Newborn Jaundice
A newborn at risk for hyperbilirubinemia…
• Baby Girl T was delivered to a 40 y/o G1P0 at 35 6/7 wks
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GA via emergent c/s for fetal bradycardia occurring
following combined spinal-epidural for planned external
cephalic version in setting of PPROM and breech
DOB 5-13-15 at 05:50, Apgars 3 & 9, L&D BW 2260g
PPV at delivery, MBU for couplet care, MBU BW 2240g
Initial bili 7.2 at 28 hours of life
Coombs negative
Exclusively breastfed
D/c’d home day 3, f/u day 5 with bili of 20.3, wt 2120g
How is newborn jaundice evaluated in the
outpatient setting?
• Is breast milk intake adequate?
• Insufficient intakedecreased stool
productionincreased reabsorption of bili from
gutelevated unconjugated (indirect) bili
• Weight loss or insufficient gain?
• Poor urine or stool output? Persistent meconium stools?
• Elevated bililethargy and poor feedinghigher bili
• Inadequate intakedehydration, malnutrition, risk of
kernicterus
• Often called “breastfeeding jaundice” but should be
called “not-enough-breastfeeding jaundice”
How is newborn jaundice evaluated in the
outpatient setting?
• Are there risk factors for hemolysis?
• Polycythemia
• Cephalohematoma or bruising at birth
• ABO incompatibility or Rh isoimmunization
• Red cell glucose metabolism enzyme deficiencies:
pyruvate kinase
• Hereditary spherocytosis or other RBC membrane
abnormalities
Could it be breast milk jaundice? What is that?
• Presents in the first or second week of life
• Can persist for up to 12 weeks
• Resolves spontaneously
• Incidence 36% in exclusively breastfed infants
• Hypothesized to involve a breast milk component that
increases enterohepatic circulation of bilirubin
• Weight gain, stool/urine output, and physical exam should
all be normal
• Total serum bili in breast milk jaundice alone should be <
12 mg/dl
• Conjugated (direct) bili should be less than 1mg/dl
How can you be sure it’s just breast milk
jaundice?
• If direct bili <1 but total bili is >12, additional evaluation is
needed
• First r/o hemolysis: hct or hgb, reticulocyte count, coombs, peripheral
smear
• Test for G6PD deficiency
• People of African, Asian, Latino, Mediterranean and Middle Eastern descent
at higher risk
• 4.9% of world’s population affected: 12% of African American men, 4.3% of
Asian American men
• X-linked, but can also affect females
• Risk of false negative test from larger amount of G6PD in young RBCs,
more released w/ hemolysis—consider retesting when jaundice is resolved
• Review newborn metabolic screen results
• Consider parental bili levels for Gilbert’s
• Testing for all UGT 1A1 mutations is not readily available, but some
are obtained w/ newborn metabolic screening
What does UGT 1A1 do and what are the
associated mutations?
• UGT 1A1 (uridine diphosphate glucuronosyltransferase 1A1) =
hepatic enzyme that conjugates bilirubin
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After conjugation, bili travels to small intestine in bile
Intestinal flora converts it to stercobilin
Stercobilin is excreted in stool
Beta-glucuronidase can deconjugate bili
Deconjugated bili is absorbed by intestinal mucosa and returned to
liver via portal circulation (enterohepatic circulation)
• UGT 1A1 mutations
• Crigler-Najjar type I: 1 in 1 million babies, no enzyme production,
critically high bili, kernicterus and death if untx’d in newborn period,
most die later in life of kernicterus; liver transplant is currative
• Crigler-Najjar type II: indolent course, elevated bili but below LL,
responds to phenobarb which induces UGT 1A1 production
• Gilbert’s syndrome: ~8% prevalence, eznyme levels 1/3rd to 1/10th of
normal, mild effect on bili but could be additive w/ another cause
What are some other non-hemolytic
etiologies?
• Biliary atresia
• Neonatal hepatitis
• Galactosemia
• Hypothyroidism
• Pyloric stenosis
• Annular pancreas
• Duodenal or jejunal atresia
• Sepsis
• Medication exposures: ceftriaxone, dicloxicillin,
sulphonamides
Our patient’s clinical course…
Date
Time
Bili
Tx Level
5/14
09:45
7.2
10.5
Observe
5/15
07:00
10.0
13.2
Observe
5/16
06:00
13.8
15.5
2100
D/c home
5/18
08:45
20.3
18
2120
Admit for photo tx
5/18
21:00
15.0
18
5/19
08:30
10.7
18
5/22
10:45
14.1
5/28
09:15
18.0
(dir=0.4)
2330
MCH consulted, feed freq’ly, f/u for wt
6/1
15:45
17.8
(dir=0.4)
2410
F/u 4-7d
6/8
09:30
19.7
(dir=0.6)
2330
Wt loss noted, MCH consulted w/ plan to
admit, PCP rec = no admit, supplement
w/ formula, G6PD, retic, repeat coombs.
6/9
15:15
16.2
(dir=0.5)
2380
On-call resident leaves vm for mom to go
to Peds ED. Email communication b/w
mom and PCP that Peds ED not needed.
2450
Got 30cc formula after each breast feed.
6/10
6/11
11:45
12.7
Weight
Action
Continue photo tx
2150
D/c photo tx and d/c home
F/u in 6d
Mom notified by PCP, continuing care at
Phototherapy Guidelines
Newborn Jaundice Clinical Decision Making Pathway
Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed (2010). doi:10.1136/adc.2010.184416
References
• Bartick M. Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost
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analysis. Pediatrics. 2010 May;125(5):e1048-56.
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