Neonatal Jaundice — MCQs

10 questions

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?

Which of the following statements about Kernicterus is TRUE?

A term neonate, with a birth weight of 2700 g, who is otherwise well, and is exclusively breastfed, presents for routine evaluation. His total serum bilirubin is found to be 14mg/dl on day 5. What is the management?

In a term baby who is 72 hours old, breastfeeding well, and has a bilirubin level of 14 mg/dL, which of the following statements is true?

All are involved in bilirubin metabolism except?

An 11-year-old boy was brought to the outpatient clinic with intention tremor and poor scholastic performance. His sister has similar complaints. On examination, hepatomegaly is seen. The eye finding is shown in the image. What is the probable diagnosis?

All of the following are features of physiologic jaundice, except which of the following?

Estimation of the blood sugar is relevant in all except –

A preterm infant with poor respiration at birth starts throwing seizures at 10 hours after birth. Antiepileptic of choice shall be:

Q10

Which of the following is NOT included in the resuscitation of a neonate with HR < 60/min?

Neonatal Jaundice Indian Medical PG Practice Questions and MCQs

Question 1: 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?

A. Stop breast feeding and do phototherapy
B. Initiate exchange transfusion
C. Start iv fluids and give phototherapy
D. Start phototherapy and continue breast feeding (Correct Answer)

Explanation: ***Start phototherapy and continue breast feeding*** - For a 4-day-old, otherwise healthy, term neonate with a bilirubin level of 18 mg/dL, **phototherapy** is the recommended initial treatment to lower bilirubin levels and prevent **kernicterus**. - **Breastfeeding should be continued** as it is crucial for hydration and nutrition, and interruption is generally not needed unless the bilirubin levels are extremely high and unresponsive to phototherapy. *Stop breast feeding and do phototherapy* - **Stopping breastfeeding is usually not necessary** for a bilirubin level of 18 mg/dL in a healthy, term neonate, as the benefits of breast milk outweigh the risks associated with this level of jaundice. - While **phototherapy** is appropriate, discontinuing breastfeeding can lead to complications such as dehydration and decreased milk supply. *Initiate exchange transfusion* - **Exchange transfusion** is typically reserved for much higher bilirubin levels (e.g., >25 mg/dL in a term neonate) or when there are signs of **acute bilirubin encephalopathy**, which are not present here. - It is an invasive procedure with potential risks, making it unsuitable as a first-line treatment for this bilirubin level. *Start iv fluids and given phototherapy* - **Intravenous fluids** are generally not indicated for an otherwise well, breastfed neonate unless there are signs of significant dehydration, which is not mentioned in this scenario. - While **phototherapy** is appropriate, routine IV fluid administration can lead to **fluid overload** and is not standard practice in uncomplicated neonatal jaundice.

Question 2: Which of the following statements about Kernicterus is TRUE?

A. Prematurity is the primary cause of Kernicterus
B. Kernicterus is due to Unconjugated Hyperbilirubinemia (Correct Answer)
C. Kernicterus is not associated with increased morbidity.
D. Yellowish staining occurs primarily in the Cerebellum in Kernicterus

Explanation: ***Kernicterus is due to Unconjugated Hyperbilirubinemia*** - **Kernicterus** is a rare but severe neurological condition caused by **high levels of unconjugated bilirubin** in a newborn's blood. - **Unconjugated bilirubin** is lipophilic and can cross the **blood-brain barrier**, particularly when levels are excessively high or the barrier is compromised. *Prematurity is the primary cause of Kernicterus* - **Prematurity** is a **major risk factor** for kernicterus, as premature infants have immature livers, reduced albumin binding sites, and a less developed blood-brain barrier. - However, the primary cause is the **unconjugated hyperbilirubinemia** itself, which can occur in both term and preterm infants, though it is more common and severe in prematures. *Yellowish staining occurs primarily in the Cerebellum in Kernicterus* - While kernicterus does affect the **cerebellum**, the **primary and most characteristic sites** of bilirubin deposition are the **basal ganglia**, hippocampus, and brainstem nuclei. - The **basal ganglia** are the predominant target, not the cerebellum, making this statement anatomically incorrect. *Kernicterus is not associated with increased morbidity.* - Kernicterus is associated with **significant morbidity** and can lead to permanent neurological damage, including **cerebral palsy**, hearing loss, intellectual disabilities, and gaze abnormalities. - It is a medical emergency that requires prompt diagnosis and treatment to prevent long-term neurological sequelae.

Question 3: A term neonate, with a birth weight of 2700 g, who is otherwise well, and is exclusively breastfed, presents for routine evaluation. His total serum bilirubin is found to be 14mg/dl on day 5. What is the management?

A. No active treatment required (Correct Answer)
B. Stop breastfeeding for 2 days
C. Phototherapy
D. Exchange transfusion

Explanation: ***No active treatment required*** - A total serum bilirubin of **14 mg/dL** on day 5 in an otherwise well, exclusively breastfed term neonate (birth weight 2700g, which is >2500g) falls within the **physiologic jaundice range** and below thresholds for intervention. - This level is considered **normal for breastfed infants** at this age and does not warrant medical intervention as per current guidelines. *Stop breastfeeding for 2 days* - This intervention, known as **breast milk jaundice interruption**, is usually reserved for higher bilirubin levels or if there is concern for significant breast milk jaundice, which is not indicated here. - Temporarily stopping breastfeeding can disrupt the establishment of breastfeeding and is generally discouraged unless strictly necessary. *Phototherapy* - **Phototherapy** is indicated for bilirubin levels typically >15-18 mg/dL in a healthy term neonate on day 5, depending on risk factors, which this infant does not meet. - It works by converting unconjugated bilirubin into water-soluble isomers that can be excreted more easily. *Exchange transfusion* - **Exchange transfusion** is reserved for severe hyperbilirubinemia, usually with bilirubin levels approaching or exceeding 20-25 mg/dL, especially if there are signs of **acute bilirubin encephalopathy**. - This level is far below the threshold for such an invasive procedure.

Question 4: In a term baby who is 72 hours old, breastfeeding well, and has a bilirubin level of 14 mg/dL, which of the following statements is true?

A. Exchange transfusion
B. Continue to breastfeed (Correct Answer)
C. Phototherapy
D. None of the options

Explanation: ***Continue to breastfeed*** - A bilirubin level of **14 mg/dL at 72 hours of age** in a healthy, full-term, breastfeeding baby is usually within the range considered **physiological jaundice** and does not warrant stopping breastfeeding. - **Breastfeeding should continue** regardless of jaundice management, as interruption can cause a **decrease in milk supply** and may worsen jaundice by reducing bilirubin excretion through stool. - Continued breastfeeding (8-12 times per day) helps promote bilirubin clearance. *Exchange transfusion* - This is an **invasive procedure** reserved for very high bilirubin levels (typically **>20-25 mg/dL** in full-term infants depending on age and risk factors) or in cases of **acute bilirubin encephalopathy**. - A bilirubin level of 14 mg/dL is **well below the threshold** for exchange transfusion in a healthy term infant. *Phototherapy* - According to **AAP guidelines**, phototherapy thresholds are age-dependent: - At **72 hours of age**, phototherapy is typically considered at bilirubin levels **>15-18 mg/dL** in low-risk term infants. - At 14 mg/dL, **close monitoring** with repeat bilirubin measurement is appropriate, but phototherapy is generally **not yet indicated** for a healthy term infant without risk factors. *None of the options* - This option is incorrect because **continuing to breastfeed** is the appropriate and evidence-based management for this clinical scenario. - The other interventions (exchange transfusion, phototherapy) are **not indicated** at this bilirubin level and age in a healthy term infant.

Question 5: All are involved in bilirubin metabolism except?

A. Biliverdin reductase
B. Heme oxygenase
C. Glucuronyl transferase
D. ALA synthase (Correct Answer)

Explanation: ***ALA synthase*** - **ALA synthase** is the enzyme responsible for the first committed step in **heme synthesis**, not bilirubin metabolism. - It catalyzes the condensation of **succinyl CoA** and **glycine** to form δ-aminolevulinic acid (ALA). *Biliverdin reductase* - This enzyme catalyzes the conversion of **biliverdin**, a green pigment, into **unconjugated bilirubin**, a yellow pigment. - It is an essential step in the breakdown pathway of **heme** into bilirubin. *Heme oxygenase* - **Heme oxygenase** is the enzyme that cleaves the **heme ring** to form **biliverdin**, releasing carbon monoxide and iron. - This is the initial and rate-limiting step in **heme catabolism**, leading to bilirubin formation. *Glucuronyl transferase* - **UDP-glucuronyl transferase** (UGT) conjugates unconjugated bilirubin with **glucuronic acid** in the liver. - This conjugation process makes bilirubin water-soluble, allowing its excretion into the **bile**.

Question 6: An 11-year-old boy was brought to the outpatient clinic with intention tremor and poor scholastic performance. His sister has similar complaints. On examination, hepatomegaly is seen. The eye finding is shown in the image. What is the probable diagnosis?

A. Glutaric aciduria
B. Wilson's disease (Correct Answer)
C. Hepatitis A
D. Huntington's chorea

Explanation: ***Wilson's disease*** - The combination of **intention tremor**, **poor scholastic performance** (indicating neurological involvement), **hepatomegaly**, and the **eye finding** (Kayser-Fleischer ring seen in the image) points strongly to Wilson's disease. The sister having similar complaints suggests an **autosomal recessive** inheritance pattern, consistent with Wilson's disease. - The image shows **Kayser-Fleischer ring**, a golden-brown ring at the corneal limbus due to **copper deposition in Descemet's membrane**, which is pathognomonic for Wilson's disease with neurological involvement. - Wilson's disease is caused by mutations in the **ATP7B gene**, leading to impaired copper excretion and accumulation in the liver, brain, and cornea. *Glutaric aciduria* - This is a rare **autosomal recessive metabolic disorder** that primarily affects the brain, leading to **dystonia** and **developmental delay**. - While it can cause neurological symptoms, it typically does not present with **hepatomegaly** or **Kayser-Fleischer rings** as prominent features. *Hepatitis A* - **Hepatitis A** is an acute viral infection of the liver, causing symptoms like fever, fatigue, nausea, vomiting, and **jaundice**. - However, it typically does not cause **intention tremor**, **poor scholastic performance**, or have a familial pattern suggesting an inherited neurological disorder. It also does not cause Kayser-Fleischer rings. *Huntington's chorea* - **Huntington's chorea** is an **autosomal dominant neurodegenerative disorder** characterized by **chorea**, psychiatric symptoms, and cognitive decline, typically manifesting in adulthood. - It does not present with **hepatomegaly** or **Kayser-Fleischer rings** at this age and is not associated with the constellation of liver and neurological symptoms described.

Question 7: All of the following are features of physiologic jaundice, except which of the following?

A. Total bilirubin of less than 15 mg/dl
B. Disappearance of jaundice by 3-4 weeks in preterm infant
C. Jaundice visible within 24 hrs of age (Correct Answer)
D. Rate of rise of bilirubin less than 3 mg/dl per day

Explanation: ***Jaundice visible within 24 hrs of age*** - The appearance of **jaundice within the first 24 hours of life** is a hallmark of **pathologic jaundice**, not physiologic jaundice. - This early onset suggests a more serious underlying cause, such as **hemolytic disease of the newborn**, and warrants prompt investigation. *Total bilirubin of less than 15 mg/dl* - In physiologic jaundice, the **total serum bilirubin level** typically peaks at less than 15 mg/dL in full-term infants. - Higher bilirubin levels, especially above 15 mg/dL, would raise suspicion for a **pathologic cause**. *Disappearance of jaundice by 3-4 weeks in preterm infant* - While physiologic jaundice in full-term infants usually resolves by 1-2 weeks, in **preterm infants**, it can persist longer, up to 3-4 weeks. - This extended duration is due to the **immaturity of the preterm infant's liver** in conjugating bilirubin. *Rate of rise of bilirubin less than 3 mg/dl per day* - A gradual increase in bilirubin, with a rate of rise **less than 3 mg/dL per day**, is characteristic of physiologic jaundice. - A **rapid increase** (>5 mg/dL/day) is a red flag for **pathologic jaundice** and requires further evaluation.

Question 8: Estimation of the blood sugar is relevant in all except –

A. Large for date baby
B. Birth asphyxia
C. Rh Incompatibility
D. Baby of hypothyroid mother (Correct Answer)

Explanation: ***Baby of hypothyroid mother*** - While maternal hypothyroidism can affect fetal development and lead to various complications, it does not directly cause **neonatal hypoglycemia** or **hyperglycemia**, making routine blood sugar monitoring less critical unless other risk factors are present. - The primary concerns for a baby born to a hypothyroid mother are related to thyroid function itself, such as **congenital hypothyroidism**, not blood glucose dysregulation. *Large for date baby* - **Macrosomic infants**, especially those born to mothers with gestational diabetes, are at increased risk for **hypoglycemia** due to chronic fetal hyperinsulinemia. - Close monitoring of blood glucose levels is essential to prevent neurological damage from sustained low sugar. *Birth asphyxia* - Infants who experience **birth asphyxia** are under significant stress, which can deplete their glycogen stores and impair gluconeogenesis, leading to **hypoglycemia**. - Monitoring blood glucose is a critical component of their post-resuscitation care and management. *Rh Incompatibility* - Severe **Rh incompatibility** can lead to **hydrops fetalis** and other complications, including liver dysfunction and extramedullary hematopoiesis, which can impair glucose regulation. - These infants are at risk for both **hypoglycemia** due to increased metabolic demand and **hyperglycemia** secondary to stress and liver involvement, necessitating blood sugar monitoring.

Question 9: A preterm infant with poor respiration at birth starts throwing seizures at 10 hours after birth. Antiepileptic of choice shall be:

A. Phenobarbitone (Correct Answer)
B. Lorazepam
C. Levetiracetam
D. Phenytoin

Explanation: ***Phenobarbitone*** - **Phenobarbitone** is the **first-line antiepileptic drug** recommended for neonatal seizures due to its established efficacy and safety profile in this population. - It acts primarily by **potentiating GABAA receptor-mediated chloride currents**, leading to central nervous system depression and seizure control. *Lorazepam* - While **benzodiazepines** like lorazepam can be used for acute seizure cessation, especially status epilepticus, they are generally **not the first-line choice for maintenance therapy** due to potential sedation and respiratory depression in neonates. - Its short duration of action and risk of rebound seizures make it less suitable as a sole agent for ongoing seizure control. *Levetiracetam* - **Levetiracetam** is an increasingly common antiepileptic in neonates, but its long-term efficacy and safety, particularly regarding neurodevelopmental outcomes, are **still under investigation** compared to phenobarbitone. - While it may be used as a second-line agent or in specific situations, it is **not universally considered the first-line drug of choice** for neonatal seizures. *Phenytoin* - **Phenytoin** is typically considered a **second-line or third-line antiepileptic** for neonatal seizures, primarily used if phenobarbitone is ineffective. - Its use is limited by potential side effects such as **cardiac arrhythmias, hypotension, and infiltration at the injection site**, which can be particularly concerning in premature infants.

Question 10: Which of the following is NOT included in the resuscitation of a neonate with HR < 60/min?

A. Endotracheal tube intubation
B. Chest compression
C. Adrenaline
D. None of the above (Correct Answer)

Explanation: ***None of the above*** - All listed interventions—**endotracheal tube intubation**, **chest compressions**, and **adrenaline administration**—are standard components of neonatal resuscitation when the heart rate remains below 60 beats/min despite initial steps. - This question asks which is *NOT* included, implying that all options are, in fact, appropriate interventions in this critical scenario. *Endotracheal tube intubation* - This is a critical step in **securing the airway** and ensuring effective positive pressure ventilation when other methods fail or prolonged mechanical ventilation is anticipated. - It's indicated if the heart rate remains below 60 bpm despite adequate bag-mask ventilation and chest compressions. *Chest compression* - **Chest compressions** are initiated when the heart rate is less than 60 bpm *after* 30 seconds of effective positive pressure ventilation. - They are used in conjunction with positive pressure ventilation to improve cardiac output and myocardial perfusion. *Adrenaline* - **Adrenaline** is administered if the heart rate remains below 60 bpm *despite* adequate ventilation and chest compressions. - It acts as a potent **vasopressor** and **cardiac stimulant**, increasing heart rate and contractility.

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