Neonatal hyperbilirubinemia: A case of complex management involving ABO incompatibility, sepsis, and suspected G6PD deficiency treated with methyl prednisolone.

Abstract

Newborn jaundice (NNJ), especially due to ABO incompatibility, is a major global health concern. Phototherapy is
the standard treatment, with exchange transfusions reserved for severe cases. However, in some babies these therapies
may be ineffective, requiring additional immunomodulatory treatments. Limited access to these treatments in
developing countries creates a critical gap, worsening jaundice severity. A 22-hour-old term neonate presented with
rapidly progressive severe neonatal hyperbilirubinemia (NNJ) within 15 hours of life, consistent with ABO
incompatibility based on discordant maternal and infant’s blood types (mother: O, baby: B-positive). Despite
aggressive initial management with phototherapy and exchange transfusions, the NNJ exhibited limited
improvement. Sepsis and G6PD deficiency were considered as potential contributing factors, although
confirmatory testing for G6PD deficiency was deferred due to unavailability of the diagnostic test in our setting.
Given a sibling's documented successful response to methylprednisolone for a similar presentation, a brief course
of low-dose intravenous methylprednisolone (1mg/kg/day in 2 divided doses) (off-label use) was cautiously
initiated. This resulted in a rapid and significant improvement in the neonate's hyperbilirubinemia.
Methylprednisolone was prescribed for 3 days after which it was discontinued. Following close observation for 3
days and confirmation of no neurological sequelae, the neonate was discharged home in stable condition.
Managing severe, worsening NNJ, especially with multiple aetiologies, is complex. Standard therapies may be
inadequate. While promising, immunomodulatory therapies like IVIG may be limited in resource-poor settings.
Methylprednisolone shows potential but lacks strong clinical evidence. Well-designed studies are essential to
explore its safety and efficacy, particularly in developing countries with limited treatment options.