Neonatal jaundice — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the bedside."

Model response — say it in this order: ^[1][3]

• "This is pathological, unconjugated, haemolytic jaundice of immune origin — onset in the first 24 hours, rapid rise, positive direct antiglobulin test in a rhesus-negative mother with anti-D antibodies. It is not physiological."
• "I would plot the bilirubin against postnatal age in hours on the gestational-age-stratified nomogram, applying the lower risk-factor threshold line because of the haemolysis."
• "He is at the phototherapy threshold with a rapid rise, so I would start intensive phototherapy now, ensure hydration, warmth and feeding, send the full haemolysis work-up, and recheck the bilirubin within 2 to 3 hours."^[1]

Examiner is listening for: the classification, the nomogram framework named, the risk-factor line applied, and the recheck interval. ^[1]

Probe 1 — "What is the framework you are using to set the threshold?"

• "The AAP 2022 clinical practice guideline (PMID 35927462), the NICE CG98 threshold graphs, and the Queensland Clinical Guidelines neonatal jaundice nomograms all apply the same principle: thresholds are read off a graph stratified by gestational age and postnatal age in hours, with a lower threshold applied when any neurotoxicity risk factor is present — haemolysis, prematurity, G6PD deficiency, sepsis, acidosis, or albumin under 30 g per litre."
• "This infant has immune haemolysis, so he sits on the lower risk-factor line, not the standard line."^[1][2]

Probe 2 — "His bilirubin is now 360 despite intensive phototherapy. What next?"

• "Intravenous immunoglobulin — indicated in immune-mediated haemolysis when the bilirubin continues to rise despite intensive phototherapy, with the aim of reducing the exchange rate."^[1]
• "And I would prepare for exchange transfusion — indicated when the bilirubin reaches the exchange threshold despite intensive phototherapy and IVIG, or at the first sign of acute bilirubin encephalopathy."^[1]
• "I would acknowledge the complications of exchange — thrombocytopenia, electrolyte disturbance, necrotising enterocolitis, and serious adverse events in a small minority — and reserve it for genuine threshold-crossing."^[5]

Probe 3 — "What are the long-term consequences of missing this?"

• "Acute bilirubin encephalopathy progressing to chronic kernicterus — the tetrad of athetoid cerebral palsy, sensorineural hearing loss, gaze palsy (especially upward gaze), and dental enamel dysplasia. Once established, the injury is largely irreversible."
• "The bilirubin that crosses the immature blood-brain barrier binds neurons in the basal ganglia, cochlear nuclei and brainstem. Prematurity, acidosis and hypoalbuminaemia all lower the barrier — which is why the risk-factor line matters."^[4]

Probe 4 — "The mother is in tears and asks if her baby has brain damage."

This is a scored communication domain. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, brief plainly: "Your baby's blood type and yours are not compatible in a way that has caused some of his red cells to break down faster than usual. That makes a substance called bilirubin, which is what makes him yellow. We are treating him with special lights to bring the level down. If the level keeps rising, we have other treatments ready."^[1]
• Acknowledge fear directly: "I know the word 'brain damage' is frightening. We are watching his level very closely and treating aggressively to keep it in a safe range. We will keep you informed at every step."
• Commit to a named person for questions and a debrief once the picture stabilises.

Probe 5 — "What is your discharge plan if he recovers?"

• "Stop phototherapy once the bilirubin has fallen at least 50 micromoles per litre below the threshold. Recheck at 24 hours for rebound — ongoing haemolysis can drive the bilirubin back up. Document a clear safety-net conversation: return if feeding poorly, lethargic, feverish, or if the colour deepens."^[1][3]