Review baby with jaundice

You go to review the jaundiced baby in the ED.

Baby Orode is now 3 days old. She was born at 40+3 weeks with a birthweight of 4.2kg. There are no risk factors for sepsis identified. Mother is blood group B+ve and has sickle cell trait. Baby is breastfeeding well, and has opened her bowels and passed urine. On examination, her sclerae appear slightly yellow, but she appears otherwise well.

You decide to take a bilirubin level and blood group from baby. Shortly after taking baby Orode’s blood tests, you are fast-bleeped to see the poorly feeding baby.

You review the baby on postnatal ward. She is now 15 hours old.

Bella Potter was born at 41 weeks gestation with a birthweight of 3.0kg. Mum booked late in her pregnancy. Her initial scan at 17 weeks was reported normal, as was a subsequent scan at 22 weeks. This was mother’s first pregnancy. She used to smoke, but denied smoking during pregnancy. She is otherwise well and had no complications during her pregnancy. 

Bella was born vaginally following spontaneous onset of labour. Mother’s waters broke 18 hours before delivery. There was a history of meconium stained liquor at delivery, which was suctioned by the midwife. Baby cried at 30 seconds and was dried and warmed, with no further resuscitation required. Apgars were scored at 8 at 1 minute, 9 at 5 minutes. She has attempted to be bottle fed, but has taken around 20ml milk in total since birth.

Examination is undertaken:

Respiratory: RR 70/min, grunting, subcostal recessions. Clear breath sounds, air entry audible.

Cardiovascular: HR 170/min. Left arm cuff BP 70/38, MABP 40, no difference between upper and lower limb BP. Blue lips and peripheries noted. There is a grade 3 ejection systolic murmur at the left sternal edge which radiates across praecordium. Her heart sounds are normal. Femoral pulses palpable bilaterally. 

Abdomen: Not distended, soft on palpation. 1cm liver edge palpable below costal margin.

Neurological: Active and crying, moving all 4 limbs to stimulation. Normotensive anterior fontanelle. 

You call the registrar. When she arrives, the registrar tells you that a baby with signs of respiratory distress such as grunting, nasal flaring, sternal recessions and tachypnoea should always be reviewed promptly, as these are indicators of a sick baby.

You take the baby to the neonatal unit. Her oxygen saturations on right hand are 68%, right foot 69%. Left arm cuff BP 70/38, MABP 40, no difference between upper and lower limb BP.

You place the baby in 100% oxygen. Her oxygen saturations after 10 minutes are 70%. A cannula is sited and blood tests including full blood count, renal profile, liver function, CRP, and blood culture taken.

She is started on benzylpenicillin and gentamicin and given a 20ml/kg normal saline bolus. 

Capillary blood gas:

pH 7.27
pCO₂ 7.9 kPa
pO₂ 4.0 kPa 
HCO₃ 21.6 mmol/l
BE -2.4 mmol/l
Lactate 2.2 mmol/l
Glucose 4.1 mmol/l 

You request a chest x-ray:

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org.
From the case rID: 8049

The registrar calls the consultant for support.

What treatment option should be considered next?