History Taking · Intermediate · Paediatrics

Neonatal Jaundice with Feeding Difficulty - One Week Old

Practise this PLAB 2 history taking station on Neonatal Jaundice. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the neonatal clinic. You see Simone, a seven-day-old girl, brought by her parents David and Katherine for assessment of persistent jaundice. The parents are concerned about inadequate feeding and yellow discolouration of Simone's skin that seems to be worsening. Please take a focused history, perform appropriate examination, and discuss investigation and management including phototherapy and exchange transfusion thresholds.

Background notes: PMH: Nil significant

What this station tests

  • Timing of onset as the critical assessment: within 24 hours is pathological emergency, day 2-14 is usually physiological
  • Breastfeeding assessment: frequency, latch, nappy output, weight trajectory
  • NICE NG98 treatment threshold chart: plotting bilirubin against age to determine phototherapy need
  • Biliary atresia screening: prolonged jaundice beyond 14 days with pale stools and dark urine needs urgent split bilirubin
  • Phototherapy explanation: blue light breaks down bilirubin in the skin, safe and effective

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Neonatal jaundice assessment hinges on the timing of onset: jaundice within 24 hours is pathological and urgent, while jaundice from day 2 to 14 is usually physiological but requires monitoring. Simone is 7 days old with persistent jaundice. Open with: 'Katherine and David, I can see you are worried about Simone's colour. Tell me when you first noticed the jaundice and how she has been feeding.'

Core approach

Timing is everything. Simone was not jaundiced at birth but developed it on day 2 to 3 (physiological timing). It has persisted to day 7 (still within the physiological window for breastfed infants, but needs monitoring). If it had appeared within 24 hours, this would be pathological (haemolysis, sepsis) and an emergency.

Assess feeding. Is she breastfed? (Yes.) Breastfeeding jaundice is common and usually benign but requires adequate intake assessment. How often is she feeding? (Every 2 to 3 hours.) Is she latching well? Are there enough wet and dirty nappies? (The minimum expected is 6 wet nappies per day by day 6.) Weight: has she regained birth weight? (Weight loss up to 10% in the first week is normal; failure to regain by day 10 to 14 is concerning.)

Screen for pathological causes. Blood group incompatibility (check mother and baby blood groups, Coombs test). Infection (is she febrile, lethargic, feeding poorly?). G6PD deficiency. Hypothyroidism (Guthrie test result). Biliary atresia (if jaundice persists beyond 14 days with pale stools and dark urine, urgent investigation needed).

Check bilirubin level. Transcutaneous bilirubinometry for screening, serum bilirubin for confirmation. Plot on the treatment threshold chart (NICE NG98) for gestational age and postnatal age.

Closing and safety netting

If bilirubin is below treatment threshold: reassure and arrange repeat measurement in 24 to 48 hours. Encourage frequent breastfeeding (8 to 12 times per 24 hours). If above threshold: phototherapy. Explain: 'Phototherapy uses a special blue light that helps break down the bilirubin in Simone's skin. It is very safe and effective.'

Prolonged jaundice safety netting: 'If the jaundice is still visible at 14 days, come back for a split bilirubin test. We specifically need to check for a condition called biliary atresia, which is rare but important to catch early.' Pale stools and dark urine are the red flags.

Reassure: 'Jaundice in the first week of life is very common, especially in breastfed babies. Most cases resolve on their own with continued feeding.' Address their anxiety without dismissing it.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for neonatal jaundice. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Onset timing established. Feeding assessed. Nappy output checked. Weight trajectory noted. Pathological causes screened (blood groups, infection, G6PD). Bilirubin measured.

Costs marks: Not establishing timing. Not assessing feeding. Not screening pathological causes.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Bilirubin plotted on NICE threshold chart. Phototherapy if indicated. Feeding advice. Prolonged jaundice safety netting at 14 days. Split bilirubin for biliary atresia screening.

Costs marks: Not knowing threshold chart. No prolonged jaundice safety netting. Not mentioning biliary atresia.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Reassuring about physiological jaundice being common. Normalising parental anxiety. Explaining phototherapy in simple terms. Encouraging continued breastfeeding.

Costs marks: Alarming unnecessarily. Suggesting stopping breastfeeding. Not explaining phototherapy.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not establishing the timing of onset. Jaundice within 24 hours is an emergency (haemolysis, sepsis). Day 2 to 3 onset is likely physiological. Candidates who do not ask when the jaundice first appeared cannot stratify urgency.
  2. Not assessing feeding adequacy. Breastfeeding jaundice is common, and inadequate intake worsens it. Candidates who check bilirubin without assessing feeding miss the commonest modifiable factor.
  3. Not mentioning biliary atresia screening at 14 days. Biliary atresia requires surgery within 60 days for best outcomes. Candidates who do not safety net for prolonged jaundice miss a time-critical diagnosis.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a neonatal jaundice history in PLAB 2?

Neonatal jaundice assessment hinges on the timing of onset: jaundice within 24 hours is pathological and urgent, while jaundice from day 2 to 14 is usually physiological but requires monitoring. Simone is 7 days old with persistent jaundice. Open with: 'Katherine and David, I can see you are worried about Simone's colour.

Where are marks won and lost in this neonatal jaundice station?

Examiners reward: Onset timing established. Feeding assessed. Nappy output checked. Weight trajectory noted. Pathological causes screened (blood groups, infection, G6PD). Candidates are penalised for: Not establishing timing. Not assessing feeding. Not screening pathological causes.

Where do candidates most often go wrong in this station?

Not establishing the timing of onset. Jaundice within 24 hours is an emergency (haemolysis, sepsis). Day 2 to 3 onset is likely physiological.

Can I do well in this station without real-world experience of neonatal jaundice?

This station rewards process over personal experience. The skill being assessed: Breastfeeding assessment: frequency, latch, nappy output, weight trajectory. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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