What is the management for a 19-day-old infant with hyperbilirubinemia (elevated bilirubin level of 13.7)?

From the Guidelines

Management for a 19-day-old infant with a bilirubin level of 13.7 mg/dL should prioritize distinguishing between conjugated and unconjugated hyperbilirubinemia and assessing for underlying conditions, with phototherapy considered based on the infant's age, bilirubin level, and risk factors, as guided by the most recent evidence from 1 and 1. The initial step is to measure direct and total bilirubin levels to determine the type of hyperbilirubinemia. If unconjugated hyperbilirubinemia is confirmed, the infant should be assessed for breastfeeding jaundice, breast milk jaundice, hemolysis, or other underlying conditions. Laboratory tests should include complete blood count, blood type, Coombs test, reticulocyte count, and liver function tests, as suggested by 1.

• Ensuring adequate hydration and frequent breastfeeding (8-12 times daily) is important, as noted in 1.
• If breast milk jaundice is suspected, continuation of breastfeeding is generally recommended as levels typically resolve spontaneously.
• Close follow-up within 24-48 hours is essential to monitor bilirubin trends, with the timing of follow-up measurements guided by the TSB trajectory and infant age, as recommended in 1.
• If the bilirubin level continues to rise or if conjugated hyperbilirubinemia is present (direct bilirubin >2 mg/dL or >20% of total), prompt referral to pediatric gastroenterology or hepatology is warranted to evaluate for conditions like biliary atresia, which requires timely intervention, as emphasized in 1. Phototherapy may be indicated depending on the infant's age, bilirubin level, and risk factors, though at 19 days it's less commonly needed than in the first week of life, and its use should be guided by the latest recommendations from 1 and 1.

From the Research

Management of Hyperbilirubinemia

The management of a 19-day-old infant with a bilirubin level of 13.7 involves careful evaluation and consideration of the risk of bilirubin-related neurotoxicity.

• The American Academy of Pediatrics (AAP) recommends universal neonatal hyperbilirubinemia screening in newborns 35 weeks' gestational age or greater 2.
• Phototherapy is a simple and effective way to reduce bilirubin levels, and is recommended for newborns who exceed thresholds recommended by the current AAP hour-specific phototherapy nomograms 2.
• The decision to initiate phototherapy should be based on the infant's gestational age, bilirubin level, and the presence of neurotoxicity risk factors 2, 3.

Risk Stratification

• The infant's risk of bilirubin-related neurotoxicity should be assessed, taking into account factors such as gestational age, birth weight, and the presence of hemolytic diseases 2, 3.
• Nomograms can be used to plot total serum bilirubin levels and determine the need for phototherapy or exchange transfusion 2, 3.

Treatment Thresholds

• The AAP recommends treatment thresholds for phototherapy based on gestational age and the presence of neurotoxicity risk factors, with higher thresholds than in previous guidelines 2.
• Exchange transfusion may be necessary in cases where phototherapy is not effective or the infant has a high risk of kernicterus 4, 5.
• The goal of treatment is to keep bilirubin levels below a certain threshold, which varies depending on the infant's gestational age and risk factors 2, 6.