Is a bilirubin level of 250 micromoles per liter (hyperbilirubinemia) at 120 hours of age, following 24 hours of phototherapy, a normal and acceptable level for a newborn who had a bilirubin level of 175 micromoles per liter at day 3 and 185 micromoles per liter at day 4?

From the Guidelines

The bilirubin level of 250 micromoles per liter at 120 hours of age, following 24 hours of phototherapy, is not a normal and acceptable level for a newborn who had a bilirubin level of 175 micromoles per liter at day 3 and 185 micromoles per liter at day 4, and requires immediate medical attention to prevent potential kernicterus. This level exceeds safe thresholds for this age and puts the baby at risk for brain damage from high bilirubin. According to the most recent guidelines on phototherapy to prevent severe neonatal hyperbilirubinemia 1, the decision to discontinue phototherapy should be individualized, considering the TSB level at which phototherapy was initiated, the cause of the hyperbilirubinemia, and the risk of rebound hyperbilirubinemia.

Key Considerations

• The infant's bilirubin level increased significantly after phototherapy was discontinued, suggesting an ongoing process causing bilirubin production to exceed the infant's elimination capacity.
• The guidelines recommend evaluating the underlying cause or causes of hyperbilirubinemia in infants who require phototherapy, including measuring glucose-6-phosphate dehydrogenase enzyme activity in any infant with jaundice of unknown cause whose TSB rises despite intensive phototherapy 1.
• Phototherapy should be restarted immediately, and the infant should be evaluated for underlying causes of persistent hyperbilirubinemia, such as hemolysis, infection, or metabolic disorders.

Recommended Course of Action

• Restart phototherapy immediately to reduce the bilirubin level and prevent further increase.
• Evaluate the infant for underlying causes of persistent hyperbilirubinemia, including hemolysis, infection, or metabolic disorders.
• Consider more intensive phototherapy with multiple light sources, possible exchange transfusion if levels continue to rise or remain dangerously high, and close monitoring of bilirubin levels every 4-6 hours.
• Ensure adequate hydration and feeding to promote bilirubin excretion. The most recent and highest quality study on this topic, published in 2024 in the journal Pediatrics 1, provides guidance on the use of phototherapy to prevent severe neonatal hyperbilirubinemia, including the timing of intervention and the evaluation of underlying causes of hyperbilirubinemia.

From the Research

Bilirubin Levels and Phototherapy

• The provided bilirubin levels for the newborn are 175 micromoles per liter at day 3 and 185 micromoles per liter at day 4, followed by 24 hours of phototherapy, resulting in a level of 250 micromoles per liter at 120 hours of age 2, 3.
• Studies have shown that phototherapy is effective in reducing bilirubin levels in newborns with hyperbilirubinemia, with some research indicating that it can be more effective than exchange transfusion in achieving prolonged reduction of bilirubin levels 2, 4.
• However, rebound in serum bilirubin levels after phototherapy is a concern, with one study finding that 7.3% of neonates developed significant bilirubin rebound after intensive phototherapy 5.
• Another study found that the use of intensive phototherapy can lead to a sustained reduction of bilirubin levels and prevent neurological complications, but the effectiveness of phototherapy may depend on various factors, including the initial bilirubin level and the duration of treatment 2, 6.

Factors Affecting Bilirubin Levels

• Birth weight, gestational age, and the onset of jaundice can be risk factors for significant bilirubin rebound after phototherapy 5.
• The effectiveness of phototherapy may also depend on the type and intensity of the phototherapy used, with some studies suggesting that double phototherapy may be more effective in reducing bilirubin levels in certain cases 6.
• The American Academy of Pediatrics recommends monitoring bilirubin levels after phototherapy to detect any rebound, especially in infants with risk factors for severe hyperbilirubinemia 3.

Comparison of Treatment Options

• Phototherapy has been shown to be a safer and more convenient form of therapy compared to exchange transfusion, with fewer risks and complications 2, 4.
• However, exchange transfusion may still be necessary in some cases, especially when bilirubin levels are extremely high or when phototherapy is not effective 2, 4.
• The choice of treatment ultimately depends on the individual case and the clinical judgment of the healthcare provider, taking into account factors such as the severity of hyperbilirubinemia, the presence of risk factors, and the effectiveness of phototherapy 2, 3, 4.