From the Guidelines
Exchange transfusion in newborns with hyperbilirubinemia is recommended when the total serum bilirubin (TSB) level reaches specific thresholds, such as 25-30 mg/dL (428-513 mmol/L), despite intensive phototherapy, or when there are signs of acute bilirubin encephalopathy, as indicated in the guidelines for exchange transfusion in infants 35 or more weeks’ gestation 1. The criteria for exchange transfusion vary based on gestational age and risk factors, with lower thresholds for premature infants, those with hemolytic disease, or those with risk factors such as sepsis, acidosis, or hypoalbuminemia.
- For infants 38 0/7 weeks of gestation, exchange transfusion should be considered when the TSB level is above 25-30 mg/dL (428-513 mmol/L) or when the bilirubin/albumin (B/A) ratio exceeds 8.0, as suggested by the guidelines 1.
- For infants 35 0/7–36 6/7 weeks of gestation and well, or 38 0/7 weeks if higher risk or isoimmune hemolytic disease or G6PD deficiency, exchange transfusion should be considered when the TSB level is above 25-30 mg/dL (428-513 mmol/L) or when the B/A ratio exceeds 7.2, as indicated in the guidelines 1.
- For infants 35 0/7–37 6/7 weeks of gestation if higher risk or isoimmune hemolytic disease or G6PD deficiency, exchange transfusion should be considered when the TSB level is above 25-30 mg/dL (428-513 mmol/L) or when the B/A ratio exceeds 6.8, as suggested by the guidelines 1. The procedure involves removing small aliquots of the infant's blood and replacing it with donor blood, continuing until approximately twice the infant's blood volume has been exchanged, which removes about 50% of the circulating bilirubin and provides fresh albumin for binding remaining bilirubin, as described in the management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation 1.
From the Research
Criteria for Exchange Transfusion
The criteria for exchange transfusion in newborns with hyperbilirubinemia are based on several factors, including:
- The level of bilirubin in the blood [ 2 ]
- The presence of risk factors for bilirubin-related neurotoxicity, such as prematurity or hemolytic diseases [ 3 ]
- The gestational age of the newborn [ 3 ]
- The presence of neurotoxicity risk factors, such as hemolytic diseases [ 3 ]
Bilirubin/Albumin Ratio
The bilirubin/albumin ratio has been proposed as a reliable indicator of bilirubin-albumin binding and can be used to eliminate potential ambiguity in exchange transfusion criteria [ 2 ]
- The bilirubin/albumin ratio can be used to determine the risk of bilirubin-related neurotoxicity [ 2 ]
- The frequency curves for each unbound bilirubin concentration plotted against the bilirubin/albumin ratio were tested for normality [ 2 ]
Guidelines for Exchange Transfusion
The American Academy of Pediatrics (AAP) has released guidelines for the management of neonatal hyperbilirubinemia, including the use of exchange transfusion [ 3 ]
- The AAP recommends universal neonatal hyperbilirubinemia screening in newborns 35 weeks' gestational age or greater [ 3 ]
- The AAP also recommends the use of phototherapy to reduce the need for exchange transfusion [ 3 ]
Management of Jaundice
The management of jaundice in newborns depends on the underlying cause and the level of bilirubin in the blood [ 4 ]
- Phototherapy is a simple and effective way to reduce the bilirubin level [ 4 ]
- Exchange transfusion may be necessary in cases of severe hyperbilirubinemia or kernicterus [ 5 ]
Alloimmune Hemolytic Disease
Alloimmune hemolytic disease is a condition that occurs when fetal and neonatal erythroid cells are destroyed by maternal erythrocyte alloantibodies [ 6 ]