From the Guidelines
Neonatal hyperbilirubinemia should be treated with intensive phototherapy using blue light (wavelength 460-490 nm) with maximum skin exposure, as recommended by the most recent guidelines 1. The goal of treatment is to reduce the risk of bilirubin neurotoxicity and prevent kernicterus, a condition that can cause permanent neurological damage. According to the technical report on phototherapy to prevent severe neonatal hyperbilirubinemia 1, phototherapy is an essential intervention for severe hyperbilirubinemia, especially in neonates at high risk. The report also highlights the importance of serial measurements of total serum/plasma bilirubin (TSB) concentrations and screening for the presence of intrinsic risk factors for bilirubin neurotoxicity.
Key considerations in the treatment of neonatal hyperbilirubinemia include:
- The use of TSB as the definitive diagnostic test to guide all interventions 1
- The measurement of TSB if the transcutaneous bilirubin (TcB) reading is within 3.0 mg/dL of the phototherapy treatment threshold, or if the TcB exceeds the phototherapy treatment threshold, or if the TcB is ≥15 mg/dL 1
- The evaluation of the underlying cause or causes of hyperbilirubinemia in infants who require phototherapy, including glucose-6-phosphate dehydrogenase enzyme activity measurement in infants with jaundice of unknown cause 1
- The discontinuation of phototherapy when the TSB has declined by 2 to 4 mg/dL below the hour-specific threshold at the initiation of phototherapy, with individualized consideration of the TSB level, cause of hyperbilirubinemia, and risk of rebound hyperbilirubinemia 1
In terms of the rate of response to phototherapy, a decrease in TSB concentrations of >2 mg/dL is expected within 4 hours of initiation, with a minimal reduction in the TSB concentration rise suggesting a "plateau effect" and partial response 1. The clinical impact of phototherapy should become evident within 4 hours of initiation, with timely implementation reducing the need for exchange transfusion and possibly minimizing the severity of bilirubin neurotoxicity.
Overall, the treatment of neonatal hyperbilirubinemia requires a comprehensive approach that includes intensive phototherapy, serial TSB measurements, and evaluation of the underlying cause of hyperbilirubinemia, with the goal of reducing the risk of bilirubin neurotoxicity and preventing kernicterus.
From the Research
Treatment Options for Hyperbilirubinemia in Neonates
- Conventional treatments for hyperbilirubinemia include hydration and phototherapy 2, 3
- Phototherapy is instituted when the total serum bilirubin level is at or above 15 mg per dL in infants 25 to 48 hours old, 18 mg per dL in infants 49 to 72 hours old, and 20 mg per dL in infants older than 72 hours 3
- Intravenous immunoglobulin (IVIG) has been proposed as an adjunct treatment to phototherapy to decrease the rate of exchange transfusion 4, 5, 6
Use of Intravenous Immunoglobulin (IVIG)
- IVIG has been shown to be safe and effective in reducing the need for exchange transfusion in neonates with isoimmune hemolytic disease 4, 5, 6
- The use of IVIG as an adjunct treatment to phototherapy may prevent the need for exchange transfusion in some babies 2
- IVIG doses ranged from 0.5 to 1.5 g/Kg in one to three administrations 5
Clinical Outcomes and Safety
- The IVIG group had more severe hemolysis with average highest bilirubin of 14.6 ± 3.7 mg/dL in the IVIG group versus 12.6 ± 3 in the control group (P = 0.0001) 4
- There were no side effects documented in all the included infants 4
- Apnea was the only complication seen in one (1.6%) patient 6
- IVIG treatment has been shown to be safe with low side effect rates 6