What are the management strategies for newborns who develop hyperbilirubinemia (elevated bilirubin levels) after receiving a vaccine, such as the Hepatitis B (HBV) vaccine?

From the Guidelines

Newborns who develop hyperbilirubinemia after receiving a vaccine, such as the Hepatitis B vaccine, should be managed with phototherapy based on their bilirubin levels, age in hours, and risk factors, as outlined in the most recent guidelines 1. The primary goal is to prevent severe neonatal hyperbilirubinemia and its potential neurotoxic effects.

Key Considerations

• Phototherapy is the primary treatment for hyperbilirubinemia and should be initiated when total serum bilirubin (TSB) reaches certain thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours 1.
• For most term infants with no additional risk factors, phototherapy is recommended when TSB reaches 15-18 mg/dL in the first 48-72 hours of life.
• Ensuring adequate hydration and frequent feeding (8-12 times daily) helps promote bilirubin excretion.
• Close monitoring of bilirubin levels, clinical assessment for signs of kernicterus, and appropriate follow-up are essential components of management.

Management Strategies

• TSB should be used as the definitive diagnostic test to guide all interventions 1.
• Intensive phototherapy is recommended at thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours.
• For newborns who have already been discharged and then develop a TSB above the phototherapy threshold, treatment with a home LED-based phototherapy device rather than readmission to the hospital is an option for infants who meet specific listed criteria 1.
• Care should be escalated when an infant’s TSB level is at or above the exchange transfusion threshold or within 0 to 2 mg/dL below the exchange transfusion threshold 1.

Important Notes

• Vaccination should not be delayed due to mild hyperbilirubinemia, as the benefits of vaccination outweigh the minimal risk of exacerbating jaundice.
• Any jaundice developing after vaccination should be evaluated and treated according to standard protocols.
• The decision to discontinue phototherapy should be individualized to consider the TSB level at which phototherapy was initiated, the cause of the hyperbilirubinemia, the difference between the TSB level and the phototherapy threshold, and the risk of rebound hyperbilirubinemia 1.

From the Research

Management Strategies for Newborns with Hyperbilirubinemia

• The management of newborns who develop hyperbilirubinemia after receiving a vaccine, such as the Hepatitis B (HBV) vaccine, involves several strategies, including phototherapy and exchange transfusion 2, 3, 4, 5.
• Phototherapy is an effective treatment for hyperbilirubinemia, and its initiation should be based on gestational age and risk factors 2, 4, 5.
• Exchange transfusion is typically reserved for severe cases of hyperbilirubinemia, and it carries a risk of complications and mortality 2, 4.
• The American Academy of Pediatrics recommends universal screening for neonatal hyperbilirubinemia, while the U.S. Preventive Services Task Force and the American Academy of Family Physicians found insufficient evidence that screening improves outcomes 2.
• Exclusive breastfeeding is a risk factor for the development of hyperbilirubinemia, but interrupting breastfeeding for the treatment of jaundice increases the risk of early discontinuation of breastfeeding 2.

Risk Factors and Screening

• Younger gestational age and exclusive breastfeeding are the strongest risk factors for the development of hyperbilirubinemia 2.
• Infants who appear jaundiced should be evaluated by a risk score or by measurement of total serum or transcutaneous bilirubin 2.
• Universal screening for neonatal hyperbilirubinemia is controversial, and the decision to screen should be based on individual risk factors and clinical judgment 2, 3.

Treatment Thresholds

• The literature describes intervention thresholds for phototherapy and exchange transfusion in both term and preterm infants, and specific thresholds can be used to guide treatment decisions 5.
• Phototherapy should be instituted in a timely and effective manner to avoid the need for exchange transfusion 5.
• The decision to initiate phototherapy or exchange transfusion should be based on the severity of hyperbilirubinemia, gestational age, and individual risk factors 2, 4, 5.