From the Guidelines
Neonatal hyperbilirubinemia should be diagnosed and treated based on total serum bilirubin (TSB) levels, with phototherapy initiated at thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours, as recommended by the most recent guidelines 1. The diagnosis of neonatal hyperbilirubinemia involves measuring TSB levels, which should be used as the definitive diagnostic test to guide all interventions 1. Transcutaneous bilirubin (TcB) readings can be used as a screening tool, but TSB should be measured if the TcB reading is within 3.0 mg/dL of the phototherapy treatment threshold, if the TcB exceeds the phototherapy treatment threshold, or if the TcB is ≥15 mg/dL 1.
Key Considerations
- The rate of rise of TSB levels can be used to identify possible hemolysis, with a rapid rate of rise (≥0.3 mg/dL per hour in the first 24 hours or ≥0.2 mg/dL per hour thereafter) being suggestive of ongoing hemolysis 1.
- Intensive phototherapy is recommended at the thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours, with the goal of reducing the risk of bilirubin neurotoxicity and the need for exchange transfusions 1.
- The underlying cause or causes of hyperbilirubinemia should be evaluated in infants who require phototherapy, with glucose-6-phosphate dehydrogenase enzyme activity measured in any infant with jaundice of unknown cause whose TSB rises despite intensive phototherapy 1.
Treatment
- Phototherapy should be initiated based on the infant's age in hours, gestational age, and bilirubin level according to nomograms, with the goal of reducing the risk of bilirubin neurotoxicity and the need for exchange transfusions 1.
- Ensuring adequate hydration and frequent feeding (8-12 times daily) helps promote bilirubin excretion, and parents should be educated to monitor for worsening jaundice, lethargy, poor feeding, and high-pitched crying, which may indicate severe hyperbilirubinemia requiring immediate medical attention.
- Exchange transfusion may be necessary for severe cases with very high bilirubin levels (typically >20-25 mg/dL in term infants), and 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.
From the Research
Diagnosis of Neonatal Hyperbilirubinemia
- Neonatal hyperbilirubinemia, also known as jaundice, is a common condition in newborns, affecting about two thirds of them during their first weeks of life 2
- Diagnosis is typically based on measurements of total serum bilirubin levels, with treatment criteria varying depending on factors such as birth weight, gestational age, and postnatal age 3, 4
- A careful history and physical examination are essential in assessing the risk factors associated with pathologic bilirubin levels, although the overwhelming etiology of neonatal jaundice is physiologic and not due to infection or isoimmunization 2
Treatment of Neonatal Hyperbilirubinemia
- Phototherapy is the standard form of treatment for infants with neonatal hyperbilirubinemia, producing a prolonged reduction in bilirubin values with minimal side effects 3, 5, 6
- The efficacy of phototherapy is affected by factors such as initial bilirubin level, birth weight, gestational age, postnatal age, etiology of jaundice, and light intensity and spectral emission 3
- Guidelines for commencement, monitoring, and cessation of phototherapy are available, with proper nursing care enhancing the effectiveness of phototherapy and minimizing complications 3, 6
- Other treatments, such as exchange transfusions, may be necessary in severe cases, although medications such as tin mesoporphyrin and intravenous immunoglobulin may decrease the need for these procedures 2