What is the management of hyperbilirubinemia (elevated bilirubin levels)?

From the Guidelines

The management of hyperbilirubinemia should prioritize phototherapy as the first-line treatment for neonatal hyperbilirubinemia, with intensive phototherapy using blue light (460-490 nm wavelength) administered continuously until bilirubin levels decrease below treatment thresholds, as recommended by the most recent guidelines 1.

Key Considerations

• The decision to start phototherapy should be guided by total serum bilirubin (TSB) levels, with thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours 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 efficacy of phototherapy units varies widely due to differences in light source and configuration, with the most effective devices emitting light in the blue-to-green range (460-490 nm) and having an irradiance of at least 30 μW·cm−2·nm−1 1.

Treatment Approach

• For neonatal hyperbilirubinemia, phototherapy should be initiated when TSB exceeds age-specific thresholds, typically starting at 12-15 mg/dL in term infants 1.
• Exchange transfusion is reserved for severe cases not responding to phototherapy or when TSB approaches 25 mg/dL 1.
• For adults, treatment focuses on addressing the underlying cause, with options including endoscopic retrograde cholangiopancreatography (ERCP) with stent placement or surgical intervention for obstructive jaundice, cessation of offending medications or treatment of underlying conditions for hemolytic causes, and supportive management for hepatocellular causes like viral hepatitis 1.

Monitoring and Adjunctive Measures

• Regular monitoring of bilirubin levels, liver function tests, and clinical status guides treatment adjustments and helps prevent complications like kernicterus in neonates or hepatic encephalopathy in adults 1.
• Hydration, nutritional support, and vitamin K supplementation (10 mg IV or orally) are important adjunctive measures, particularly for infants who have received phototherapy 1.
• Follow-up TSB measurement is recommended 8 to 12 hours after phototherapy discontinuation and on the following day for infants who received phototherapy <48 hours of age, with a gestational age <38 weeks, with a positive direct antiglobulin test (DAT), or suspected of having hemolytic disease 1.

From the Research

Management of Hyperbilirubinemia

The management of hyperbilirubinemia involves several approaches, including:

• Phototherapy: This is the primary treatment for neonatal unconjugated hyperbilirubinemia, and it has been shown to be effective in reducing total serum bilirubin levels 2, 3, 4.
• Exchange Transfusion: This is typically reserved for cases of severe hyperbilirubinemia that do not respond to phototherapy, and it carries a significant risk of morbidity and mortality 2, 3, 5.
• Pharmacological Therapies: Several pharmacological therapies, such as metalloporhyrins, clofibrate, bile salts, laxatives, and bilirubin oxidase, are being explored as potential alternatives to phototherapy and exchange transfusion, but none have yet been evaluated sufficiently for routine clinical use 5.
• Oral Zinc Supplementation: This has been shown to be effective in reducing serum bilirubin levels in term neonates with hyperbilirubinemia undergoing phototherapy, and it may be a useful adjunctive therapy 6.

Treatment Goals

The primary goal of treatment for hyperbilirubinemia is to prevent neurotoxicity and kernicterus, while minimizing the risk of undue harm 3.

• The American Academy of Pediatrics (AAP) guidelines recommend the use of phototherapy for neonates with hyperbilirubinemia, with the goal of keeping total serum bilirubin levels below pathologic levels 6.
• The use of intensive phototherapy has been shown to be effective in reducing the need for exchange transfusion and shortening the duration of phototherapy 2, 4.

Treatment Outcomes

The outcomes of treatment for hyperbilirubinemia depend on several factors, including the severity of the condition, the effectiveness of treatment, and the presence of any underlying medical conditions.

• Phototherapy has been shown to be effective in reducing total serum bilirubin levels and preventing neurological complications in neonates with hyperbilirubinemia 2, 3, 4.
• Exchange transfusion is typically reserved for cases of severe hyperbilirubinemia that do not respond to phototherapy, and it carries a significant risk of morbidity and mortality 2, 3, 5.
• Oral zinc supplementation has been shown to be effective in reducing serum bilirubin levels in term neonates with hyperbilirubinemia undergoing phototherapy, and it may be a useful adjunctive therapy 6.