From the Guidelines
Management of hyperbilirubinemia should prioritize phototherapy as the first-line treatment when total serum bilirubin reaches risk thresholds, with intensive phototherapy recommended at thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours, as outlined in the most recent guidelines 1.
Key Considerations
- Total serum bilirubin (TSB) should be used as the definitive diagnostic test to guide all interventions, with measurement recommended if the transcutaneous bilirubin (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.
- The rate of rise of TSB may 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) suggestive of ongoing hemolysis 1.
- Intensive phototherapy should be initiated promptly when TSB levels reach the designated thresholds, with the goal of reducing the risk of neurotoxicity and other complications associated with severe hyperbilirubinemia 1.
Treatment Approach
- Phototherapy devices should emit light in the blue-to-green range (460-490 nm) with an irradiance of at least 30 μW·cm−2·nm−1, and should illuminate maximal body surface area 2.
- Exchange transfusion is reserved for severe cases not responding to phototherapy or with bilirubin levels exceeding the exchange transfusion threshold, as outlined in the guidelines 1.
- For infants 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.
Monitoring and Follow-up
- TSB should be measured regularly during phototherapy to assess response and adjust management accordingly, with the timing of TSB testing guided by the TSB trajectory and infant age 1.
- Clinicians should evaluate the underlying cause or causes of hyperbilirubinemia in infants who require phototherapy, and consider additional testing or consultation as needed 1.
- Follow-up TSB measurement is recommended after phototherapy discontinuation, with the timing and frequency of follow-up measurements dependent on the post-phototherapy TSB level and trajectory 1.
From the Research
Management of Hyperbilirubinemia
The management of hyperbilirubinemia, or elevated bilirubin levels, typically involves the following approaches:
- Phototherapy: a common treatment modality for neonatal hyperbilirubinemia, which has been shown to be effective in reducing bilirubin levels 3, 4, 5, 6
- Exchange transfusion: a more invasive procedure that may be necessary in severe cases of hyperbilirubinemia, but is associated with significant morbidity and mortality 7, 6
- Pharmacological therapies: various medications, such as metalloporhyrins, clofibrate, bile salts, laxatives, and bilirubin oxidase, are being explored as potential alternative treatments for hyperbilirubinemia, although more research is needed to fully evaluate their safety and efficacy 7, 4
- Combination therapy: administering oral Ursodeoxycholic Acid (UDCA) in addition to phototherapy has been shown to reduce total serum bilirubin levels and length of hospital stay in term neonates with indirect hyperbilirubinemia 3
Treatment Guidelines and Practices
Current guidelines and practices for managing hyperbilirubinemia vary, but generally involve:
- Assessment of risk factors and bilirubin levels to determine the need for treatment 4, 5
- Use of transcutaneous bilirubin measuring devices to monitor bilirubin levels 4
- Termination of treatment based on threshold values, although practices may vary amongst clinicians 5
- Investigation of rebound hyperbilirubinemia, which can occur in up to 10% of neonates treated for hyperbilirubinemia 5
Emerging Therapies and Developments
Several emerging therapies and developments are being explored for the management of hyperbilirubinemia, including: