Initial Treatment for Neonatal Jaundice
Phototherapy is the primary initial treatment for neonatal jaundice when total serum bilirubin (TSB) levels exceed the threshold based on the infant's age in hours, gestational age, and risk factors. 1, 2
Assessment and Diagnosis
Before initiating treatment, proper assessment is essential:
- Measure TSB or transcutaneous bilirubin (TcB) in any infant with visible jaundice in the first 24 hours of life 1
- TcB is a good screening tool, but TSB should be used for definitive diagnosis and treatment decisions 1
- TSB should be measured if:
- TcB is within 3.0 mg/dL of phototherapy threshold
- TcB exceeds phototherapy threshold
- TcB is ≥15 mg/dL 1
- Interpret all bilirubin levels according to the infant's age in hours 1
Phototherapy Initiation Criteria
Initiate phototherapy when TSB exceeds threshold values based on:
- Gestational age
- Age in hours
- Presence of risk factors for bilirubin neurotoxicity 2
Threshold values for phototherapy:
| Risk Category | Threshold Value (mg/dL) |
|---|---|
| Low-risk | 18-20 |
| Medium-risk | 15-18 |
| High-risk | 13-15 |
Phototherapy Administration
For optimal effectiveness, phototherapy should be administered with:
- Blue-green wavelength light (460-490 nm), with peak at 478 nm 1, 2
- Minimum irradiance of 30 μW·cm⁻²·nm⁻¹ 1, 2
- Maximum body surface area exposure (35-80% of skin) 1
- LED light sources (preferred due to specific wavelengths with minimal heat) 2
Monitoring During Phototherapy
- Measure TSB to verify efficacy after starting phototherapy 1
- Frequency of TSB measurement depends on initial level:
- Every 2-3 hours if TSB ≥25 mg/dL
- Every 3-4 hours if TSB 20-25 mg/dL
- Every 4-6 hours if TSB <20 mg/dL 2
- Monitor for signs of acute bilirubin encephalopathy (lethargy, poor feeding, high-pitched cry, hypertonia) 2
- Assess hydration status and provide IV fluids if dehydration is present 2
Additional Management
- Continue breastfeeding or bottle-feeding every 2-3 hours 2
- Consider supplementation with formula if bilirubin levels are not decreasing 2
- Evaluate for underlying causes of hyperbilirubinemia 1
- Measure G6PD enzyme activity if jaundice is of unknown cause or TSB rises despite intensive phototherapy 1
Escalation of Care
- Escalate care when TSB is at or above exchange transfusion threshold or within 0-2 mg/dL below it 1
- For severe hyperbilirubinemia (TSB >20 mg/dL):
- Provide IV hydration and emergent intensive phototherapy
- Obtain type and crossmatch
- Consider intravenous immunoglobulin (0.5-1 g/kg over 2 hours) if hemolytic disease is suspected 2
Common Pitfalls to Avoid
- Do not subtract direct bilirubin from total bilirubin when making treatment decisions 2
- Do not delay treatment while waiting for additional test results 2
- Home phototherapy is not appropriate for infants with severe hyperbilirubinemia (TSB >20 mg/dL) 2
- Visual estimation of bilirubin levels can lead to errors, particularly in darkly pigmented infants 1
Discontinuation of Phototherapy
- Consider discontinuing when TSB has declined by 2-4 mg/dL below the hour-specific threshold 1
- For readmitted infants, discontinue when TSB falls below 13-14 mg/dL 2
- Measure follow-up TSB 8-12 hours after discontinuation if:
With proper administration of effective phototherapy, TSB concentrations typically decrease within the first 4-6 hours of initiation in infants without concurrent hemolysis 1.