Treatment for Elevated Bilirubin Levels
Phototherapy is the primary treatment for elevated bilirubin levels, with exchange transfusion reserved for severe cases that don't respond to phototherapy or show signs of bilirubin encephalopathy. 1, 2
Assessment and Risk Stratification
When evaluating elevated bilirubin levels, consider:
- Total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) levels
- Infant's age in hours
- Gestational age
- Presence of risk factors for neurotoxicity
Risk Factors for Severe Hyperbilirubinemia 1, 2
- Family history of neonatal jaundice
- Exclusive breastfeeding
- Bruising or cephalohematoma
- Asian or Black ethnicity
- Maternal age >25 years
- Male sex
- Glucose-6-phosphate dehydrogenase (G6PD) deficiency
- Gestational age <38 weeks
- Hemolytic disease (ABO, Rh incompatibility)
Treatment Algorithm
1. Phototherapy
Initiate phototherapy based on TSB levels and risk category 1, 2:
| Risk Category | Threshold Value (mg/dL) |
|---|---|
| Low-risk | 18-20 |
| Medium-risk | 15-18 |
| High-risk | 13-15 |
Phototherapy Administration
- Use blue-green wavelength light (460-490 nm)
- Ensure minimum irradiance of 30 μW·cm⁻²·nm⁻¹
- Maximize body surface area exposure (35-80% of skin)
- For severe cases, use intensive phototherapy (multiple light sources)
- Line bassinet with aluminum foil or white material to increase light exposure
Monitoring During Phototherapy
- Measure TSB to verify efficacy:
- 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. Supportive Care 2
- Assess for dehydration and provide IV fluids if present
- Continue breastfeeding or bottle-feeding every 2-3 hours
- Consider formula supplementation if bilirubin levels aren't decreasing
- Maintain adequate hydration to promote bilirubin excretion
3. Exchange Transfusion 1, 2
Consider exchange transfusion when:
- TSB reaches exchange threshold levels despite intensive phototherapy
- TSB ≥25 mg/dL at any time (medical emergency)
- Signs of acute bilirubin encephalopathy are present (lethargy, poor feeding, high-pitched cry, hypertonia, arching, retrocollis)
Important Considerations
- Exchange transfusion should only be performed by trained personnel in a NICU with full monitoring and resuscitation capabilities
- If TSB is at or approaching exchange level, send blood for immediate type and crossmatch
4. Adjunctive Treatments 1
- For isoimmune hemolytic disease, administer intravenous immunoglobulin (0.5-1 g/kg over 2 hours) if:
- TSB is rising despite intensive phototherapy
- TSB level is within 2-3 mg/dL of exchange level
When to Discontinue Phototherapy 2
- Consider discontinuing when TSB has declined by 2-4 mg/dL below the hour-specific threshold
- Measure follow-up TSB 8-12 hours after discontinuation if:
- Phototherapy was initiated <48 hours of age
- Gestational age <38 weeks
- Positive direct antiglobulin test
- Suspected hemolytic disease
Laboratory Evaluation for Severe Hyperbilirubinemia 1, 2
- TSB and direct bilirubin levels
- Blood type (ABO, Rh)
- Direct antibody test (Coombs')
- Serum albumin
- Complete blood count with differential
- Reticulocyte count
- G6PD if suggested by ethnic/geographic origin or poor response to phototherapy
Clinical Pearls and Pitfalls
- Severe hyperbilirubinemia (TSB ≥25 mg/dL) is a medical emergency requiring immediate hospitalization and intensive phototherapy 1, 2
- Do not subtract direct bilirubin from total bilirubin when making treatment decisions 1
- Infants with peak bilirubin >24 mg/dL have significantly higher risk of requiring exchange transfusion 3
- Early initiation of phototherapy (within an hour of admission) for infants with high bilirubin levels is crucial to prevent bilirubin encephalopathy 3
- While most jaundiced infants recover without serious problems, there is always a risk of bilirubin encephalopathy during periods of hyperbilirubinemia 4
- Hemolysis should be suspected if TSB does not decrease or continues to rise during intensive phototherapy 1