What is the management approach for neonates presenting with jaundice?

Management of Neonatal Jaundice

Phototherapy is the cornerstone treatment for neonatal jaundice and should be initiated based on total serum bilirubin (TSB) levels plotted on hour-specific nomograms that consider gestational age and risk factors. 1

Diagnosis and Assessment

• Obtain TSB measurement in all infants who appear jaundiced
• Plot TSB on hour-specific nomogram to determine risk zone
• Calculate rate of bilirubin rise to identify ongoing hemolysis
• Assess for risk factors that influence treatment thresholds:
  • Gestational age (especially 35-38 weeks)
  • ABO or Rh incompatibility
  • G6PD deficiency
  • Evidence of hemolysis

Treatment Approach

Phototherapy

• Initiate phototherapy when TSB reaches thresholds based on:

  • Age of infant (hours)
  • Gestational age
  • Presence of risk factors for neurotoxicity

• Optimal phototherapy delivery:

  • Use LED-based devices for maximum efficacy 2
  • Ensure maximum skin exposure
  • Position infant appropriately (supine or prone, alternating positions) 2
  • Continue breastfeeding during phototherapy

Monitoring During Treatment

• Monitor TSB every 4-6 hours until declining
• Then monitor every 8-12 hours
• Ensure adequate hydration and nutrition
• Continue frequent feeding (at least 8-10 times in 24 hours)

Discontinuing Phototherapy

• Discontinue when TSB has declined 2-4 mg/dL below the threshold at which phototherapy was initiated 1
• Obtain follow-up TSB measurement 8-12 hours after discontinuing phototherapy
• Consider additional TSB measurement on the following day

Special Considerations

Breastfeeding

• Continue breastfeeding during phototherapy
• Breastfed infants may have higher bilirubin levels than formula-fed infants (physiologic)
• Inadequate breastfeeding can contribute to hyperbilirubinemia
• Evaluate for weight loss, wet diapers, and stools

Cholestatic Jaundice

• If jaundice persists beyond 2 weeks, obtain direct bilirubin measurement to rule out cholestatic jaundice
• Phototherapy in infants with cholestasis may cause bronze infant syndrome (dark, grayish-brown discoloration of skin, serum, and urine) 2
• Direct hyperbilirubinemia is not a contraindication to phototherapy if needed 2

Severe Hyperbilirubinemia

• TSB ≥25 mg/dL (428 μmol/L) is a medical emergency
• Prepare for exchange transfusion if:
  • TSB reaches exchange transfusion threshold based on age and risk factors
  • TSB continues rising despite intensive phototherapy
• Exchange transfusion should use O negative RBCs compatible with maternal antibodies

Common Pitfalls and Caveats

1. Sunlight exposure: While sunlight contains the appropriate wavelength spectrum, it is not recommended due to practical difficulties in safely exposing infants and risk of sunburn 2

2. Contraindications to phototherapy:

   • Congenital porphyria or family history of porphyria (absolute contraindication)
   • Concomitant use of photosensitizing drugs 2

3. Rebound hyperbilirubinemia: Can occur after discontinuing phototherapy, necessitating follow-up bilirubin measurements

4. Overtreatment: Recent guidelines have raised thresholds for phototherapy, as evidence suggests kernicterus occurs at higher bilirubin levels than previously thought 3

5. Potential adverse effects of phototherapy:

   • Diarrhea
   • Increased risk of seizures
   • Potential impact on breastfeeding success 3

The American Academy of Pediatrics has recently updated its clinical practice guideline with higher thresholds for initiating phototherapy, based on gestational age rather than racial factors, reflecting evolving understanding of neonatal hyperbilirubinemia management 4, 3.