What is the management of hyperbilirubinemia in this patient?

Management of Hyperbilirubinemia

The management of hyperbilirubinemia requires initiating phototherapy based on total serum bilirubin (TSB) levels, gestational age, and risk factors, with consideration for intravenous immunoglobulin (IVIG) if TSB is rising despite intensive phototherapy. 1

Initial Assessment and Monitoring

• Obtain baseline total serum bilirubin (TSB) and direct bilirubin levels
• Check blood type (ABO, Rh) of infant and mother
• Measure TSB every 8-12 hours while in hospital
• Ensure adequate feeding (8-12 times per day for breastfed infants)

Phototherapy Implementation

When to Initiate Phototherapy

• Use the AAP phototherapy nomogram (Figure 3 in AAP guideline) to determine when to start phototherapy based on:
  • Age of infant in hours
  • Gestational age
  • Presence of risk factors (including positive Coombs test)

Optimizing Phototherapy Effectiveness

1. Light Spectrum: Use special blue fluorescent tubes or LED light sources with output in the blue-green spectrum (425-475 nm) for intensive phototherapy 2
2. Irradiance Level:
   • Standard phototherapy delivers 8-10 mW/cm² per nm
   • Intensive phototherapy requires >30 mW/cm² per nm
   • Position special blue fluorescent tubes 10-15 cm above the infant to produce irradiance of at least 35 mW/cm² per nm 2
3. Surface Area Exposure:
   • Maximize exposed surface area for intensive phototherapy
   • Place lights above and fiber-optic pad or special blue fluorescent tubes below the infant
   • Line sides of bassinet, warmer bed, or incubator with aluminum foil to increase exposure 2

Additional Interventions

• IVIG Administration: Consider IVIG (0.5-1 g/kg over 2 hours) if:

  • TSB is rising despite intensive phototherapy
  • TSB is within 2-3 mg/dL of exchange transfusion threshold 1

• Exchange Transfusion: Prepare for exchange transfusion if:

  • TSB ≥25 mg/dL (428 μmol/L)
  • TSB reaches exchange level per AAP guidelines (Figure 4)
  • Use O negative RBCs compatible with maternal antibodies, with blood crossmatched against mother's serum 1

Monitoring During Treatment

• Continue TSB measurements until bilirubin levels are clearly declining
• For hemolytic conditions (e.g., ABO incompatibility), start phototherapy at lower TSB levels and use intensive phototherapy 2
• Anticipate more rapid decrease in TSB when initial levels are >20 mg/dL (342 mmol/L) 2

Post-Treatment Follow-up

• Measure TSB 8-12 hours after discontinuing phototherapy
• Consider additional TSB measurement the following day to ensure bilirubin levels continue to decline
• Schedule follow-up at 2-4 weeks to check hemoglobin levels, especially with rare antibodies, to monitor for late-onset anemia 1

Important Considerations and Pitfalls

• Contraindications: Congenital porphyria or family history of porphyria is an absolute contraindication to phototherapy 1
• Breastfeeding: Can be continued during phototherapy, though breastfed infants may have higher bilirubin levels than formula-fed infants 1
• Rebound Hyperbilirubinemia: Can occur after discontinuing phototherapy, necessitating follow-up measurements 1
• Risk Factors: Pay special attention to:
  • Gestational age 37-38 weeks
  • G6PD deficiency (can cause sudden increases in bilirubin levels)
  • Hemolytic conditions (may make phototherapy less effective) 2, 1

Special Circumstances

• Home Phototherapy: Consider for borderline cases with reliable follow-up 1
• Direct Hyperbilirubinemia: If direct bilirubin is elevated, watch for bronze baby syndrome or blistering during phototherapy 2

By following this structured approach to managing hyperbilirubinemia, you can effectively reduce bilirubin levels and minimize the risk of complications such as kernicterus.