Initial Approach to Treating Hyperbilirubinemia
The initial approach to treating hyperbilirubinemia should be guided by the type of hyperbilirubinemia, with phototherapy as the first-line treatment for unconjugated hyperbilirubinemia when bilirubin levels reach treatment thresholds based on age, gestational age, and risk factors. 1
Classification and Assessment
Types of Hyperbilirubinemia
- Unconjugated (indirect) hyperbilirubinemia
- Most common in neonates (60% of term and 80% of preterm infants) 2
- Physiologic jaundice
- Pathologic causes (hemolysis, genetic disorders)
- Conjugated (direct) hyperbilirubinemia
- Suggests biliary obstruction or liver disease
- Requires urgent evaluation, especially if persisting beyond 2 weeks 1
Risk Factor Assessment
- Premature birth (<38 weeks gestation)
- Exclusive breastfeeding
- Weight loss >10% after birth
- Cephalohematoma or significant bruising
- Family history of jaundice or blood disorders (including G6PD deficiency)
- Blood type incompatibility (ABO, Rh) 1
Diagnostic Approach
Measure total serum bilirubin (TSB) and direct bilirubin levels
- For neonates: Check every 8-12 hours while in hospital until levels are clearly declining 1
- Plot values on age-specific nomograms to determine risk
Blood typing
- Check blood type (ABO, Rh) of infant and mother
- Consider Coombs test if blood type incompatibility is suspected 1
Additional testing based on clinical presentation
- Complete blood count with peripheral smear
- Liver function tests
- G6PD screening if indicated
- End-tidal carbon monoxide measurement (if available) to assess hemolysis 3
Treatment Algorithm
1. Unconjugated Hyperbilirubinemia in Neonates
Phototherapy
Initiate when TSB reaches thresholds based on:
- Age of infant in hours
- Gestational age
- Presence of risk factors 1
Optimal phototherapy technique:
- Use special blue fluorescent tubes or LED light sources (425-475 nm wavelength)
- Irradiance level >30 mW/cm² per nm
- Maximize exposed surface area
- Line sides of bassinet with aluminum foil to increase exposure 1
Monitoring during phototherapy:
- Continue TSB measurements until levels are clearly declining
- Monitor for complications: dehydration, temperature instability, bronze baby syndrome 1
Exchange Transfusion
Consider when:
- TSB ≥25 mg/dL (428 μmol/L)
- TSB reaches exchange level per AAP guidelines
- Signs of acute bilirubin encephalopathy are present 1
Before exchange transfusion:
- Consider IVIG (0.5-1 g/kg over 2 hours) if TSB is rising despite intensive phototherapy or if TSB is within 2-3 mg/dL of exchange transfusion threshold 1
2. Unconjugated Hyperbilirubinemia in Adults (Crigler-Najjar)
- For Crigler-Najjar syndrome type I:
- Long-term phototherapy (8-12 hours daily minimum)
- Liver transplantation should be considered before brain damage develops 4
3. Conjugated Hyperbilirubinemia
- Treat the underlying cause:
Follow-up and Monitoring
- Schedule follow-up at 2-4 weeks to check hemoglobin levels, especially with rare antibodies
- Measure TSB 8-12 hours after discontinuing phototherapy
- Consider additional TSB measurement the following day to ensure bilirubin levels continue to decline 1
Special Considerations
- Breastfeeding: Can be continued during phototherapy despite potentially higher bilirubin levels 1
- Pharmacological alternatives: Metalloporphyrins, clofibrate, bile salts, and laxatives may be considered in the future but are not yet recommended for routine use 5
- Contraindications to phototherapy: Congenital porphyria and concomitant use of photosensitizing drugs 1
Complications to Watch For
- Kernicterus (bilirubin encephalopathy) - irreversible neurological damage
- Bronze baby syndrome during phototherapy (if direct bilirubin is elevated)
- Rebound hyperbilirubinemia after discontinuing phototherapy 1
By following this structured approach to hyperbilirubinemia, clinicians can effectively manage this common condition while minimizing the risk of serious complications.