What are the guidelines for managing elevated bilirubin levels in newborns?

Management of Neonatal Hyperbilirubinemia

Newborns with elevated bilirubin should be managed according to the American Academy of Pediatrics (AAP) phototherapy nomogram, with phototherapy initiated when total serum bilirubin (TSB) reaches thresholds based on age in hours, gestational age, and presence of risk factors. 1

Risk Assessment and Prevention

Early identification of infants at risk for severe hyperbilirubinemia is essential:

• Perform systematic risk assessment before discharge including:

  • Gestational age <38 weeks (higher risk)
  • Exclusive breastfeeding
  • Weight loss >10% after birth
  • Presence of cephalohematoma or significant bruising
  • Family history of jaundice, blood disorders, or G6PD deficiency 1

• All pregnant women should be tested for ABO and Rh(D) blood types and screened for unusual isoimmune antibodies 2

• Support successful breastfeeding by advising mothers to nurse 8-12 times per day for the first several days 2

  • Avoid routine supplementation with water or dextrose water in nondehydrated breastfed infants 2

Clinical Evaluation

• Consider jaundice pathologic if:

  • It appears within the first 24 hours after birth
  • TSB rises by >5 mg/dL (86 μmol/L) per day
  • TSB is higher than 17 mg/dL (290 μmol/L)
  • Infant shows signs of serious illness 3

• Laboratory evaluation:

  • Measure TSB every 8-12 hours while in hospital until levels are clearly declining 1
  • Obtain blood type (ABO, Rh) of infant and mother
  • Perform direct Coombs' test 1
  • Check direct bilirubin if jaundice persists beyond 2 weeks 1

Treatment Guidelines

Phototherapy

• Initiate phototherapy based on AAP nomogram thresholds:

  • Use special blue fluorescent tubes or LED light sources (425-475 nm wavelength)
  • Maintain irradiance level of >30 mW/cm² per nm for intensive phototherapy
  • Maximize exposed surface area by placing lights above and fiber-optic pad below 1

• Continue monitoring TSB during phototherapy until bilirubin levels are clearly declining 1

• Contraindications to phototherapy:

  • Congenital porphyria or family history of porphyria
  • Concomitant use of photosensitizing drugs 1

Exchange Transfusion

• Prepare for exchange transfusion if:

  • TSB ≥25 mg/dL (428 μmol/L)
  • TSB reaches exchange level per AAP guidelines
  • Bilirubin continues to rise despite intensive phototherapy 1

• 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

Follow-up and Monitoring

• Schedule follow-up based on discharge timing:

  • Earlier follow-up for those discharged before 24 hours 1
  • Measure TSB 8-12 hours after discontinuing phototherapy
  • Consider additional TSB measurement the following day 1

• Monitor for prolonged jaundice:

  • Jaundice persisting beyond 2 weeks requires urgent evaluation to rule out biliary atresia
  • Check direct bilirubin in any infant still jaundiced at 3 weeks 1, 4

Special Considerations

• Treat 35-37 week gestation infants more cautiously than full-term infants:

  • These infants are four times more likely to have serum bilirubin >13 mg/dL than 40-week infants
  • Avoid early discharge (before 48 hours) for 35-week gestation infants 4

• First-day bilirubin measurement is valuable:

  • A serum bilirubin ≥6 mg/dL in the first 24 hours predicts 90% of newborns who will develop significant hyperbilirubinemia 5
  • Newborns with first-day bilirubin <6 mg/dL have a very low risk (2.05%) of developing significant hyperbilirubinemia 5

• Watch for signs of bilirubin encephalopathy which can occur if bilirubin levels are not properly managed, even in healthy term infants 4