What is the treatment approach for hyperbilirubinemia (elevated bilirubin levels) greater than 13 mg/dL?

Treatment for Bilirubin Levels Greater Than 13 mg/dL

For neonates with bilirubin levels greater than 13 mg/dL, intensive phototherapy is the primary treatment, which can be discontinued when levels fall below 13-14 mg/dL. 1

Initial Assessment and Management

• For infants with total serum bilirubin (TSB) ≥ 13 mg/dL, initiate intensive phototherapy according to gestational age and risk factor-based thresholds 1
• Measure TSB and direct bilirubin levels, blood type (ABO, Rh), direct antibody test (Coombs'), serum albumin, complete blood count with differential, reticulocyte count, and G6PD if indicated by ethnic origin or poor response to therapy 1
• If TSB ≥ 25 mg/dL or ≥ 20 mg/dL in a sick infant or infant < 38 weeks gestation, obtain blood type and crossmatch in preparation for possible exchange transfusion 1

Phototherapy Implementation

• Use intensive phototherapy with special blue light in the 430-490 nm spectrum with irradiance of ≥30 μW/cm²/nm 1
• Maximize skin exposure by removing the infant's diaper when bilirubin levels approach exchange transfusion range 1
• Position the light source as close as safely possible to maximize irradiance 1
• For extremely high bilirubin levels (>30 mg/dL), expect a decline of up to 10 mg/dL within a few hours and at least 0.5-1 mg/dL per hour in the first 4-8 hours 1
• For standard cases requiring phototherapy, expect a 30-40% reduction in initial bilirubin level within 24 hours of intensive phototherapy, with the most significant decline occurring in the first 4-6 hours 1

Hydration and Feeding During Treatment

• Continue breastfeeding or bottle-feeding every 2-3 hours during phototherapy 1
• For infants with signs of dehydration or weight loss >12% from birth, supplement with formula or expressed breast milk 1
• Milk-based formula can help lower serum bilirubin by inhibiting the enterohepatic circulation of bilirubin 1
• Routine intravenous fluid supplementation is not necessary unless there is evidence of dehydration 1

Monitoring During Treatment

• For TSB ≥ 25 mg/dL, repeat TSB measurement within 2-3 hours 1
• For TSB 20-25 mg/dL, repeat within 3-4 hours 1
• For TSB < 20 mg/dL, repeat in 4-6 hours, and if continuing to fall, repeat in 8-12 hours 1
• Monitor for signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) which would require immediate exchange transfusion 1

Additional Interventions

• For infants with isoimmune hemolytic disease and rising TSB despite intensive phototherapy, administer intravenous immunoglobulin 0.5-1 g/kg over 2 hours and repeat in 12 hours if necessary 1
• Consider measuring serum albumin and using the bilirubin/albumin ratio as an additional factor in determining the need for exchange transfusion 1
• If TSB is not decreasing or approaching exchange transfusion levels, prepare for possible exchange transfusion 1

Discontinuation of Phototherapy

• Discontinue phototherapy when serum bilirubin levels fall below 13-14 mg/dL 1
• For infants with hemolytic disease or those who received phototherapy before 3-4 days of age, obtain follow-up bilirubin measurement within 24 hours after discharge 1
• For other infants readmitted and treated for hyperbilirubinemia, significant rebound is rare, but follow-up measurement or clinical assessment 24 hours after discharge is recommended 1

Special Considerations and Pitfalls

• Home phototherapy should only be used for infants with bilirubin levels in the "optional phototherapy" range, not for those with higher concentrations 1
• Avoid using sunlight exposure as a therapeutic tool due to practical difficulties in safely exposing infants and risk of sunburn 1, 2
• Do not subtract direct (conjugated) bilirubin from total bilirubin when making treatment decisions 3
• Be aware that in the presence of hemolysis, G6PD levels can be elevated, which may obscure the diagnosis in the newborn period 3