What is the management for a 9-day-old infant with hyperbilirubinemia (bilirubin level of 13.3 mg/dL)?

Management of a 9-Day-Old Infant with Bilirubin Level of 13.3 mg/dL

For a 9-day-old infant with a bilirubin level of 13.3 mg/dL, phototherapy should be discontinued as this level is below the recommended threshold of 13-14 mg/dL for stopping treatment. 1, 2

Assessment and Monitoring

• Determine if the hyperbilirubinemia is predominantly conjugated or unconjugated by obtaining fractionated bilirubin levels 3
• For infants with total serum bilirubin (TSB) ≥ 13 mg/dL, the American Academy of Pediatrics recommends evaluation based on gestational age and risk factor-based thresholds 2
• If the infant has been receiving phototherapy, it can be discontinued as the current level (13.3 mg/dL) is below the recommended threshold for stopping treatment (13-14 mg/dL) 1, 2
• Consider underlying causes of hyperbilirubinemia, particularly if this is a late-rising bilirubin level which could indicate G6PD deficiency 4

Follow-up Recommendations

• For infants who received phototherapy for hemolytic disease or before 3-4 days of age, obtain a follow-up bilirubin measurement within 24 hours after discharge 1, 2
• For infants who were readmitted with hyperbilirubinemia and then discharged, a repeat TSB measurement or clinical follow-up 24 hours after discharge is recommended 1
• Evaluate for signs of rebound hyperbilirubinemia, which is rare but possible, especially in infants with hemolytic disease 2

Feeding Recommendations

• Continue breastfeeding or bottle-feeding every 2-3 hours to maintain adequate hydration 1, 2
• If the infant shows signs of dehydration or has had excessive weight loss (>12% from birth), supplement with formula or expressed breast milk 2
• Milk-based formula can help lower serum bilirubin by inhibiting the enterohepatic circulation of bilirubin if supplementation is needed 1

Warning Signs for Parents

• Educate parents about signs of worsening jaundice and acute bilirubin encephalopathy, including altered feeding patterns, lethargy, and high-pitched crying 2
• Instruct parents to seek immediate medical attention if the infant develops hypotonia or hypertonia, opisthotonus, retrocollis, or fever 2
• Emphasize that prolonged jaundice (beyond 2 weeks) requires evaluation to rule out other causes, particularly if direct hyperbilirubinemia is suspected 4

Important Pitfalls to Avoid

• Do not rely on visual assessment of jaundice alone; always obtain TSB or transcutaneous bilirubin (TcB) measurement 2, 5
• Do not subtract direct bilirubin from total bilirubin when making clinical decisions 2, 3
• Do not ignore prolonged jaundice (beyond 2-3 weeks), as it may indicate other underlying conditions such as biliary atresia or hypothyroidism 4
• Avoid unnecessary prolongation of phototherapy, as it separates mother and infant and may interfere with breastfeeding 2
• Do not use sunlight exposure as a reliable therapeutic tool despite its theoretical benefits, as it poses risks of sunburn and temperature instability 1, 6

Special Considerations

• If the infant is exclusively breastfed, be aware that this is a risk factor for developing hyperbilirubinemia, but interrupting breastfeeding may lead to early discontinuation 5
• If the infant's bilirubin level rises despite adequate phototherapy, consider an unrecognized hemolytic process 4
• For infants with direct bilirubin >50% of total bilirubin, consultation with a specialist is recommended 3