When can phototherapy be discontinued in a neonate with hyperbilirubinemia (elevated bilirubin level) who has previously undergone phototherapy?

Discontinuing Phototherapy in Neonates with Hyperbilirubinemia

Phototherapy can be discontinued when the total serum bilirubin (TSB) has declined by 2-4 mg/dL below the hour-specific threshold at which phototherapy was initiated. 1

Decision-Making Framework for Discontinuation

• Consider these key factors when deciding to stop phototherapy:

  • The initial TSB level that triggered phototherapy 1
  • The underlying cause of hyperbilirubinemia 1
  • The difference between current TSB level and the phototherapy threshold 1
  • The risk of rebound hyperbilirubinemia 1, 2

• A practical threshold for discontinuation is when TSB falls below 13-14 mg/dL 1, 3, 2

Post-Phototherapy Monitoring

High-Risk Infants

Follow-up TSB measurement is essential for infants who:

• Received phototherapy before 48 hours of age 1, 2
• Have gestational age <38 weeks 1
• Have a positive direct antiglobulin test (DAT) 1
• Have suspected hemolytic disease 1, 2

For these high-risk infants:

• Obtain follow-up TSB measurement 8-12 hours after phototherapy discontinuation 1, 2
• Perform an additional TSB measurement on the following day 1, 2

Standard-Risk Infants

• For all other infants who received phototherapy, obtain follow-up TSB within 1-2 days after discontinuation 1, 2
• Transcutaneous bilirubin (TcB) can be used instead of TSB if ≥24 hours have passed since phototherapy was stopped 1, 2

Warning Signs of Rebound Hyperbilirubinemia

• Monitor for rapid rate of bilirubin rise (≥0.3 mg/dL per hour in first 24 hours or ≥0.2 mg/dL per hour thereafter), which suggests ongoing hemolysis 1, 2
• Be alert for bilirubin that rises despite intensive phototherapy or rises after an initial decline 1
• Consider G6PD enzyme activity testing in infants with jaundice of unknown cause whose TSB rises despite phototherapy 1

Pitfalls to Avoid

• Do not rely solely on visual assessment of jaundice; always obtain objective TSB or TcB measurements 2, 4
• Avoid unnecessarily prolonged phototherapy, as it separates mother and infant and may interfere with breastfeeding 3, 2
• Don't ignore failure of response to phototherapy, which may indicate an unrecognized hemolytic process 4
• Do not use sunlight exposure as a reliable therapeutic alternative to conventional phototherapy, despite theoretical benefits 3, 2

Special Considerations

• For infants with ABO incompatibility or other hemolytic diseases, be particularly vigilant about rebound hyperbilirubinemia 5
• Continue appropriate feeding during and after phototherapy - breastfeeding or bottle-feeding every 2-3 hours 1, 2
• For infants with signs of dehydration or weight loss >12% from birth, supplement with formula or expressed breast milk 1, 2