What is the management approach for neonatal jaundice?

Management of Neonatal Jaundice

Neonatal jaundice requires a structured approach including systematic risk assessment, early detection, and prompt treatment with phototherapy or exchange transfusion when indicated to prevent severe hyperbilirubinemia and bilirubin encephalopathy (kernicterus). 1

Pathophysiology and Clinical Significance

• Jaundice occurs in approximately 80% of newborn infants and is typically benign, but can progress to severe hyperbilirubinemia and potentially kernicterus if not properly managed 2
• Bilirubin encephalopathy describes clinical central nervous system findings caused by bilirubin toxicity to the basal ganglia and brainstem nuclei 1
• Kernicterus, originally a pathologic diagnosis characterized by bilirubin staining of the brainstem nuclei and cerebellum, is now used interchangeably with both acute and chronic findings of bilirubin encephalopathy 1

Prevention and Risk Assessment

Primary Prevention

• Promote and support successful breastfeeding with 8-12 feedings per day for the first several days 1, 3
• Avoid routine supplementation of nondehydrated breastfed infants with water or dextrose water, as it will not prevent hyperbilirubinemia 1
• Perform prenatal testing of all pregnant women for ABO and Rh(D) blood types and screen for unusual isoimmune antibodies 1

Risk Assessment

• Perform systematic assessment during the neonatal period for risk of developing severe hyperbilirubinemia 1
• If mother has not had prenatal blood grouping or is Rh-negative, obtain direct antibody test (Coombs' test), blood type, and Rh(D) type on infant's cord blood 1
• For infants born to mothers with blood group O, Rh-positive, consider testing cord blood for infant's blood type and direct antibody test 1
• Assess maternal factors including blood type, Rh status, and GBS status to determine jaundice risk 4

Monitoring and Diagnosis

• Monitor all infants routinely for jaundice whenever vital signs are measured, but no less than every 8-12 hours 1
• Perform transcutaneous bilirubin (TcB) and/or total serum bilirubin (TSB) measurement on every infant jaundiced in the first 24 hours after birth 1
• Plot bilirubin measurements on hour-specific nomograms to assess risk and response to treatment 4
• Investigate the cause of jaundice in infants receiving phototherapy or whose TSB level is rising rapidly 1
• For sick infants and those jaundiced at or beyond 3 weeks, measure total and direct/conjugated bilirubin to identify cholestasis 1
• Check newborn thyroid and galactosemia screen results in infants with prolonged jaundice 1

Treatment

Phototherapy

• Initiate phototherapy based on TSB levels, gestational age, and risk factors using appropriate nomograms 4, 5
• Use special blue fluorescent tubes or LED lights that deliver irradiance of >30 mW/cm²/nm for intensive phototherapy 4
• Position lights at optimal distance (10-15 cm above the infant) to maximize irradiance 4
• Maximize skin exposure by removing clothing except for a diaper and providing eye protection 4
• Expect a decrease of more than 2 mg/dL (34 μmol/L) in serum bilirubin concentration within 4-6 hours of initiating effective phototherapy 1
• Change infant's posture every 2-3 hours to maximize area exposed to light 1
• Avoid physical obstruction of light by equipment, large diapers, head covers, electrode patches, etc. 1

Complications and Contraindications of Phototherapy

• Phototherapy may cause separation of mother and infant and eye patching, which can be disturbing to parents 1
• Bronze infant syndrome may occur in infants with cholestatic jaundice exposed to phototherapy 1
• Congenital porphyria or family history of porphyria is an absolute contraindication to phototherapy 1
• Avoid using sunlight as a therapeutic tool due to practical difficulties in safely exposing a naked newborn to the sun 1

Exchange Transfusion

• Consider exchange transfusion if TSB is in the intensive phototherapy range and phototherapy does not promptly lower the TSB 1
• Do not subtract direct serum bilirubin from the TSB concentration when making decisions about exchange transfusions 1

Follow-up and Monitoring

• Provide early and focused follow-up based on risk assessment 1
• After discharge, follow-up within 24-48 hours to reassess bilirubin levels and monitor for signs of worsening jaundice 4, 3
• Consider outpatient phototherapy if TSB levels remain elevated but below exchange transfusion threshold 4
• Educate parents about signs of worsening jaundice and when to seek immediate medical attention 4
• Monitor the effectiveness of phototherapy with serial bilirubin measurements, with frequency based on clinical judgment 1

Special Considerations

• Early onset jaundice (within first 24 hours) suggests hemolytic disease and is a risk factor for severe hyperbilirubinemia 4
• Late preterm infants are at higher risk for developing severe hyperbilirubinemia and require closer monitoring 4
• Assess hydration status and consider supplemental fluids if dehydration is present or oral intake is inadequate 4

By following this structured approach to neonatal jaundice management, clinicians can effectively prevent severe hyperbilirubinemia and its potentially devastating neurological consequences while minimizing unnecessary interventions.