What are the treatment options for hyperbilirubinemia?

Treatment Options for Hyperbilirubinemia

Phototherapy is the primary treatment for hyperbilirubinemia, which safely and effectively decreases total serum bilirubin concentrations within 4-6 hours of initiation when properly administered. 1

Phototherapy Implementation

• Phototherapy should be delivered using blue-green light in the 460-490 nm wavelength range (optimal peak at 478 nm) 1
• Effective phototherapy requires an irradiance of 25-35 mW/cm²/nm delivered to at least one surface of the body (ventral or dorsal) 1
• LED light sources are preferred as they deliver specific wavelengths in narrow bandwidths with minimal heat generation 1
• Maximize exposed body surface area (35-80% of total body surface) by changing the infant's position every 2-3 hours 1
• Avoid obstructing light with equipment such as radiant warmers, large diapers, head covers, or electrode patches 1

Monitoring During Phototherapy

• Continue breastfeeding or bottle-feeding every 2-3 hours during phototherapy to maintain adequate hydration 1, 2
• Monitor bilirubin levels regularly with the following schedule 1, 3:
  • If TSB ≥ 25 mg/dL (428 μmol/L), repeat TSB within 2-3 hours
  • If TSB 20-25 mg/dL (342-428 μmol/L), repeat within 3-4 hours
  • If TSB < 20 mg/dL (342 μmol/L), repeat in 4-6 hours
• Clinical response should be evident within 4-6 hours with an anticipated decrease of more than 2 mg/dL in serum bilirubin concentration 1

Discontinuation of Phototherapy

• Phototherapy can be discontinued when serum bilirubin levels fall below 13-14 mg/dL 1, 2, 3
• Consider measuring TSB 24 hours after discharge to check for rebound hyperbilirubinemia, especially in infants with hemolytic disease 1, 2

Pharmacological Alternatives

• Intravenous immunoglobulin (0.5-1 g/kg over 2 hours) may be administered for infants with isoimmune hemolytic disease and rapidly rising TSB levels despite intensive phototherapy 1
• Tin-mesoporphyrin (a heme oxygenase inhibitor) may effectively prevent or treat hyperbilirubinemia, though it is not yet FDA-approved 1, 4
• Other pharmacological therapies under investigation include clofibrate, bile salts, and laxatives, but none are currently recommended for routine clinical use 4

Exchange Transfusion

• Exchange transfusion is indicated when TSB levels approach or exceed exchange level thresholds despite intensive phototherapy 1
• Immediate exchange transfusion is recommended for any infant showing signs of intermediate to advanced stages of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) even if TSB is falling 1
• Prepare for possible exchange transfusion by obtaining blood type and crossmatch when TSB ≥ 25 mg/dL (428 μmol/L) or ≥ 20 mg/dL (342 μmol/L) in sick infants or those < 38 weeks gestation 1

Special Considerations

• For infants with hemolysis, phototherapy may be less effective and more intensive treatment may be required 1
• In breastfed infants requiring phototherapy, breastfeeding should be continued if possible, though temporary interruption with formula supplementation is an option to enhance efficacy 1
• In resource-limited settings, filtered sunlight phototherapy may be considered as an alternative, though it carries risks of hyperthermia and requires careful monitoring 5

Important Pitfalls to Avoid

• Do not rely solely on visual assessment of jaundice; always obtain TSB or transcutaneous bilirubin measurements 2
• Do not subtract direct bilirubin from total bilirubin when making clinical decisions 2
• Avoid unnecessary prolongation of phototherapy as it separates mother and infant and may interfere with breastfeeding 2
• Do not use unfiltered sunlight as a reliable therapeutic tool despite its theoretical benefits, as it poses risks of sunburn and temperature instability 2, 5