What is the recommended management for neonatal hyperbilirubinemia?

Management of Neonatal Hyperbilirubinemia

Intensive phototherapy is the recommended first-line treatment for neonatal hyperbilirubinemia, using blue-green spectrum light (430-490 nm) at an irradiance of at least 30 μW/cm²/nm delivered to as much of the infant's body surface as possible. 1, 2, 3

Initial Assessment and Laboratory Evaluation

• Obtain total serum bilirubin (TSB) and direct bilirubin levels, blood type, direct antibody test, complete blood count with differential, reticulocyte count, and serum albumin for comprehensive evaluation 4, 3
• Consider G6PD testing if bilirubin rises despite phototherapy or rises after initial decline 3
• Determine if hyperbilirubinemia is predominantly conjugated or unconjugated through fractionated bilirubin levels 2
• Evaluate for underlying causes of hyperbilirubinemia, particularly hemolysis, indicated by bilirubin rise ≥0.3 mg/dL per hour in first 24 hours or ≥0.2 mg/dL per hour thereafter 3

Phototherapy Implementation

• Initiate phototherapy according to gestational age and risk factor-based thresholds established by the American Academy of Pediatrics 1, 4
• Use special blue light in the 430-490 nm spectrum with irradiance of ≥30 μW/cm²/nm for optimal effectiveness 3, 5
• Maximize skin exposure by removing the infant's diaper when bilirubin levels approach exchange transfusion range 3
• 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 3
• Line the sides of the bassinet, incubator, or warmer with aluminum foil or white material if TSB approaches exchange transfusion levels to increase surface area exposed and improve efficacy 1

Monitoring During Treatment

• For TSB ≥25 mg/dL, repeat measurement within 2-3 hours 1, 3
• For TSB 20-25 mg/dL, repeat within 3-4 hours 1, 3
• For TSB <20 mg/dL, repeat in 4-6 hours 1, 3
• If TSB continues to fall, repeat in 8-12 hours 1
• If TSB is not decreasing or is moving closer to exchange transfusion level, consider exchange transfusion 1
• Monitor for signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) which would require immediate exchange transfusion even if TSB is falling 1, 3

Feeding and Hydration During Treatment

• Continue breastfeeding or bottle-feeding every 2-3 hours during phototherapy 1, 2, 3
• Supplement with formula or expressed breast milk for infants with signs of dehydration or weight loss >12% from birth 2, 3
• Milk-based formula can help lower serum bilirubin by inhibiting the enterohepatic circulation of bilirubin if supplementation is needed 2, 3

Discontinuation of Phototherapy and Follow-up

• Discontinue phototherapy when TSB falls below 13-14 mg/dL 1, 2, 4, 3
• For infants who received phototherapy for hemolytic disease or before 3-4 days of age, obtain follow-up bilirubin measurement within 24 hours after discharge 2, 4, 3
• For infants readmitted with hyperbilirubinemia and then discharged, obtain repeat TSB measurement or clinical follow-up 24 hours after discharge 2
• Consider measuring TSB 24 hours after discharge to check for rebound hyperbilirubinemia, depending on the cause 1

Exchange Transfusion Considerations

• Immediate exchange transfusion is recommended for any jaundiced infant showing signs of intermediate to advanced stages of acute bilirubin encephalopathy, even if TSB is falling 1
• Consider exchange transfusion if TSB/albumin ratio exceeds thresholds based on risk category and gestational age 1
• If exchange transfusion is being considered, measure serum albumin level and use the bilirubin/albumin ratio in conjunction with TSB level 1
• For TSB at or approaching exchange level, send blood for immediate type and crossmatch 1

Important Pitfalls to Avoid

• Do not rely on visual assessment of jaundice alone; always obtain TSB or transcutaneous bilirubin measurement 2, 3
• Do not subtract direct bilirubin from total bilirubin when making clinical decisions 1, 2, 3
• Avoid using sunlight as a therapeutic tool despite its theoretical benefits, as it poses risks of sunburn and temperature instability 1, 2, 3
• Be aware that infants with cholestatic jaundice receiving phototherapy may develop bronze infant syndrome (dark, grayish-brown discoloration of skin, serum, and urine) 1
• If bronze infant syndrome develops and TSB is in intensive phototherapy range without prompt decrease, consider exchange transfusion 1
• Recognize that congenital porphyria or family history of porphyria is an absolute contraindication to phototherapy 1