What is the initial treatment for neonatal hyperbilirubinemia?

Initial Treatment for Neonatal Hyperbilirubinemia

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

Indications for Phototherapy

• Initiation of phototherapy is determined by total serum bilirubin (TSB) threshold values based on:

  • Gestational age (in weeks)
  • Postnatal age (in hours)
  • Presence or absence of risk factors for bilirubin neurotoxicity 1, 2

• If TSB ≥ 25 mg/dL (428 μmol/L) or ≥ 20 mg/dL (342 μmol/L) in a sick infant or infant < 38 weeks gestation, this is a medical emergency requiring immediate admission to a hospital pediatric service for intensive phototherapy 1, 2

• For infants with TSB ≥ 13 mg/dL, phototherapy should be initiated according to gestational age and risk factor-based thresholds 2, 3

Proper Administration of Phototherapy

• Use blue-green light in the 460-490 nm wavelength range (optimal peak at 478 nm) 1

• Deliver irradiance of 25-35 mW/cm²/nm to at least one surface of the body (ventral or dorsal) 1, 3

• LED light sources are preferred as they deliver specific wavelengths with minimal heat generation 1, 3

• Maximize exposed body surface area (35-80% of total body surface) by:

  • Removing the infant's diaper when bilirubin levels approach exchange transfusion range
  • Changing the infant's position every 2-3 hours 2, 3

• Position the light source as close as safely possible to maximize irradiance 2

Laboratory Assessment

• Measure TSB and direct bilirubin levels 1, 2

• Obtain blood type (ABO, Rh) and direct antibody test (Coombs') 1, 2

• Check serum albumin, complete blood count with differential, and reticulocyte count 1, 2

• Consider G6PD testing if suggested by ethnic or geographic origin or if poor response to phototherapy 1, 2

• If TSB ≥ 25 mg/dL or ≥ 20 mg/dL in a sick infant or infant < 38 weeks gestation, obtain blood type and crossmatch in preparation for possible exchange transfusion 1, 2

Monitoring During Treatment

• Continue feeding every 2-3 hours during phototherapy to maintain adequate hydration 2, 3

• Monitor bilirubin levels regularly with the following schedule:

  • If TSB ≥ 25 mg/dL, repeat TSB within 2-3 hours
  • If TSB 20-25 mg/dL, repeat within 3-4 hours
  • If TSB < 20 mg/dL, repeat in 4-6 hours 2, 4

• With proper phototherapy, expect a decline of TSB within the first 4-6 hours of initiation 1, 5

  • For extremely high bilirubin levels (>30 mg/dL), expect a decline of up to 10 mg/dL within a few hours
  • Expect at least 0.5-1 mg/dL per hour decline in the first 4-8 hours 2, 4

Special Considerations

• For infants with isoimmune hemolytic disease and TSB level rising despite intensive phototherapy or within 2-3 mg/dL of exchange level, administer intravenous immunoglobulin 0.5-1 g/kg over 2 hours 1, 3

• Continue breastfeeding during phototherapy when possible, as interrupting breastfeeding increases the risk of early discontinuation 2, 6

• Supplementing with formula or expressed breast milk may be necessary for infants with signs of dehydration or weight loss >12% from birth 2

• Exchange transfusion should be performed only by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities 1

Discontinuation of Phototherapy

• Phototherapy can be discontinued when serum bilirubin levels fall below 13-14 mg/dL 2, 3

• Consider obtaining follow-up bilirubin measurement within 24 hours after discharge for infants with hemolytic disease or those who received phototherapy before 3-4 days of age 2, 3

• Monitor for rebound hyperbilirubinemia, which occurs in approximately 15% of cases 4