What is the management of physiological jaundice in newborns?

Management of Physiological Jaundice in Newborns

For physiological jaundice in healthy term newborns (≥35 weeks gestation), the primary management strategy is to promote successful breastfeeding with 8-12 feedings daily, perform systematic risk assessment before discharge, and initiate phototherapy only when bilirubin levels reach treatment thresholds based on hour-specific nomograms—not routinely for all jaundiced infants. 1, 2

Understanding Physiological Jaundice

Physiological jaundice occurs in most newborns as a benign condition resulting from normal transitional changes in bilirubin metabolism. 1, 3 The key distinction is that physiological jaundice typically:

• Appears after 24 hours of life (jaundice in the first 24 hours suggests hemolytic disease and requires immediate investigation) 1, 2
• Peaks around days 3-5 in term infants 3
• Resolves spontaneously in most cases, particularly in female infants 4

Prevention and Supportive Care

Breastfeeding optimization is the cornerstone of prevention:

• Encourage 8-12 breastfeeding sessions per day during the first several days 2
• Do not routinely supplement non-dehydrated breastfed infants with water or dextrose water, as this does not prevent hyperbilirubinemia 2
• If supplementation is needed for dehydration, use milk-based formula rather than water, as it inhibits enterohepatic circulation of bilirubin 1

Monitoring Protocol

All infants require systematic jaundice assessment:

• Monitor for jaundice whenever vital signs are measured, but no less than every 8-12 hours 1, 2
• Assess jaundice by blanching the skin with digital pressure, though visual estimation can lead to errors, especially in darkly pigmented infants 1
• Perform transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) measurement on any infant jaundiced in the first 24 hours 1, 2
• Measure TcB/TSB if jaundice appears excessive for the infant's age 1
• Plot all bilirubin measurements on hour-specific nomograms to interpret risk appropriately 2

When to Investigate Further

Most healthy term infants with physiological jaundice require minimal laboratory evaluation. 5 However, obtain additional testing when:

• Jaundice appears in the first 24 hours (suggests hemolysis) 1, 2
• TSB is rising rapidly (crossing percentiles on nomogram) 1
• Jaundice persists beyond 3 weeks—measure total and direct/conjugated bilirubin to identify cholestasis and verify newborn thyroid and galactosemia screening 1, 6
• The infant appears ill or has other concerning signs 1

Essential initial tests include:

• Maternal and infant blood type and Rh status 2
• Direct antibody test (Coombs') if mother is Rh-negative or type O 1

Phototherapy Indications

The decision to initiate phototherapy should be based on TSB levels plotted on hour-specific nomograms, considering gestational age and risk factors—not on arbitrary cutoffs. 1, 2

Key principles:

• For healthy term infants without hemolysis, phototherapy can safely be withheld until TSB exceeds 320 μmol/L (18.7 mg/dL), as most cases resolve spontaneously 4, 5
• Infants with hemolytic disease require closer monitoring and lower treatment thresholds (aim to keep TSB below 300-400 μmol/L or 17.5-23.4 mg/dL) 5
• Use intensive phototherapy with special blue fluorescent tubes or LED lights delivering irradiance >30 μW/cm²/nm 2, 7

Effective phototherapy technique:

• Position lights 10-15 cm above the infant 7
• Maximize skin exposure by removing all clothing except diaper 7
• Provide eye protection 7
• Change infant's position every 2-3 hours to maximize light exposure 2
• Avoid physical obstruction by equipment, large diapers, or electrode patches 2
• Expect TSB to decrease by >2 mg/dL (34 μmol/L) within 4-6 hours of effective phototherapy 2

Hydration Management

Routine intravenous fluids or supplementation with dextrose water is not necessary for term infants receiving phototherapy unless dehydration is present. 1 If dehydration exists:

• Provide supplemental fluids to correct dehydration 1
• Use milk-based formula rather than water, as it inhibits enterohepatic bilirubin circulation 1
• Maintain adequate hydration to support excretion of phototherapy products in urine and bile 1

Discontinuing Phototherapy

Stopping criteria depend on the age at initiation and underlying cause:

• For infants readmitted with TSB ≥18 mg/dL (308 μmol/L), discontinue when TSB falls below 13-14 mg/dL (222-239 μmol/L) 1
• Discharge need not be delayed to observe for rebound 1
• If phototherapy is initiated early (before 3-4 days) or for hemolytic disease, obtain follow-up bilirubin measurement within 24 hours after discharge 1
• For readmitted infants, significant rebound is rare, but follow-up TSB or clinical assessment within 24 hours is a reasonable option 1

Follow-Up Strategy

Provide early and focused follow-up based on initial risk assessment:

• Schedule follow-up within 24-48 hours after discharge to reassess bilirubin levels and monitor for worsening jaundice 2, 7
• Educate parents about signs of worsening jaundice and when to seek immediate attention 2, 7
• Consider outpatient phototherapy if TSB remains elevated but below exchange transfusion threshold 2, 7

Critical Pitfalls to Avoid

Common errors in managing physiological jaundice:

• Over-treatment: Phototherapy separates mother and infant and causes parental anxiety; avoid treating mild physiological jaundice that will resolve spontaneously 1, 4
• Visual estimation alone: Do not rely on visual assessment of jaundice severity—always measure TcB or TSB when in doubt 1
• Ignoring hour-specific interpretation: Bilirubin levels must be interpreted according to the infant's age in hours, not as absolute values 1
• Routine water supplementation: This does not prevent hyperbilirubinemia and may interfere with breastfeeding 2
• Missing early jaundice: Jaundice in the first 24 hours is never physiological and requires immediate investigation 1, 2
• Inadequate follow-up: Late preterm infants (35-37 weeks) are at higher risk and require closer monitoring than term infants 2, 7

Exchange Transfusion Consideration

Exchange transfusion should be considered if:

• TSB reaches intensive phototherapy range and phototherapy does not promptly lower TSB 1, 2
• Do not subtract direct bilirubin from TSB when making exchange transfusion decisions 2