What is the treatment for neonatal jaundice?

Treatment of Neonatal Jaundice

Phototherapy is the primary treatment for neonatal hyperbilirubinemia, initiated based on hour-specific bilirubin nomograms that account for gestational age and neurotoxicity risk factors, with exchange transfusion reserved for extreme hyperbilirubinemia unresponsive to intensive phototherapy. 1

Initial Assessment and Monitoring

Measure transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) immediately in any infant appearing jaundiced, particularly within the first 24 hours of life, as early-onset jaundice suggests hemolytic disease and carries higher risk 2, 1. Plot all bilirubin values on hour-specific nomograms to determine risk stratification and treatment thresholds 2, 1.

Laboratory Evaluation Based on Clinical Context

For infants requiring phototherapy or with rapidly rising bilirubin:

• Blood type and Coombs' test (if not obtained from cord blood) 2
• Complete blood count with smear 2
• Direct or conjugated bilirubin measurement 2
• Consider reticulocyte count and G6PD testing, particularly in African American infants (11-13% prevalence) where G6PD deficiency accounts for 31.5% of kernicterus cases 2

For prolonged jaundice (≥3 weeks) or sick infants:

• Total and direct/conjugated bilirubin to identify cholestasis 2, 1
• Verify newborn thyroid and galactosemia screening results 2, 1
• Urinalysis and urine culture if direct bilirubin is elevated 2

Phototherapy Implementation

Initiation Criteria

Use the 2022 AAP hour-specific nomograms that incorporate gestational age at birth and presence of neurotoxicity risk factors, with higher treatment thresholds than previous guidelines 3. The American Academy of Pediatrics provides specific phototherapy initiation thresholds based on these factors 1.

Technical Requirements for Effective Phototherapy

• Use special blue fluorescent tubes or LED lights delivering irradiance >30 μW/cm²/nm for intensive phototherapy 1
• Minimize distance between light source and infant while maintaining safety 2
• Maximize exposed body surface area by avoiding physical obstruction from equipment, large diapers, head covers, or electrode patches 1
• Change infant's posture every 2-3 hours to optimize light exposure 1

Expected Response and Monitoring

Effective phototherapy should decrease serum bilirubin by >2 mg/dL (34 μmol/L) within 4-6 hours of initiation 2, 1. Monitor with serial bilirubin measurements at intervals based on clinical judgment, recognizing that values can be confounded by changes in bilirubin production or rebound after discontinuation 2.

Phototherapy can be interrupted for feeding and maternal-infant bonding once bilirubin levels show documented decrease 2.

Protective Measures During Phototherapy

• Eye masks are used routinely to prevent theoretical retinal damage, though evidence supporting this practice is limited to animal studies 2
• Monitor for adequate hydration, nutrition, and temperature control throughout treatment 2
• Assess for signs of early bilirubin encephalopathy: changes in sleeping pattern, deteriorating feeding, or inconsolable crying 2

Exchange Transfusion

Consider exchange transfusion if TSB reaches intensive phototherapy range and phototherapy fails to promptly lower TSB 1. This intervention carries significant risks: 5% experience morbidity (apnea, bradycardia, cyanosis, vasospasm, thrombosis, necrotizing enterocolitis) and rare mortality 2.

Do not subtract direct bilirubin from TSB when making exchange transfusion decisions 1.

Supportive Management and Prevention

Breastfeeding Support

Promote 8-12 breastfeeding sessions daily in the first several days of life 1. Avoid routine supplementation with water or dextrose water in nondehydrated breastfed infants, as this does not prevent hyperbilirubinemia 1.

Do not interrupt breastfeeding for jaundice treatment, as this increases risk of early breastfeeding discontinuation 3, 4. Assess hydration status and consider supplemental fluids only if dehydration is present or oral intake is inadequate 1.

High-Risk Populations Requiring Closer Monitoring

• Late preterm infants (35-37 weeks) have higher risk for severe hyperbilirubinemia 1
• Infants with hemolytic disease require more aggressive monitoring with lower treatment thresholds 2
• Exclusively breastfed infants with inadequate caloric intake are at increased risk 4

Follow-Up After Discharge

Schedule follow-up within 24-48 hours of discharge to reassess bilirubin levels and monitor for worsening jaundice 1. Educate parents about signs of worsening jaundice and when to seek immediate medical attention 1. Consider outpatient phototherapy if TSB remains elevated but below exchange transfusion threshold 1.

Common Pitfalls to Avoid

Visual estimation of jaundice severity is unreliable, particularly in darkly pigmented infants—always measure bilirubin objectively 2. Universal screening increases phototherapy use without proven reduction in kernicterus incidence, so treatment decisions should be based on validated nomograms rather than screening alone 3. The number needed to treat with phototherapy varies widely (6-10 infants to prevent one from exceeding 20 mg/dL), so avoid overtreatment in low-risk populations 2.