What is the management for elevated bilirubin levels?

Management of Elevated Bilirubin Levels in Newborns

For newborns ≥35 weeks gestation with elevated bilirubin, use intensive phototherapy as the primary treatment, with exchange transfusion reserved for extreme hyperbilirubinemia (TSB ≥25 mg/dL or levels approaching exchange thresholds), and always interpret bilirubin levels according to the infant's age in hours rather than absolute values alone. 1

Initial Assessment and Risk Stratification

Measurement Requirements

• Obtain total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) measurement if jaundice appears excessive for the infant's age—never rely on visual estimation alone, particularly in darkly pigmented infants 1
• Interpret all bilirubin levels according to the infant's age in hours, not days, using hour-specific nomograms to determine risk zones 1, 2
• Plot the TSB value on the Bhutani nomogram to identify if the infant falls into high-risk, intermediate-risk, or low-risk zones for severe hyperbilirubinemia 1

Essential Laboratory Workup

When bilirubin is elevated or rising rapidly, obtain: 1

• TSB and direct (conjugated) bilirubin levels
• Blood type (ABO, Rh) and direct antibody test (Coombs')
• Complete blood count with differential and red cell morphology
• Reticulocyte count
• Serum albumin
• G6PD testing if suggested by ethnic/geographic origin or poor response to phototherapy
• End-tidal carbon monoxide (ETCOc) if available

Critical caveat: If direct bilirubin is ≥50% of total bilirubin, do not use standard phototherapy/exchange guidelines—consult a specialist immediately as this suggests cholestasis requiring different management 1, 2

Treatment Thresholds and Interventions

Phototherapy Initiation

Start phototherapy based on age-specific and risk-factor-adjusted thresholds: 1, 3

• 25-48 hours old: TSB ≥15 mg/dL (257 μmol/L)
• 49-72 hours old: TSB ≥18 mg/dL (308 μmol/L)

• 72 hours old: TSB ≥20 mg/dL (342 μmol/L)

These thresholds should be adjusted downward for infants with risk factors (hemolytic disease, G6PD deficiency, prematurity, sepsis) 1

Intensive Phototherapy Specifications

Effective phototherapy requires specific technical parameters: 4

• Spectral irradiance ≥30 μW/cm²/nm at blue light wavelengths (peak emission 450 ± 20 nm)
• Exposure to as much body surface area as possible (up to 80%)
• For extremely high levels (approaching exchange thresholds), remove the diaper and line bassinet sides with aluminum foil or white cloth to maximize surface area exposure 1

Expected response: With intensive phototherapy, expect a 30-40% decrease in initial bilirubin within 24 hours, with the most significant decline in the first 4-6 hours 1. When TSB >30 mg/dL, a decline of up to 10 mg/dL can occur within hours, with rates of 0.5-1 mg/dL per hour expected in the first 4-8 hours 1

Exchange Transfusion Criteria

This is a medical emergency requiring immediate action: 1

• TSB ≥25 mg/dL (428 μmol/L) at any time
• TSB at age-specific exchange transfusion thresholds (refer to AAP nomograms)
• Admit directly to hospital pediatric service with intensive phototherapy capability—do not route through emergency department as this delays treatment 1
• Exchange transfusions must be performed only by trained personnel in a NICU with full monitoring and resuscitation capabilities 1

Adjunctive Therapy for Hemolytic Disease

In isoimmune hemolytic disease (Rh, ABO), administer intravenous immunoglobulin (IVIG) 0.5-1 g/kg over 2 hours if: 1

• TSB continues rising despite intensive phototherapy, OR
• TSB is within 2-3 mg/dL (34-51 μmol/L) of the exchange transfusion threshold

IVIG reduces the need for exchange transfusion in Rh and ABO hemolytic disease and is reasonable to use for other Rh antibodies (anti-C, anti-E) 1

Discontinuing Phototherapy

Stop phototherapy when TSB decreases to 1-2 mg/dL below the threshold that initially required treatment 2, 5. For infants readmitted with TSB ≥18 mg/dL, phototherapy can typically be discontinued when levels reach 13-14 mg/dL 2

Do not subtract direct bilirubin from total bilirubin when making treatment decisions 1, 2

Phototherapy should be continuous (not intermittent) when bilirubin approaches exchange levels, though brief interruptions for feeding or parental visits are acceptable when levels are not critically elevated 1

Follow-Up After Discharge

Timing of Follow-Up Visits

All infants require structured follow-up based on discharge timing: 1

Infant Discharged	Should Be Seen by Age
Before 24 hours	72 hours
Between 24-47.9 hours	96 hours
Between 48-72 hours	120 hours

Infants discharged before 48 hours may require two follow-up visits (first at 24-72 hours, second at 72-120 hours) 1

High-Risk Follow-Up

• 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
• Earlier or more frequent follow-up is essential for infants with risk factors (G6PD deficiency, hemolytic disease, early discharge) 1
• Rebound hyperbilirubinemia occurs in approximately 15-20% of cases, particularly with hemolytic disease or G6PD deficiency 6, 5

If appropriate follow-up cannot be ensured in high-risk infants, delay discharge until 72-96 hours when the period of greatest risk has passed 1

Feeding and Hydration Management

Continue breastfeeding or bottle-feeding every 2-3 hours 2. If the infant shows signs of dehydration or excessive weight loss (>12% from birth), supplement with formula or expressed breast milk 2

Milk-based formula is preferred for supplementation as it inhibits enterohepatic circulation of bilirubin and helps lower serum levels 1, 2. Routine intravenous fluids or dextrose water supplementation is not necessary unless dehydration is documented 1

Critical Warning Signs for Parents

Educate parents to seek immediate medical attention if the infant develops: 2

• Altered feeding patterns or poor feeding
• Lethargy or excessive sleepiness
• High-pitched crying
• Hypotonia (floppiness) or hypertonia (stiffness)
• Opisthotonus (arching of back) or retrocollis (neck extension)
• Fever

Common Pitfalls to Avoid

• Never use visual assessment alone—always obtain objective TSB or TcB measurement 1, 2
• Do not subtract conjugated bilirubin from total bilirubin when determining treatment thresholds 1, 2
• Avoid unnecessary prolongation of phototherapy as it separates mother and infant and may interfere with breastfeeding establishment 2
• Do not use sunlight exposure as therapeutic intervention despite theoretical benefits—risks include sunburn and temperature instability 2
• Screen for G6PD deficiency in at-risk populations (African American, Mediterranean, Asian descent), as it accounts for up to 31% of kernicterus cases 1
• Recognize pathologic jaundice: jaundice in first 24 hours, TSB rising >5 mg/dL per day, or TSB >17 mg/dL requires investigation for underlying pathology 3