What is the initial approach to managing neonatal jaundice?

Initial Approach to Managing Neonatal Jaundice

All newborns should undergo systematic risk assessment and regular jaundice monitoring every 8-12 hours, with objective bilirubin measurement (transcutaneous or serum) for any visible jaundice, plotted on hour-specific nomograms to guide phototherapy decisions. 1

Pre-discharge Risk Assessment

Maternal and Cord Blood Testing

• All pregnant women must be tested for ABO and Rh(D) blood types with antibody screening to identify isoimmune hemolysis risk 2, 1
• If the mother is Rh-negative or blood type is unknown, obtain cord blood for direct antibody test (Coombs'), blood type, and Rh(D) typing 2, 1
• For mothers with blood type O Rh-positive, cord blood testing is optional if adequate surveillance and follow-up are ensured 2

Clinical Monitoring Protocol

• Assess jaundice whenever vital signs are measured, but no less than every 8-12 hours 2, 1
• Examine by blanching the skin with digital pressure to reveal underlying color 2, 1
• Visual assessment alone is unreliable—jaundice in the first 24 hours always requires objective measurement 1

Bilirubin Measurement Strategy

When to Measure

• Any infant with visible jaundice in the first 24 hours requires immediate TcB or TSB measurement 1
• Establish nursery protocols allowing nursing staff to obtain TcB or order TSB based on clinical assessment 2

Measurement Methods

• Transcutaneous bilirubinometry (TcB) provides valid estimates for TSB levels <15 mg/dL (257 μmol/L) 2, 1
• TcB can be used during phototherapy if a strip of black tape covers the sternum, which is uncovered for measurements 3
• At TcB levels >250 μmol/L (approximately 14.6 mg/dL), confirm with serum bilirubin as TcB tends to underestimate at higher levels 3
• All bilirubin measurements must be plotted on hour-specific nomograms to determine risk zone (low, intermediate, or high) 1, 4

Feeding Management

Breastfeeding Support

• Do NOT routinely supplement non-dehydrated breastfed infants with water or dextrose water—this does not prevent hyperbilirubinemia or decrease bilirubin levels 2, 1
• Encourage frequent breastfeeding (8-12 times per 24 hours) to decrease likelihood of significant hyperbilirubinemia 2, 1
• Assess adequacy of intake by monitoring weight change, urination pattern, and stool frequency 1

Diagnostic Workup for Pathologic Jaundice

When to Investigate Further

• Jaundice in the first 24 hours is always pathologic and requires immediate evaluation 1
• Rapidly rising bilirubin (crossing percentiles on nomogram) not explained by history and physical examination 2, 1
• Any infant requiring phototherapy 2

Initial Laboratory Tests

• Blood type and Coombs' test if not already performed 1
• Complete blood count with peripheral smear to evaluate for hemolysis 1
• Total and direct/conjugated bilirubin 1

Special Circumstances

• For jaundice persisting at or beyond 3 weeks: measure total and direct bilirubin to identify cholestasis 2, 1, 5
• Verify newborn thyroid and galactosemia screening results 2, 5
• Consider urinalysis and urine culture if direct bilirubin is elevated 5

Phototherapy Initiation

Treatment Thresholds

• Initiate phototherapy when total bilirubin reaches or exceeds the phototherapy threshold for the infant's age in hours and risk category 1
• Use current AAP hour-specific nomograms that account for gestational age and neurotoxicity risk factors 6
• Do NOT subtract direct bilirubin from total bilirubin when making phototherapy decisions 7

Phototherapy Technique

• Maximize skin exposure by minimizing physical obstructions (large diapers, head covers, eye masks, electrode patches) 1
• Expect bilirubin decrease of >2 mg/dL within 4-6 hours if phototherapy is effective 1

Follow-up Timing

Risk-Stratified Approach

• Infants with risk factors or rapidly rising bilirubin: recheck within 4-12 hours 1
• Stable infants without risk factors: recheck within 12-24 hours 1
• Infants with bilirubin approaching treatment thresholds: follow-up within 24 hours 1
• All infants should have follow-up within 24-72 hours of discharge based on risk zone 4

Critical Pitfalls to Avoid

• Never rely on visual assessment alone—always obtain objective measurements for jaundiced infants 2, 1
• Do not delay measurement in infants jaundiced within 24 hours—this represents pathologic jaundice requiring urgent evaluation 1
• Avoid unnecessary supplementation in breastfed infants, which does not help and may undermine breastfeeding success 2, 1
• Do not miss cholestasis—any jaundice beyond 3 weeks requires direct bilirubin measurement 2, 5
• Remember that kernicterus remains preventable with systematic assessment, close follow-up, and prompt intervention 2