What is the management of physiological jaundice in newborns?

Management of Physiological Jaundice in Newborns

Physiological jaundice in newborns requires systematic monitoring and risk-based intervention rather than routine treatment, with the primary goals being prevention of kernicterus through early detection, promotion of adequate feeding (especially breastfeeding 8-12 times daily), and timely phototherapy when bilirubin levels reach age- and risk-specific thresholds. 1, 2

Understanding Physiological vs. Pathological Jaundice

Physiological jaundice is benign and self-limited, but requires vigilant monitoring to prevent progression to dangerous hyperbilirubinemia. 1, 3

• Physiological jaundice typically appears after 24 hours of life, peaks at 3-5 days, and resolves by 1-2 weeks 3, 4
• Jaundice appearing within the first 24 hours is always pathological and requires immediate investigation 1, 5
• Most jaundice is benign, but bilirubin neurotoxicity can cause permanent damage to basal ganglia and brainstem nuclei, leading to kernicterus 1, 5

Primary Prevention Strategies

Support successful breastfeeding as the cornerstone of prevention, while avoiding interventions that undermine it. 1, 2

• Promote 8-12 breastfeeding sessions per 24 hours during the first several days of life 2, 6
• Do not routinely supplement non-dehydrated breastfed infants with water or dextrose water, as this will not prevent hyperbilirubinemia 2
• Perform prenatal blood typing (ABO and Rh[D]) on all pregnant women and screen for unusual isoimmune antibodies 2
• If mother is Rh-negative or blood type unknown, obtain cord blood for infant's blood type, Rh(D) type, and direct antibody test (Coombs' test) 2

Systematic Monitoring Protocol

All newborns require routine jaundice assessment at least every 8-12 hours, with objective bilirubin measurement when jaundice is present. 1

• Assess jaundice whenever vital signs are measured, but no less than every 8-12 hours 1, 2
• Never rely on visual estimation alone—measure transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) if any jaundice is present 1
• Visual assessment is particularly unreliable in darkly pigmented infants 1
• Perform TcB/TSB measurement on every infant jaundiced in the first 24 hours 1
• TcB devices provide measurements within 2-3 mg/dL of TSB for levels <15 mg/dL and can replace serum measurement in many circumstances 1

Risk Stratification Before Discharge

Systematically assess every infant's risk for severe hyperbilirubinemia before discharge using predischarge bilirubin levels plotted on hour-specific nomograms. 1

Major Risk Factors for Severe Hyperbilirubinemia:

• Predischarge bilirubin level in the high-risk zone on nomogram 1, 5
• Jaundice observed in the first 24 hours 1, 5
• Blood group incompatibility with positive direct antiglobulin test or other hemolytic disease (G6PD deficiency) 1
• Gestational age 35-36 weeks 1, 5
• Exclusive breastfeeding with poor intake and excessive weight loss 1, 5
• Cephalohematoma or significant bruising 1
• East Asian race 1, 5

Decreased Risk Factors:

• TSB/TcB level in the low-risk zone on nomogram 1
• Gestational age ≥41 weeks 1
• Exclusive bottle feeding 1
• Black race 1
• Discharge after 72 hours 1

Post-Discharge Follow-Up Requirements

Early and focused follow-up based on risk assessment is essential to prevent severe hyperbilirubinemia after discharge. 1, 2

Timing of Follow-Up:

• Infants discharged before 24 hours: see by 72 hours of age 1
• Infants discharged between 24-47.9 hours: see by 96 hours of age 1
• Infants discharged between 48-72 hours: see by 120 hours of age 1
• Some newborns discharged before 48 hours may require two follow-up visits 1
• If appropriate follow-up cannot be ensured with elevated risk factors present, delay discharge until 72-96 hours 1

Follow-Up Assessment Components:

• Infant's weight and percentage change from birth weight 1
• Adequacy of intake (number of feedings, voiding, stooling patterns) 1
• Presence or absence of jaundice with TcB/TSB measurement if any doubt exists 1

When to Investigate Underlying Causes

Seek the cause of jaundice when it appears excessive, occurs early, persists beyond 3 weeks, or rises rapidly despite intervention. 1

Laboratory Evaluation Indications:

• Jaundice in first 24 hours: measure TcB/TSB immediately 1
• Jaundice appears excessive for infant's age 1
• Infant receiving phototherapy or TSB rising rapidly (crossing percentiles) 1
• Jaundice at or beyond 3 weeks: measure total and direct/conjugated bilirubin to identify cholestasis 1

Recommended Laboratory Tests:

• Blood type and Coombs' test if not obtained from cord blood 1
• Complete blood count with smear 1
• Direct or conjugated bilirubin 1
• Optional: reticulocyte count, G6PD testing, end-tidal CO measurement 1, 7
• Check newborn thyroid and galactosemia screening results for prolonged jaundice 1

Treatment Thresholds and Phototherapy

Initiate phototherapy based on hour-specific bilirubin nomograms that account for gestational age and risk factors, not arbitrary fixed values. 1, 2

Phototherapy Implementation:

• Use intensive phototherapy with special blue fluorescent tubes or LED lights delivering irradiance >30 μW/cm²/nm 2, 7
• Position light source as close as safely possible to maximize irradiance 7
• Maximize skin exposure by removing diaper when bilirubin approaches exchange transfusion range 7
• Change infant's posture every 2-3 hours to maximize light-exposed surface area 2
• Avoid physical obstruction by equipment, large diapers, head covers, or electrode patches 2

Expected Response:

• Expect TSB decrease >2 mg/dL within 4-6 hours of initiating effective phototherapy 2, 7
• For extremely high levels (>30 mg/dL), expect decline up to 10 mg/dL within a few hours 7
• If TSB does not fall or continues rising despite intensive phototherapy, hemolysis is very likely occurring 1

Feeding During Phototherapy:

• Continue breastfeeding or bottle-feeding every 2-3 hours during phototherapy 7
• Supplement with formula or expressed breast milk for infants with dehydration or weight loss >12% from birth 7
• Milk-based formula can help lower bilirubin by inhibiting enterohepatic circulation 7

Monitoring During Treatment

Serial bilirubin measurements guide treatment intensity and duration, with frequency based on initial severity. 7

• TSB ≥25 mg/dL: repeat measurement within 2-3 hours 7
• TSB 20-25 mg/dL: repeat within 3-4 hours 7
• TSB <20 mg/dL: repeat in 4-6 hours 7
• Monitor continuously for signs of acute bilirubin encephalopathy (lethargy, hypotonia, poor feeding, high-pitched cry, hypertonia, retrocollis, opisthotonos) 1, 7

Discontinuing Phototherapy

Discontinue phototherapy when TSB falls 2-4 mg/dL below the hour-specific threshold at which it was initiated, typically when levels reach 13-14 mg/dL. 7

Post-Phototherapy Monitoring:

• High-risk infants: obtain follow-up TSB 8-12 hours after discontinuation, then again the following day 7
• Standard-risk infants: obtain follow-up TSB within 1-2 days after discontinuation 7
• TcB can be used instead of TSB if ≥24 hours have passed since phototherapy stopped 7
• Infants with hemolytic disease or who received phototherapy before 3-4 days of age require follow-up bilirubin measurement within 24 hours after discharge 7

Exchange Transfusion Considerations

Consider exchange transfusion if TSB is in the intensive phototherapy range and phototherapy does not promptly lower TSB, or if signs of acute bilirubin encephalopathy are present. 2

• Do not subtract direct bilirubin from TSB when making exchange transfusion decisions 2, 7
• For TSB ≥25 mg/dL or ≥20 mg/dL in sick/premature infants, obtain blood type and crossmatch in preparation 7

Parent Education and Warning Signs

Provide written and verbal information to parents at discharge about jaundice monitoring and when to seek care. 1, 7

Key Warning Signs Parents Should Monitor:

• Worsening yellow color of skin, especially if extending to arms and legs 1
• Poor feeding, lethargy, or difficulty waking infant 7
• High-pitched crying 7
• Arching of neck or body (retrocollis, opisthotonos) 7
• Fever, hypotonia, or hypertonia 7

Common Pitfalls to Avoid

• Never use visual assessment alone—always measure bilirubin objectively 7
• Do not use sunlight exposure as a therapeutic tool 7
• Avoid unnecessary prolongation of phototherapy as it separates mother and infant and may interfere with breastfeeding 7
• Do not routinely supplement breastfed infants with water, as this does not prevent hyperbilirubinemia 2
• TcB and visual assessment are unreliable during phototherapy due to skin bleaching 1