What is the management for a newborn with hyperbilirubinemia (elevated bilirubin level) of 289 at 72 hours old?

Management of Bilirubin 289 μmol/L (17 mg/dL) at 72 Hours

This 72-hour-old newborn with a bilirubin of 289 μmol/L (17 mg/dL) requires immediate phototherapy initiation and close monitoring, as this level is above the 95th percentile for age and approaches treatment thresholds for most term infants. 1, 2

Immediate Actions Required

1. Initiate Phototherapy

• Start intensive phototherapy immediately if the infant is at or above the phototherapy threshold based on gestational age and risk factors 3, 2
• For a term infant at 72 hours with a bilirubin of 17 mg/dL, this level typically warrants phototherapy for most risk categories 2
• Do not subtract direct bilirubin from total bilirubin when making treatment decisions 3

2. Recheck Bilirubin Levels

• Measure total serum bilirubin within 4-24 hours to assess trajectory and phototherapy efficacy 2
• If risk factors for neurotoxicity exist or bilirubin is rising rapidly (>0.2 mg/dL/hour), recheck within 4-12 hours 2
• For stable infants without risk factors, recheck within 12-24 hours 2

3. Evaluate for Underlying Causes

Obtain the following laboratory tests immediately: 1, 2

• Blood type and Coombs' test (if not already done)
• Complete blood count with smear
• Direct or conjugated bilirubin measurement
• Reticulocyte count (optional but helpful)
• G6PD screening (particularly important as G6PD deficiency causes 31.5% of kernicterus cases) 1

Risk Stratification

Major Risk Factors to Assess: 1

• Gestational age: 35-36 weeks carries higher risk than ≥39 weeks
• Hemolytic disease: ABO/Rh incompatibility, G6PD deficiency
• Feeding status: Exclusive breastfeeding with poor intake/excessive weight loss increases risk
• Cephalohematoma or significant bruising
• East Asian race (higher risk) vs. Black race (lower risk)
• Jaundice observed in first 24 hours

Assess for Hemolysis: 2

• A rise >0.2 mg/dL/hour after 24 hours suggests hemolysis
• If bilirubin continues rising despite intensive phototherapy, hemolysis is very likely 3

Treatment Monitoring

Phototherapy Efficacy: 3, 4

• Phototherapy reduces risk of bilirubin >20 mg/dL by 10-17% in healthy jaundiced infants
• Measure total serum bilirubin after starting phototherapy to verify efficacy 2
• If bilirubin does not fall or continues rising despite intensive phototherapy, consider exchange transfusion 3

Exchange Transfusion Considerations: 4

• Reserved for bilirubin levels approaching exchange thresholds (typically >25-30 mg/dL depending on risk factors)
• Mortality risk: 3-4 per 1,000 term infants without serious hemolytic disease
• Permanent sequelae risk: 5-10% in sick infants who survive

Special Considerations

If Direct Bilirubin is Elevated: 3

• Direct bilirubin >1.0 mg/dL is abnormal if total bilirubin ≤5 mg/dL
• Phototherapy efficacy is reduced in cholestasis, and bronze infant syndrome may develop
• Do not withhold phototherapy if needed—direct hyperbilirubinemia is not a contraindication 3
• If direct bilirubin is ≥50% of total bilirubin, consult an expert 3

Breastfeeding Management: 5

• Do not interrupt breastfeeding unnecessarily, as this increases risk of early discontinuation
• Ensure adequate caloric intake and assess feeding adequacy 1
• Monitor weight loss and voiding/stooling patterns 1

Follow-Up Plan

Short-Term: 1, 2

• Continue phototherapy until bilirubin falls below treatment threshold
• Recheck bilirubin 4-24 hours after starting phototherapy
• Monitor for signs of bilirubin encephalopathy (lethargy, poor feeding, high-pitched cry, hypotonia)

Post-Discharge: 1

• Ensure follow-up within 24-48 hours if discharged before bilirubin peaks
• Provide written and verbal information to parents about jaundice monitoring
• Instruct parents on when to seek immediate medical attention

Critical Pitfalls to Avoid

• Do not rely on visual assessment alone—always measure bilirubin levels, especially in darkly pigmented infants 1
• Do not delay phototherapy while waiting for laboratory results if clinical jaundice is significant 2
• Do not subtract direct bilirubin from total bilirubin when determining treatment thresholds 3
• Do not discharge without ensuring appropriate follow-up, particularly if risk factors are present 1