Treatment of Hyperbilirubinemia
Phototherapy is the primary treatment for neonatal hyperbilirubinemia, with specific bilirubin thresholds determining when to initiate therapy based on the infant's age in hours. 1, 2
Treatment Thresholds and Initiation
Initiate phototherapy at the following total serum bilirubin (TSB) levels based on infant age: 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)
If TSB reaches exchange transfusion levels or ≥25 mg/dL at any time, this is a medical emergency requiring immediate hospital admission for intensive phototherapy—do not route through the emergency department as this delays treatment. 1
Phototherapy Implementation
Technical Specifications
Use blue-green LED light sources at 460-490 nm wavelength (optimal peak 478 nm) delivering 25-35 mW/cm²/nm irradiance to at least one body surface. 2 LED sources are preferred because they deliver specific wavelengths with minimal heat generation. 2
Maximizing Efficacy
Position light rays perpendicular to the incubator surface and minimize distance between device and infant. 2 Expose 35-80% of total body surface area by repositioning the infant every 2-3 hours. 2 Remove all physical obstructions including radiant warmers, large diapers, head covers, electrode patches, and plastic covers. 2
For rapidly rising or severe hyperbilirubinemia approaching exchange levels, implement intensive phototherapy using multiple devices simultaneously (combine fluorescent tubes with fiber-optic pads or LED mattresses) to maximize exposed surface area. 2
Monitoring Response
Expect clinical response within 4-6 hours with TSB decrease >2 mg/dL (34 μmol/L). 2 Discontinue phototherapy when TSB falls below 13-14 mg/dL. 2 Note that phototherapy may be less effective in infants with hemolysis, requiring more intensive treatment. 2
Exchange Transfusion
Perform exchange transfusion when TSB approaches or exceeds exchange level thresholds despite intensive phototherapy. 2 Immediately perform exchange transfusion for any infant showing signs of intermediate to advanced acute bilirubin encephalopathy (altered feeding, lethargy, high-pitched crying, hypotonia, hypertonia, opisthotonus, retrocollis), even if TSB is falling. 2
Exchange transfusions must be performed only by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities. 1 Use modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant. 2 Be aware that significant morbidity (apnea, bradycardia, cyanosis, vasospasm, thrombosis, necrotizing enterocolitis) occurs in up to 5% of patients undergoing exchange transfusion. 1
Pharmacological Adjuncts
For isoimmune hemolytic disease (Rh, ABO, anti-C, anti-E), administer intravenous immunoglobulin (IVIG) 0.5-1 g/kg over 2 hours if TSB is rising despite intensive phototherapy or is within 2-3 mg/dL (34-51 μmol/L) of exchange level. 1, 2 IVIG has been shown to reduce the need for exchange transfusions in hemolytic disease. 1
Tin-mesoporphyrin (a heme oxygenase inhibitor) shows promise but is not FDA-approved for routine use. 2, 4
Breastfeeding Management
Continue breastfeeding during phototherapy whenever possible. 2 Consider temporary interruption with formula supplementation to enhance phototherapy efficacy in severe cases, as milk-based formula inhibits enterohepatic circulation of bilirubin. 2
Critical Pitfalls to Avoid
Do not subtract direct (conjugated) bilirubin from total bilirubin when making treatment decisions. 1, 2 The exception is when direct bilirubin is ≥50% of total bilirubin—in this unusual situation, consult an expert. 1
Never rely on visual assessment of jaundice alone—always obtain TSB or transcutaneous bilirubin measurement. 2
Do not use sunlight exposure as therapeutic intervention in high-resource settings due to risks of sunburn and temperature instability. 2
Post-Treatment 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 to check for rebound hyperbilirubinemia. 2
Educate parents to seek immediate medical attention for warning signs of acute bilirubin encephalopathy: altered feeding patterns, lethargy, high-pitched crying, hypotonia, hypertonia, opisthotonus, or retrocollis. 2
Special Populations
Crigler-Najjar Type I
For Crigler-Najjar Type I (complete UGT deficiency), liver transplantation is the only effective curative treatment and should be discussed at diagnosis. 1 While phototherapy (20-24 hours daily during crises, minimum 8-12 hours daily for maintenance) can manage hyperbilirubinemia temporarily, it is difficult to maintain long-term and does not prevent eventual brain damage. 1