What is the management approach for jaundice in newborns?

Management of Neonatal Jaundice

All jaundiced newborns require objective bilirubin measurement (transcutaneous or total serum bilirubin) rather than visual assessment, with interpretation based on the infant's age in hours using hour-specific nomograms to determine risk stratification and guide treatment decisions. 1, 2

Initial Assessment and Measurement

• Measure transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) immediately if jaundice appears in the first 24 hours after birth, as this is pathologic until proven otherwise 1, 3
• Obtain TcB or TSB if jaundice appears excessive for the infant's age, as visual estimation is unreliable, particularly in darkly pigmented infants 1, 4
• Plot all bilirubin values on the hour-specific Bhutani nomogram to determine risk zone (low, intermediate, or high risk for severe hyperbilirubinemia) 1, 2
• TcB devices provide valid estimates when TSB levels are below 15 mg/dL (257 μmol/L); above this threshold, obtain serum measurements 1, 4

Laboratory Evaluation Based on Clinical Presentation

For jaundice in first 24 hours or rapidly rising bilirubin:

• Blood type and Coombs' test (if not obtained from cord blood) 1
• Complete blood count with peripheral smear 1
• Direct or conjugated bilirubin level 1
• Reticulocyte count and G6PD level (particularly in at-risk ethnic groups: Greek, Turkish, Sardinian, Nigerian, and Sephardic Jewish backgrounds) 1, 3

For jaundice at or beyond 3 weeks of age:

• Measure total and direct (or conjugated) bilirubin to identify cholestasis 1, 4
• Verify results of newborn thyroid and galactosemia screening 1
• Perform urinalysis and urine culture if direct bilirubin is elevated 1
• Evaluate for sepsis if indicated by clinical signs 1

Treatment Thresholds and Phototherapy

Phototherapy initiation:

• Use intensive phototherapy (irradiance ≥30 μW/cm²/nm in blue-green spectrum, 430-490 nm wavelengths) delivered to maximum body surface area 1
• Thresholds vary by age in hours and risk factors; lower thresholds apply for infants with: 1
  • Gestational age 35-37 weeks
  • Isoimmune hemolytic disease
  • G6PD deficiency
  • Asphyxia, sepsis, acidosis
  • Serum albumin <3.0 g/dL

During phototherapy:

• Continue breastfeeding every 2-3 hours; do not routinely interrupt breastfeeding 1, 2
• Supplement with expressed breast milk or formula only if intake is inadequate, weight loss exceeds 12%, or clinical/biochemical dehydration is present 1
• Avoid routine intravenous fluids or dextrose water supplementation in well-hydrated term infants 1
• Repeat TSB every 2-3 hours if ≥25 mg/dL (428 μmol/L), every 3-4 hours if 20-25 mg/dL, or every 4-6 hours if <20 mg/dL 1

Discontinuing phototherapy:

• Stop when TSB falls below 13-14 mg/dL (239 μmol/L) for readmitted infants 1
• Obtain follow-up bilirubin measurement within 24 hours if phototherapy discontinued before 3-4 days of age or in hemolytic disease 1

Exchange Transfusion Considerations

• Perform immediate exchange transfusion for any jaundiced infant manifesting acute bilirubin encephalopathy signs (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry), even if TSB is falling 1
• Measure serum albumin and use bilirubin/albumin ratio in conjunction with TSB level when considering exchange transfusion 1
• For isoimmune hemolytic disease with TSB rising despite intensive phototherapy or within 2-3 mg/dL of exchange level, administer intravenous immunoglobulin 0.5-1 g/kg over 2 hours, repeat in 12 hours if necessary 1

Follow-Up and Monitoring

• Schedule clinical follow-up within 48-72 hours (by 120 hours of age) for infants discharged between 48-72 hours of life 2
• Assess weight, feeding adequacy (8-12 feedings per 24 hours if breastfeeding), voiding/stooling patterns, and presence of jaundice 2
• Obtain repeat bilirubin measurement if jaundice appears to be increasing at follow-up 2
• Do not discharge 35-week gestation infants before 48 hours, as they are four times more likely to develop significant hyperbilirubinemia than 40-week infants 3

Critical Pitfalls to Avoid

• Never rely on visual assessment alone—always obtain objective measurements when jaundice is suspected 1, 4
• Never subtract direct bilirubin from total bilirubin when making phototherapy or exchange transfusion decisions; use total bilirubin values 4
• Do not use "homeopathic doses" of phototherapy—ensure therapeutic irradiance levels are achieved and measured 3
• Investigate failure to respond to adequate phototherapy, as this suggests unrecognized hemolytic process 3
• Do not recommend sunlight exposure as therapy due to impracticality and risk of sunburn 1, 2
• Recognize that late-rising bilirubin (after initial decline) is typical of G6PD deficiency 3
• For prolonged jaundice beyond 2 weeks, check metabolic screen for hypothyroidism and ask about stool/urine color; any infant jaundiced beyond 3 weeks requires direct bilirubin measurement to exclude cholestasis 3

Special Populations

• Treat 35-37 week gestation infants with lower phototherapy thresholds—they are not full-term despite being cared for in well-baby nurseries 1, 3
• East Asian infants and those with G6PD deficiency have higher risk for significant hyperbilirubinemia and require closer monitoring 4
• Bronze infant syndrome may occur in infants with cholestasis receiving phototherapy but is not a contraindication to treatment if phototherapy is needed 1