What is the treatment for hyperbilirubinemia?

Treatment for Hyperbilirubinemia

Phototherapy is the primary treatment for neonatal hyperbilirubinemia, with exchange transfusion reserved for extreme cases that fail to respond to intensive phototherapy or when total serum bilirubin (TSB) reaches emergency levels. 1

Immediate Management Based on Bilirubin Levels

Emergency Situations (TSB ≥ 25 mg/dL or ≥ 20 mg/dL in sick/preterm infants)

• Admit the infant immediately and directly to a hospital pediatric service for intensive phototherapy—do not refer to the emergency department as this delays treatment. 1
• Obtain type and crossmatch for potential exchange transfusion. 1
• Repeat TSB within 2-3 hours to monitor response. 1

Intensive Phototherapy Indications

• Use phototherapy devices that deliver irradiance of at least 30 μW·cm⁻²·nm⁻¹ in the blue-to-green range (460-490 nm) over maximal body surface area. 1
• The American Academy of Pediatrics provides age-specific thresholds: initiate phototherapy at TSB ≥ 15 mg/dL for infants 25-48 hours old, ≥ 18 mg/dL for 49-72 hours old, and ≥ 20 mg/dL for infants older than 72 hours. 2
• Discontinue phototherapy when TSB falls below 13-14 mg/dL. 1, 3

Exchange Transfusion

Indications

• TSB reaches levels indicated in American Academy of Pediatrics nomograms (Figure 4 in guidelines). 1
• TSB ≥ 25 mg/dL at any time despite intensive phototherapy. 1
• TSB continues rising despite intensive phototherapy or approaches exchange levels. 1

Critical Requirements

• Exchange transfusions must be performed only by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities. 1
• Recognize that significant morbidity (apnea, bradycardia, cyanosis, vasospasm, thrombosis, necrotizing enterocolitis) occurs in up to 5% of exchange transfusions. 1

Isoimmune Hemolytic Disease

For infants with isoimmune hemolytic disease (Rh or ABO), 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 of exchange level. 1

• Repeat IVIG dose in 12 hours if necessary. 1
• This intervention reduces the need for exchange transfusions in hemolytic disease. 1

Supportive Care During Treatment

Feeding and Hydration

• Continue breastfeeding or bottle-feeding every 2-3 hours during phototherapy. 1, 3
• If weight loss exceeds 12% from birth or clinical/biochemical dehydration is present, supplement with formula or expressed breast milk. 1
• Consider intravenous fluids if oral intake is questionable. 1

Monitoring During Intensive Phototherapy

• For TSB 20-25 mg/dL: repeat within 3-4 hours. 1
• For TSB < 20 mg/dL: repeat in 4-6 hours, then 8-12 hours if continuing to fall. 1
• Ensure phototherapy devices fully illuminate the infant's body surface area—blocking the light source or reducing exposed body surface should be avoided. 1

Essential Laboratory Evaluation

Obtain the following tests to identify underlying causes: 1

• TSB and direct (fractionated) bilirubin levels
• Blood type (ABO, Rh) and direct antibody test (Coombs')
• Complete blood count with differential and red cell morphology
• Reticulocyte count
• Serum albumin
• G6PD if suggested by ethnic/geographic origin or poor phototherapy response
• Urine for reducing substances (to evaluate for galactosemia)
• If sepsis suspected: blood culture, urine culture, and cerebrospinal fluid analysis

Critical Pitfalls to Avoid

Do not subtract direct (conjugated) bilirubin from total bilirubin when making treatment decisions. 1, 4, 3 This is a common error that can lead to undertreatment.

Do not rely on visual assessment of jaundice alone—always obtain measured bilirubin levels. 4, 3

Do not use sunlight exposure as a therapeutic tool despite its theoretical benefits, as practical difficulties in safely exposing a naked newborn to sun (avoiding sunburn and temperature instability) preclude its reliable use. 1, 3

Special Circumstances

Bronze Infant Syndrome (Direct Hyperbilirubinemia)

• When direct bilirubin is ≥ 50% of total bilirubin, consult an expert in the field. 1, 3
• The presence of cholestatic jaundice should not be considered a contraindication to phototherapy if needed. 1
• Consider exchange transfusion if TSB is in the intensive phototherapy range and phototherapy does not promptly lower TSB. 1

Follow-up After Treatment

• 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. 3
• Monitor for rebound hyperbilirubinemia, which occurs in approximately 15% of cases. 5