What is the treatment for elevated bilirubin levels in newborns?

Treatment of Neonatal Hyperbilirubinemia

Phototherapy is the primary treatment for elevated bilirubin levels in newborns, using blue-green light (460-490 nm wavelength, optimal peak 478 nm) with an irradiance of 25-35 mW/cm²/nm delivered to maximize body surface area exposure. 1, 2

Phototherapy Implementation

Light Specifications and Equipment

• Use LED light sources as the preferred technology because they deliver specific wavelengths in narrow bandwidths with minimal heat generation 1, 2
• Special blue fluorescent tubes are acceptable alternatives, providing light predominantly in the blue-green spectrum where bilirubin absorption is maximal 3
• Ensure irradiance of at least 30 mW/cm²/nm for intensive phototherapy when bilirubin levels are severely elevated 3, 1
• Standard phototherapy delivers 8-10 mW/cm²/nm, while intensive phototherapy requires >30 mW/cm²/nm 3

Maximizing Treatment Efficacy

• Position fluorescent tubes as close as possible to the infant (approximately 10 cm) to dramatically increase spectral irradiance 3
• Place infants in bassinets rather than incubators, as incubator tops prevent adequate proximity of light sources 3
• Expose 35-80% of total body surface area by changing the infant's position every 2-3 hours 1, 2
• Remove the diaper when bilirubin levels approach exchange transfusion range to maximize exposed surface area 3
• Use multiple devices simultaneously (fluorescent tubes above with fiber-optic pads below) for severe hyperbilirubinemia 3, 1
• Line bassinet sides with aluminum foil or white cloth to increase surface area exposure when bilirubin levels are extremely high 3

Critical Technical Considerations

• Ensure light rays are perpendicular to the incubator surface to minimize reflectance 1
• Avoid physical obstructions including radiant warmers, large diapers, head covers, electrode patches, and insulating plastic covers 1, 2
• Keep reflectors, light sources, and transparent filters clean 3
• Do not position halogen lamps closer than manufacturer recommendations due to burn risk 3

Expected Clinical Response

Timeline and Magnitude

• Clinical impact should be evident within 4-6 hours with an anticipated decrease of >2 mg/dL (34 μmol/L) 3, 1, 2
• For extremely high bilirubin levels (>30 mg/dL), intensive phototherapy can produce a decline of up to 10 mg/dL within a few hours 3
• Expect a decrease of 0.5-1 mg/dL per hour in the first 4-8 hours with intensive phototherapy 3
• Intensive phototherapy produces a 30-40% decrement in initial bilirubin level by 24 hours for infants >35 weeks gestation 3
• Standard phototherapy systems produce a 6-20% decrease in the first 24 hours 3

Monitoring Schedule

• If TSB ≥25 mg/dL, repeat measurement within 2-3 hours 1, 2
• If TSB 20-25 mg/dL, repeat within 3-4 hours 1, 2
• If TSB <20 mg/dL, repeat in 4-6 hours 1, 2

Duration and Discontinuation

Continuous vs. Intermittent Therapy

• Administer phototherapy continuously when bilirubin levels approach exchange transfusion zone until satisfactory decline occurs 3
• Brief interruptions for feeding or parental visits are acceptable when bilirubin is not critically elevated 3
• No scientific rationale exists for routine intermittent phototherapy, as all light exposure increases bilirubin excretion 3

Stopping Criteria

• Discontinue phototherapy when serum bilirubin falls below 13-14 mg/dL 3, 1, 2
• For infants with hemolytic disease or those treated before 3-4 days of age, obtain follow-up bilirubin measurement within 24 hours after discharge 3, 1, 2
• Discharge need not be delayed to observe for rebound in infants readmitted for hyperbilirubinemia 3

Supportive Care During Phototherapy

Hydration and Nutrition

• Continue feeding every 2-3 hours to maintain adequate hydration 1, 2
• Use milk-based formula for mildly dehydrated infants as it inhibits enterohepatic circulation of bilirubin 3, 1
• Routine intravenous fluids or dextrose water supplementation is unnecessary unless dehydration is present 3
• Continue breastfeeding during phototherapy when possible, though temporary interruption with formula supplementation may enhance efficacy 1, 2

Escalation to Advanced Therapies

Intensive Phototherapy Indications

• Implement aggressive "crash-cart" approach with multiple devices simultaneously when TSB approaches exchange transfusion levels 3, 1
• This rapid implementation reduces the need for exchange transfusion and may minimize bilirubin neurotoxicity severity 3

Intravenous Immunoglobulin (IVIG)

• Administer IVIG 0.5-1 g/kg over 2 hours for isoimmune hemolytic disease with rapidly rising TSB despite intensive phototherapy 1, 2

Exchange Transfusion

• Indicated when TSB levels approach or exceed exchange thresholds despite intensive phototherapy 1, 2
• Perform immediate exchange transfusion for any infant showing signs of intermediate to advanced acute bilirubin encephalopathy, even if TSB is falling 1, 2
• Use modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant 1

Special Populations

Hemolytic Disease

• Phototherapy is less effective in hemolysis, requiring more intensive treatment 3, 1, 2
• Start phototherapy at lower TSB levels when hemolysis is present 3
• Failure of phototherapy to produce expected decline suggests hemolysis as the underlying cause 3

Cholestatic Jaundice

• Bronze infant syndrome may develop (dark grayish-brown discoloration of skin, serum, and urine) 3
• Do not withhold phototherapy for direct hyperbilirubinemia if treatment is needed, as this syndrome generally has few deleterious consequences 3
• Consider exchange transfusion if TSB remains in intensive phototherapy range without prompt decline 3
• Never subtract direct bilirubin from TSB when making exchange transfusion decisions 3, 1

Premature Infants (35-36 Weeks)

• Use lower phototherapy thresholds due to increased risk of bilirubin neurotoxicity 4
• Mandatory follow-up within 24-48 hours of discharge 4
• Pre-discharge bilirubin measurement with plotting on hour-specific nomograms is essential 4

Critical Pitfalls to Avoid

• Never rely on visual assessment of jaundice alone—always obtain TSB or transcutaneous bilirubin measurement 1, 4
• Do not use sunlight exposure as a reliable therapeutic tool due to risks of sunburn and temperature instability 3, 1
• Avoid home phototherapy for bilirubin levels above the "optional phototherapy" range 3
• Congenital porphyria or family history of porphyria is an absolute contraindication to phototherapy 3
• Do not use photosensitizing drugs or agents concomitantly with phototherapy 3
• Avoid unnecessary prolongation of phototherapy as it separates mother and infant and may interfere with breastfeeding 1

Post-Treatment Education

Educate parents about warning signs requiring immediate medical attention 1:

• Altered feeding patterns
• Lethargy
• High-pitched crying
• Hypotonia or hypertonia
• Opisthotonus and retrocollis