What are the guidelines for managing neonatal jaundice in the Philippines?

Philippine Neonatal Jaundice Management Guidelines

While there are no Philippines-specific published guidelines available in the provided evidence, the American Academy of Pediatrics (AAP) 2004 guidelines for managing hyperbilirubinemia in newborns ≥35 weeks gestation provide the internationally recognized framework that should be followed in the Philippines. 1

Universal Screening and Risk Assessment

All newborns must undergo systematic assessment for jaundice risk before discharge from the hospital. 1

Pre-Discharge Requirements:

• Measure transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) on every infant who appears jaundiced in the first 24 hours after birth 1
• Plot the bilirubin level on the hour-specific Bhutani nomogram to determine risk zone (low, intermediate, or high risk) 1
• Visual estimation alone is unreliable and should never be used as the sole assessment method, particularly in darkly pigmented infants 1
• Document risk factors including: gestational age 35-37 weeks, exclusive breastfeeding, previous sibling with jaundice requiring phototherapy, cephalohematoma, East Asian race, and maternal blood group incompatibility 1

Mandatory Follow-Up Schedule

The timing of post-discharge follow-up is determined by when the infant was discharged, not by clinical judgment alone: 1

Infant Discharged	Must Be Seen By Age
Before 24 hours	72 hours
Between 24-47.9 hours	96 hours
Between 48-72 hours	120 hours

• Infants discharged before 48 hours may require two follow-up visits 1
• If adequate follow-up cannot be ensured for high-risk infants, delay discharge until 72-96 hours of age 1

Breastfeeding Management

Continue breastfeeding throughout jaundice evaluation and treatment—do not routinely discontinue. 1

• Advise mothers to nurse 8-12 times per day in the first several days 1, 2
• Poor intake and dehydration from inadequate breastfeeding contribute to hyperbilirubinemia 1, 3
• Supplementation with expressed breast milk or formula is appropriate only if intake is inadequate, weight loss is excessive, or the infant appears dehydrated 1

Laboratory Evaluation

Initial Jaundice in First 24 Hours:

• Immediately measure TcB and/or TSB 1
• Blood type and Rh of infant and mother 1
• Direct Coombs test 1

Jaundice Requiring Phototherapy or Rising Rapidly:

• Blood type and Coombs if not already done 1
• Complete blood count with smear 1
• Direct or conjugated bilirubin 1
• Consider: reticulocyte count, G6PD (particularly important in the Philippines given higher prevalence in Southeast Asian populations), end-tidal CO if available 1, 3

Jaundice at or Beyond 3 Weeks:

• Total and direct/conjugated bilirubin to identify cholestasis 1
• Check newborn thyroid and galactosemia screening results 1

Do NOT subtract direct bilirubin from total bilirubin when using treatment guidelines 1

Treatment Thresholds

Phototherapy Initiation:

Use intensive phototherapy when TSB exceeds the hour-specific threshold based on: 1

1. Infant's age in hours (not days) 1
2. Gestational age (35-36 weeks vs ≥37 weeks) 1
3. Presence of neurotoxicity risk factors:
   • Isoimmune hemolytic disease
   • G6PD deficiency
   • Asphyxia
   • Lethargy, temperature instability, sepsis, acidosis
   • Albumin <3.0 g/dL 1

Intensive Phototherapy Specifications:

• Irradiance ≥30 μW/cm²/nm in blue-green spectrum (430-490 nm) 1, 2
• Delivered to maximum infant surface area 1
• If TSB approaches exchange transfusion levels, line bassinet sides with aluminum foil or white material to increase exposed surface area 1

Exchange Transfusion:

TSB ≥25 mg/dL (428 μmol/L) at any time is a medical emergency: 1

• Admit immediately and directly to hospital pediatric service for intensive phototherapy—do NOT route through emergency department 1
• Exchange transfusion must be performed only by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities 1
• Immediate exchange transfusion is required for any jaundiced infant showing signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) regardless of bilirubin level 1

Adjunctive Therapy for Isoimmune Hemolysis:

Administer intravenous immunoglobulin (IVIG) 0.5-1 g/kg over 2 hours if: 1

• TSB is rising despite intensive phototherapy, OR
• TSB is within 2-3 mg/dL of exchange transfusion level

This applies to Rh, ABO, and other isoimmune hemolytic diseases 1

Critical Clinical Pitfalls

Signs of Acute Bilirubin Encephalopathy (Kernicterus):

Early phase: Lethargy, hypotonia, poor feeding 1

Intermediate phase: Moderate stupor, irritability, hypertonia, fever, high-pitched cry alternating with drowsiness, backward arching of neck (retrocollis) and trunk (opisthotonos) 1

Advanced phase: Pronounced retrocollis-opisthotonos, shrill cry, no feeding, apnea, deep stupor to coma, seizures 1

Common Errors to Avoid:

• Never rely on visual assessment alone—always measure bilirubin objectively 1
• Never use TcB measurements in infants receiving phototherapy—phototherapy "bleaches" the skin and renders measurements unreliable 1
• Never delay treatment for infants with TSB ≥25 mg/dL by sending to emergency department first 1
• Do not assume jaundice is benign in G6PD deficiency—these infants require intervention at lower thresholds and can develop sudden dangerous increases in bilirubin 3

Monitoring During Treatment

• Measure TSB every 2-3 hours if TSB ≥25 mg/dL 1
• Measure TSB every 3-4 hours if TSB 20-25 mg/dL 1
• Measure TSB every 4-6 hours if TSB <20 mg/dL 1
• If TSB continues to fall, extend to every 8-12 hours 1
• If TSB is not decreasing or continues rising despite intensive phototherapy, hemolysis is very likely occurring—investigate immediately 1

Discontinuing Phototherapy

• Stop phototherapy when TSB falls to <13-14 mg/dL (239 μmol/L) 1
• Consider measuring TSB 24 hours after discharge to check for rebound, depending on the cause of hyperbilirubinemia 1