What is the management of hyperbilirubinemia in a neonate?

Management of Neonatal Hyperbilirubinemia

Immediate Assessment and Risk Stratification

All neonates with visible jaundice require objective measurement of total serum bilirubin (TSB) immediately—visual assessment alone is dangerously unreliable, particularly in darkly pigmented infants. 1, 2

Obtain the following laboratory workup to identify pathologic causes:

• TSB and direct/conjugated bilirubin (if TSB ≤5 mg/dL, direct bilirubin >1.0 mg/dL is abnormal) 3, 1
• Blood type and direct antibody test (Coombs) 1, 4
• Complete blood count with differential and reticulocyte count to assess for hemolysis 1, 4
• Serum albumin level 1, 4
• G6PD level if ethnically indicated (Asian, African, Mediterranean descent), though note that G6PD can be falsely elevated during active hemolysis, requiring repeat testing at 3 months if suspicion remains high 3, 1

Obtain a detailed feeding history including adequacy of intake, weight change from birth (>12% loss is concerning), and voiding/stooling patterns 1, 4.

Any infant remaining clinically jaundiced at 2 weeks of age requires measurement of total and direct bilirubin to rule out cholestatic conditions like biliary atresia 1.

Phototherapy Initiation

Initiate intensive phototherapy when TSB reaches 13-15 mg/dL, depending on gestational age and risk factors. 1, 4

Intensive phototherapy specifications:

• Use special blue light in the 430-490 nm spectrum with irradiance ≥30 μW/cm²/nm 1, 2, 4
• Position the light source as close as safely possible to maximize irradiance 1, 4
• Maximize skin exposure by removing the diaper when bilirubin approaches exchange transfusion range 4

Continue breastfeeding or bottle-feeding every 2-3 hours during phototherapy 1, 4. Supplement with formula or expressed breast milk if the infant shows signs of dehydration or weight loss >12% from birth—milk-based formula inhibits enterohepatic circulation of bilirubin 4.

Monitoring During Treatment

The frequency of TSB monitoring depends on the initial level:

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

Continue monitoring every 4-6 hours until bilirubin shows a consistent downward trend 1, 2. Expect a decline of at least 0.5-1 mg/dL per hour in the first 4-8 hours with effective intensive phototherapy; for extremely high levels (>30 mg/dL), expect up to 10 mg/dL decline within a few hours 2, 4.

A bilirubin rise ≥0.3 mg/dL per hour in the first 24 hours or ≥0.2 mg/dL per hour thereafter suggests hemolysis and warrants more aggressive management 2, 4.

Exchange Transfusion Criteria

Prepare for immediate exchange transfusion if TSB ≥25 mg/dL (428 μmol/L) despite intensive phototherapy, or if any signs of acute bilirubin encephalopathy are present regardless of bilirubin level. 1, 2, 4

Signs of acute bilirubin encephalopathy requiring immediate exchange transfusion include: extreme lethargy, poor feeding, high-pitched crying, arching of back or neck (opisthotonus/retrocollis), altered muscle tone (hypotonia or hypertonia), or fever 2, 4.

For TSB ≥20 mg/dL in sick infants or those <38 weeks gestation, obtain blood type and crossmatch in preparation for possible exchange 4. Exchange transfusion carries a mortality risk of approximately 3-4 per 1000 procedures in term infants without serious hemolytic disease, with significant morbidity (apnea, bradycardia, vasospasm, necrotizing enterocolitis) in up to 5% of cases 3, 5.

Discontinuation of Phototherapy

Discontinue phototherapy when TSB falls below 13-14 mg/dL or 2-4 mg/dL below the threshold at which phototherapy was initiated. 1, 2, 4

Follow-up After Discontinuation

Follow-up TSB measurement timing depends on risk:

• High-risk infants (hemolytic disease, phototherapy before 3-4 days of age): obtain TSB 8-12 hours after discontinuation, then again the following day 4
• Standard-risk infants: obtain TSB within 1-2 days after discontinuation 4
• All infants who received phototherapy: obtain follow-up bilirubin within 24 hours after discharge 1, 4

Transcutaneous bilirubin can be used instead of TSB if ≥24 hours have passed since phototherapy was stopped 4.

Critical Pitfalls to Avoid

• Never rely on visual assessment alone—always obtain objective TSB or transcutaneous measurement 2, 4
• Do not subtract direct bilirubin from total bilirubin when making treatment decisions 2, 4
• Do not use sunlight exposure as a therapeutic tool 4
• Do not unnecessarily prolong phototherapy, as it separates mother and infant and interferes with breastfeeding 4
• Do not discontinue breastfeeding—mothers of jaundiced infants are more likely to stop breastfeeding unnecessarily 6

Parent Education

Educate parents about warning signs requiring immediate medical attention: poor feeding, extreme lethargy, high-pitched crying, arching of back or neck, fever, or any change in muscle tone 2. Reassure parents that with appropriate treatment, the vast majority of cases resolve without neurological sequelae 2.