Management of Hyperbilirubinemia in Newborns: Staff Handout
Initial Assessment and Risk Stratification
All newborns require systematic assessment for jaundice before discharge, with follow-up timing determined by discharge age and risk factors. 1
Pre-Discharge Requirements
- Measure total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) in all jaundiced infants—visual assessment alone is unreliable, particularly in darkly pigmented infants 2
- Obtain blood type (ABO, Rh) and Direct Antiglobulin Test (DAT/Coombs') on cord blood or infant blood 1
- Document feeding frequency, stool pattern, and weight loss from birth 2
Follow-Up Schedule Based on Discharge Timing
Structured follow-up prevents severe hyperbilirubinemia by catching rising bilirubin levels early: 1
- Discharged before 24 hours: See by 72 hours of age
- Discharged 24-47.9 hours: See by 96 hours of age
- Discharged 48-72 hours: See by 120 hours of age
Earlier or more frequent follow-up is required for infants with risk factors including prematurity (35-37 weeks), exclusive breastfeeding with poor intake, previous sibling with jaundice requiring phototherapy, cephalohematoma, or East Asian ethnicity 1
Laboratory Evaluation for Hyperbilirubinemia
Essential Initial Tests 1
- TSB and direct bilirubin levels
- Blood type (ABO, Rh) and DAT (Coombs')
- Complete blood count with differential and smear for red cell morphology
- Reticulocyte count to assess hemolysis
- Serum albumin (especially if considering exchange transfusion)
Additional Tests Based on Clinical Context 1
- G6PD testing if suggested by ethnic origin (Mediterranean, African, Asian) or poor response to phototherapy
- End-tidal CO (ETCOc) if available, to detect hemolysis
- Sepsis workup (blood culture, urine culture, CSF studies) if clinical signs suggest infection
- Thyroid and galactosemia screening if jaundice persists beyond 3 weeks 2
Management of DAT-Positive Newborns
DAT-positive infants with ABO or Rh incompatibility are at significantly higher risk for severe hyperbilirubinemia and require closer monitoring. 3
Key Clinical Facts About DAT-Positive Infants
- DAT-positive neonates have higher bilirubin levels at 24 hours (mean 8 mg/dL vs 6 mg/dL in DAT-negative) and higher peak levels (mean 12.7 mg/dL vs 10.4 mg/dL) 3
- 46.8% of DAT-positive infants require phototherapy compared to only 11.2% of DAT-negative infants with ABO incompatibility 3
- ABO incompatibility accounts for 28.9% of blood group incompatibility cases, with anti-B antibodies more prevalent than anti-A 4
- DAT-positive infants require longer phototherapy duration (mean 46 hours vs 40.2 hours in DAT-negative cases) 4
Specific Management for DAT-Positive Infants
If TSB is rising despite intensive phototherapy OR TSB is within 2-3 mg/dL of exchange transfusion level, administer intravenous immunoglobulin (IVIG) 0.5-1 g/kg over 2 hours. 1 This applies to all isoimmune hemolytic disease including ABO, Rh (D, C, E), and other antibodies 1
- Repeat IVIG dose in 12 hours if necessary 1
- IVIG reduces the need for exchange transfusion in both Rh and ABO hemolytic disease 1
Critical Pitfall: Recent data shows that IVIG is frequently overused—only 1.6% of infants receiving IVIG actually met all three AAP criteria (DAT-positive, bilirubin within 3 mg/dL of exchange level, AND rising despite intensive phototherapy) 5. Do not administer IVIG prophylactically to all DAT-positive infants; wait until criteria are met.
Phototherapy Guidelines
Indications for Phototherapy
Use hour-specific nomograms (Figures 3 in AAP guidelines) based on: 1
- Infant's age in hours
- Gestational age (≥38 weeks vs 35-37 weeks)
- Presence of risk factors (isoimmune hemolytic disease, G6PD deficiency, asphyxia, sepsis, acidosis, albumin <3.0 g/dL)
Standard Phototherapy Technique 6
- Maximize skin exposure: Remove all clothing except eye shields and diaper (remove diaper if approaching exchange levels) 7
- Use appropriate light wavelength: 430-490 nm (blue-green spectrum) is most effective 6
- Ensure adequate irradiance: ≥30 μW/cm²/nm measured at infant's skin 7
- Feed every 2-3 hours (breast milk or formula) to maintain hydration and enhance bilirubin excretion 1
Intensive Phototherapy for Severe Cases 7
When TSB approaches exchange transfusion levels or is ≥20 mg/dL, optimize phototherapy immediately:
- Remove diaper completely 7
- Place infant in bassinet, not incubator to allow closer light positioning 7
- Bring fluorescent tubes within 10 cm of infant's skin 7
- Use phototherapy above AND below infant (fiber-optic pads below with lamps above, or commercial systems like BiliBassinet) 7
- Line bassinet sides with aluminum foil or white cloth to maximize light reflection 7
- Administer continuously without interruption until bilirubin declines 7
Monitoring During Phototherapy 1
- If TSB ≥25 mg/dL: Repeat TSB within 2-3 hours
- If TSB 20-25 mg/dL: Repeat within 3-4 hours
- If TSB <20 mg/dL: Repeat in 4-6 hours, then every 8-12 hours if declining
- Discontinue phototherapy when TSB <13-14 mg/dL 1
If TSB does not fall or continues to rise despite intensive phototherapy, hemolysis is very likely occurring. 1
Exchange Transfusion
Emergency Indications 1
TSB ≥25 mg/dL (428 μmol/L) at any time is a medical emergency requiring immediate admission for intensive phototherapy. Do not refer to the emergency department—admit directly to pediatric service to avoid treatment delays 1
Proceed to exchange transfusion if: 7
- TSB continues rising or fails to decline despite optimized intensive phototherapy
- Bilirubin/albumin ratio exceeds risk-based thresholds (use Figure 4 in AAP guidelines)
- Any signs of acute bilirubin encephalopathy appear, even if bilirubin is falling (lethargy, hypotonia, poor feeding, high-pitched cry, retrocollis, opisthotonos) 7, 2
Pre-Exchange Preparation 1
- Obtain type and crossmatch immediately if TSB ≥25 mg/dL or ≥20 mg/dL in sick/premature infant (<38 weeks)
- Measure serum albumin and calculate bilirubin/albumin ratio 1
- Exchange transfusions must be performed only by trained personnel in NICU with full monitoring and resuscitation capabilities 1
Critical Rule About Direct Bilirubin 1
Do NOT subtract direct (conjugated) bilirubin from total bilirubin when using phototherapy and exchange transfusion guidelines. Use the total serum bilirubin value 1
Exception: If direct bilirubin is ≥50% of total bilirubin, this is unusual—consult an expert in the field, as standard guidelines do not apply 1
Breastfeeding Management
Early-Onset Breastfeeding Jaundice 2
Increase feeding frequency to 8-12 times per 24 hours to improve caloric intake and enhance bilirubin excretion 2
Monitor for signs of inadequate intake: 2
- Weight loss >10% of birth weight by day 3
- Fewer than 4-6 wet diapers per 24 hours by day 4
- Fewer than 3-4 stools per day by day 4
- Delayed transition from meconium to yellow mushy stools
Do NOT routinely supplement with water or dextrose water in non-dehydrated infants—this does not prevent hyperbilirubinemia and may interfere with breastfeeding 2
If weight loss exceeds 12% or clinical/biochemical dehydration is present: 1
- Supplement with expressed breast milk or formula
- Consider IV fluids if oral intake is questionable
Phototherapy and Breastfeeding 2
Continue breastfeeding during phototherapy—separation is not required 2
Breastfeeding can continue in most cases requiring phototherapy, but if TSB is rising despite intensive phototherapy in a breastfed infant, supplementation with formula or expressed breast milk is recommended 1
Late-Onset Breast Milk Jaundice 2
If jaundice persists beyond 3 weeks:
- Measure direct/conjugated bilirubin to exclude cholestasis
- Check thyroid and galactosemia screening
- Continue monitoring TSB to ensure levels remain below phototherapy thresholds
Pathologic Jaundice: Red Flags
Jaundice in the first 24 hours of life is ALWAYS pathologic and requires immediate investigation. 2, 8
Other concerning features: 8
- TSB rising >5 mg/dL per day
- TSB >17 mg/dL at any time
- Signs/symptoms of serious illness (lethargy, poor feeding, temperature instability, respiratory distress)
- Direct bilirubin >1.0 mg/dL when TSB ≤5 mg/dL 2
Key Pitfalls to Avoid
Do not delay exchange transfusion if neurological signs appear—acute bilirubin encephalopathy requires immediate exchange transfusion regardless of whether bilirubin is declining 7
Do not refer infants with TSB ≥25 mg/dL to the emergency department—admit directly to pediatric service for immediate intensive phototherapy 1
Do not use IVIG prophylactically in all DAT-positive infants—wait until specific criteria are met (rising despite intensive phototherapy OR within 2-3 mg/dL of exchange level) 1, 5
Do not rely on visual assessment of jaundice—always measure TSB or TcB if jaundice is suspected 2
Do not subtract direct bilirubin from total bilirubin when using treatment nomograms 1
Do not assume DAT-negative infants with ABO incompatibility are low-risk—11.2% still require phototherapy and need appropriate monitoring 3