Level 1 Newborn Nursery Hyperbilirubinemia Management Protocol
When to Obtain TSB After Elevated TcB
Obtain a confirmatory TSB immediately when TcB measurements are within 3 mg/dL below the phototherapy threshold for the infant's age in hours and risk category. 1
- For infants ≥35 weeks gestation, if TcB is less than 3 mg/dL below the hour-specific phototherapy threshold, confirm with TSB before making treatment decisions 1
- For infants 28-34 6/7 weeks gestation, use a 3 mg/dL safety margin below phototherapy thresholds, except for the 28-29 6/7 week group requiring phototherapy at 6 mg/dL, where a 4 mg/dL margin is needed 1
- Always obtain TSB (never rely on TcB alone) if jaundice appears in the first 24 hours of life, as this is always pathologic and demands urgent evaluation 2, 3
- Obtain TSB if TcB shows rapid rise crossing percentiles on the hour-specific nomogram, even if below phototherapy threshold 4
When to Notify Provider Immediately
Contact the provider stat for any jaundice appearing in the first 24 hours of life, regardless of bilirubin level. 2, 3
Additional urgent provider notification criteria:
- TcB or TSB approaching or exceeding age-specific phototherapy thresholds on the AAP nomogram 4, 3
- Rapid rise in bilirubin (>0.22 mg/dL per hour in first 24 hours, >0.15 mg/dL per hour between 24-48 hours, or >0.06 mg/dL per hour after 48 hours) 5
- Any infant with positive direct Coombs test, known hemolytic disease, or G6PD deficiency with rising bilirubin 4, 2
- Clinical signs of acute bilirubin encephalopathy (lethargy, poor feeding, high-pitched cry, hypotonia or hypertonia) 3
- Jaundice persisting at or beyond 3 weeks of age 4
Risk Stratification Before Discharge
Every newborn must have risk assessment for severe hyperbilirubinemia before discharge using either predischarge TSB/TcB plotted on the Bhutani nomogram, clinical risk factor assessment, or both. 4, 3
Major Risk Factors (Lower Phototherapy Thresholds):
- Predischarge TSB/TcB in high-risk zone (>95th percentile on Bhutani nomogram) 4
- Gestational age 35-36 6/7 weeks 4, 3
- Blood group incompatibility with positive direct Coombs test or other hemolytic disease (G6PD deficiency) 4, 2
- Jaundice observed in first 24 hours 4, 2
- Previous sibling who received phototherapy 4
- Cephalohematoma or significant bruising 4, 3
- Exclusive breastfeeding with poor intake or excessive weight loss 4, 3
- East Asian ethnicity 4, 6
Minor Risk Factors:
- Predischarge TSB/TcB in high-intermediate risk zone 4
- Gestational age 37-38 weeks 4
- Macrosomic infant of diabetic mother 4
- Male gender 4
Outpatient Follow-Up Timing Based on Discharge Age
Follow-up timing is determined by age at discharge and presence of risk factors, not by absolute bilirubin level. 6
Standard Follow-Up Schedule (No Risk Factors):
- Discharged <24 hours: Follow-up by 72 hours of age 6
- Discharged 24-48 hours: Follow-up by 96 hours of age 6
- Discharged 48-72 hours: Follow-up by 120 hours of age 6
Accelerated Follow-Up (With Risk Factors):
- TSB/TcB in high-intermediate or high-risk zone: Follow-up within 24 hours of discharge 4
- Gestational age 35-37 6/7 weeks: Follow-up within 24-48 hours 4, 3
- Exclusive breastfeeding with weight loss >7-8%: Follow-up within 24 hours 4
- If appropriate follow-up cannot be ensured with risk factors present, delay discharge until 72-96 hours 6
Management Based on Distance Below Phototherapy Threshold
Use the hour-specific AAP phototherapy nomogram with three risk-stratified curves to determine treatment need. 4, 3
Low-Risk Infants (≥38 weeks, well, no risk factors):
- TSB >5 mg/dL below phototherapy line: Routine follow-up per discharge age 4
- TSB 3-5 mg/dL below line: Follow-up within 24-48 hours 4
- TSB <3 mg/dL below line: Obtain repeat TSB in 4-12 hours 4, 1
Medium-Risk Infants (≥38 weeks + risk factors OR 35-37 6/7 weeks, well):
- Use medium-risk phototherapy curve (lower threshold) 4, 3
- TSB >3 mg/dL below medium-risk line: Follow-up within 24 hours 4
- TSB <3 mg/dL below line: Repeat TSB in 4-12 hours 4
High-Risk Infants (35-37 6/7 weeks + risk factors):
- Use high-risk phototherapy curve (lowest threshold) 4, 3
- Any TSB approaching high-risk line: Repeat TSB in 4-6 hours 4
Essential Laboratory Workup When TSB Obtained
When obtaining TSB for elevated TcB, simultaneously collect blood type and direct Coombs test if not done on cord blood, especially if mother is Rh-negative or blood group O. 4, 2
Additional labs based on clinical scenario:
- Complete blood count with smear and reticulocyte count if hemolysis suspected 4, 2
- G6PD level in at-risk populations (African American, Mediterranean, Asian descent) 4, 2
- Direct/conjugated bilirubin if TSB elevated or jaundice persists beyond expected timeframe 4, 2
- For jaundice at ≥10 days: Total and direct bilirubin, urinalysis and culture, evaluate thyroid and galactosemia screening results 4, 6
Critical Pitfalls to Avoid
Never rely on visual assessment of jaundice severity—always obtain objective TcB or TSB measurement, particularly in darkly pigmented infants where visual estimation is dangerously unreliable. 2, 3, 6
- Do not discharge any infant with jaundice in first 24 hours without TSB measurement and clear follow-up plan 3
- Never subtract direct bilirubin from total bilirubin when making phototherapy decisions—use total bilirubin value 3, 6
- Do not treat 35-37 6/7 week infants as term infants—they require closer monitoring and lower phototherapy thresholds 6
- Interpret all bilirubin levels by infant's age in hours (not days) using hour-specific nomograms 2, 3, 6
- Do not supplement breastfed infants with water or dextrose water 3, 6
- Recognize that TcB tends to underestimate TSB at higher bilirubin levels, particularly in infants requiring phototherapy 7
Parent Education and Discharge Instructions
Provide written and verbal education to all parents before discharge, instructing immediate return if jaundice worsens, spreads below the umbilicus, feeding decreases, or infant becomes lethargic. 6