What is the management for physiologic jaundice in a newborn?

Management of Physiologic Jaundice in Newborns

For physiologic jaundice in an otherwise healthy term newborn, management centers on systematic monitoring, ensuring adequate feeding (8-12 breastfeeds per 24 hours), and initiating phototherapy only when bilirubin levels reach age-specific treatment thresholds. 1, 2

Initial Assessment and Monitoring

All jaundiced newborns require objective bilirubin measurement rather than visual assessment alone, as visual estimation is unreliable, particularly in darkly pigmented infants. 1, 3

• Measure transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) on every infant appearing jaundiced, as TcB devices provide valid estimates for TSB levels below 15 mg/dL (257 µmol/L). 1, 2
• Assess jaundice at least every 8-12 hours by blanching the skin with digital pressure to reveal underlying skin color. 1, 2
• Plot all bilirubin values on the hour-specific Bhutani nomogram to determine risk zone based on the infant's age in hours. 3

A critical pitfall: jaundice appearing within the first 24 hours is pathologic until proven otherwise and requires immediate investigation. 3, 4

Risk Stratification

Identify risk factors that increase likelihood of severe hyperbilirubinemia: 2, 3

• Blood type incompatibility (ABO or Rh)
• Gestational age 35-37 weeks (these infants are 4 times more likely to develop TSB >13 mg/dL than 40-week infants) 4
• G6PD deficiency (particularly in families from Greece, Turkey, Sardinia, Nigeria, and Sephardic Jews)
• Inadequate breastfeeding with excessive weight loss (>12%)
• Family history of jaundice requiring phototherapy

Feeding Management

Optimize breastfeeding frequency to 8-12 times per 24 hours without interruption, as this enhances bilirubin clearance through increased stool output. 2, 5

• Do not supplement with water or dextrose water in non-dehydrated breastfed infants, as this does not prevent hyperbilirubinemia or decrease TSB levels and may interfere with breastfeeding. 2, 5
• Supplement with expressed breast milk or formula only if weight loss exceeds 12% or clinical/biochemical dehydration is present. 2, 5

Phototherapy Indications

Phototherapy should be initiated when TSB reaches age-specific thresholds: 6

• 15 mg/dL (257 µmol/L) for infants 25-48 hours old
• 18 mg/dL (308 µmol/L) for infants 49-72 hours old
• 20 mg/dL (342 µmol/L) for infants older than 72 hours

When phototherapy is needed: 2, 3

• Use special blue light (430-490 nm spectrum) with irradiance ≥30 µW/cm²/nm
• Maximize exposed skin surface area by minimizing diapers, head covers, eye masks, and electrode patches
• Expect bilirubin decline of 0.5-1 mg/dL per hour in first 4-8 hours, with clinical impact evident within 4-6 hours
• Recheck TSB within 2-3 hours to assess response

Follow-Up Timing

Infants discharged before 48 hours must be seen by a healthcare professional within 2-3 days of discharge. 4

For infants with measured bilirubin: 2

• High-risk zone or rapidly rising levels: recheck within 4-12 hours
• Stable without risk factors: recheck within 12-24 hours
• Approaching treatment thresholds: follow-up within 24 hours

Red Flags Requiring Investigation

Obtain complete laboratory workup (blood type, Coombs test, CBC with smear, reticulocyte count) if: 1, 3

• Jaundice appears in first 24 hours
• TSB rises >5 mg/dL per day or crosses percentiles rapidly
• Bilirubin fails to respond to adequate phototherapy (suggests unrecognized hemolytic process)
• Jaundice persists beyond 3 weeks (measure direct/conjugated bilirubin to rule out cholestasis)

G6PD deficiency characteristically presents with late-rising bilirubin, so maintain high suspicion in appropriate ethnic backgrounds. 4

When Physiologic Becomes Pathologic

Any infant manifesting signs of acute bilirubin encephalopathy (lethargy, hypotonia, poor feeding, high-pitched cry, retrocollis, opisthotonos) requires immediate exchange transfusion regardless of bilirubin level. 1, 2, 5

For severe hyperbilirubinemia with isoimmune hemolytic disease and TSB rising despite intensive phototherapy, consider intravenous immunoglobulin 0.5-1 g/kg over 2 hours. 2, 7

Special Considerations for 35-37 Week Infants

Do not treat near-term infants (35-37 weeks) as full-term, as they nurse less vigorously and have higher risk of significant hyperbilirubinemia. 4

• Never discharge 35-week gestation infants before 48 hours
• Use lower phototherapy thresholds based on gestational age
• Ensure more frequent follow-up