What is the diagnosis and treatment for neonatal hyperbilirubinemia (jaundice)?

From the Guidelines

Neonatal jaundice should be managed with phototherapy when the total serum bilirubin (TSB) level exceeds the phototherapy treatment threshold, which is based on gestational age, neurotoxicity risk factors, and age of the infant in hours, as recommended by the most recent guidelines 1.

Key Considerations

• The decision to start phototherapy should be guided by the TSB level, with intensive phototherapy recommended at the thresholds based on gestational age, neurotoxicity risk factors, and age of the infant in hours 1.
• TSB should be used as the definitive diagnostic test to guide all interventions, and it should be measured if the transcutaneous bilirubin (TcB) reading is within 3.0 mg/dL of the phototherapy treatment threshold, if the TcB exceeds the phototherapy treatment threshold, or if the TcB is ≥15 mg/dL 1.
• The rate of rise of TSB may be used to identify possible hemolysis, with a rapid rate of rise (≥0.3 mg/dL per hour in the first 24 hours or ≥0.2 mg/dL per hour thereafter) being suggestive of ongoing hemolysis 1.

Treatment and Monitoring

• Phototherapy is an essential intervention for severe hyperbilirubinemia, especially in neonates at high risk, and its use reduces the risk of bilirubin neurotoxicity as well as the use of exchange transfusions 2.
• The timing of intervention is guided by performing serial measurements of TSB concentrations and screening for the presence of intrinsic risk factors for bilirubin neurotoxicity 2.
• TSB should be measured to verify efficacy after starting phototherapy, with the timing of TSB testing guided by the TSB trajectory and infant age 1.
• Clinicians should evaluate the underlying cause or causes of hyperbilirubinemia in infants who require phototherapy, and glucose-6-phosphate dehydrogenase enzyme activity should be measured in any infant with jaundice of unknown cause whose TSB rises despite intensive phototherapy 1.

Discontinuation of Phototherapy

• It is an option to discontinue phototherapy when the TSB has declined by 2 to 4 mg/dL below the hour-specific threshold at the initiation of phototherapy, with the decision to discontinue phototherapy individualized to consider the TSB level at which phototherapy was initiated, the cause of the hyperbilirubinemia, the difference between the TSB level and the phototherapy threshold, and the risk of rebound hyperbilirubinemia 1.

From the Research

Definition and Prevalence of Neonatal Jaundice

• Neonatal jaundice is a common condition affecting four out of five healthy newborns, characterized by the yellowing of the skin due to elevated bilirubin levels 3.
• This condition, known as hyperbilirubinemia, is typically benign and transient when properly managed but may progress to severe complications such as kernicterus-a permanent neurologic condition-if untreated.

Risk Factors and Pathophysiology

• Newborns are particularly susceptible to jaundice due to increased red blood cell turnover, immature liver enzymes, and delayed stooling patterns 3.
• Preventive measures during pregnancy, such as maternal blood typing and Rh immunoglobulin administration, can mitigate the risk of hemolytic conditions leading to jaundice.

Diagnostic Methods and Treatment Guidelines

• Early detection through bilirubin screening and prompt treatment, including phototherapy, are critical to preventing neurotoxicity 3.
• Recent updates to the American Academy of Pediatrics guidelines emphasize higher thresholds for intervention, stratified by gestational age and risk factors.
• Phototherapy is a conventional treatment for neonatal jaundice and widely considered as a safe procedure 4.
• Exchange transfusion (ET) is typically applied for cases of refractory severe hyperbilirubinemia despite its risk of various complications, but double-LED phototherapy may be a good treatment strategy to replace ET for infants with severe hyperbilirubinemia 4.

Management Protocols and Quality of Care

• A nurse-initiated jaundice management protocol can improve quality of care in the paediatric emergency department by reducing time to serum bilirubin sampling, phototherapy initiation, and ED length of stay 5.
• Implementation of a neonatal jaundice management protocol is associated with improved timeliness and standardization of care for this common and important condition 5.
• There is considerable variability among neonatal units in their approaches to the jaundiced neonate, including type of phototherapy lights used, practical implementation of phototherapy, and use of fluid supplementation 6.