Management of Neonatal Jaundice
All neonates should undergo systematic risk assessment and monitoring for jaundice, with objective bilirubin measurement (total serum bilirubin or transcutaneous bilirubin) guiding treatment decisions based on hour-specific nomograms that stratify by gestational age and risk factors. 1, 2
Prenatal and Initial Assessment
Maternal Testing
- Test all pregnant women for ABO and Rh(D) blood types with serum screen for unusual isoimmune antibodies. 1
- If mother is Rh-negative or blood type unknown, obtain direct antibody test (Coombs'), infant blood type, and Rh(D) type on cord blood. 1
- For mothers with blood group O Rh-positive, cord blood testing is optional if appropriate surveillance and follow-up are ensured. 1
Routine Monitoring Protocol
- Assess all infants for jaundice at least every 8-12 hours by blanching skin with digital pressure to reveal underlying color. 1
- Never rely on visual estimation alone—this leads to dangerous errors, particularly in darkly pigmented infants. 2, 3
- Obtain objective TSB or TcB measurement if any doubt exists about jaundice severity. 1, 2
Bilirubin Measurement Strategy
When to Measure
- Jaundice in first 24 hours: Always pathologic—measure TSB/TcB immediately. 2, 3
- Any infant appearing jaundiced requires TcB or TSB measurement. 1
- TcB devices provide valid estimates when TSB expected <15 mg/dL (257 μmol/L). 1, 4
Initial Laboratory Workup
When elevated bilirubin identified, obtain: 2, 3
- Blood type (ABO, Rh) and direct antibody test (Coombs')
- Complete blood count with differential and peripheral smear
- Reticulocyte count
- Total and direct/conjugated bilirubin
- Serum albumin
- G6PD level if suggested by ethnic origin or poor phototherapy response
Interpretation
- Plot all bilirubin levels on hour-specific nomograms according to infant's age in hours, not days. 2, 3, 5
- Direct bilirubin >1.0 mg/dL is abnormal when TSB ≤5 mg/dL. 3
- Do not subtract direct bilirubin from total when making treatment decisions. 1, 2
Risk Stratification
Major Risk Factors (Lower Treatment Thresholds)
- Gestational age 35-37 weeks 1, 2
- Isoimmune hemolytic disease (positive Coombs' test) 2, 3
- G6PD deficiency 2, 3
- Sepsis or acidosis 2
- Albumin <3.0 g/dL 2
- East Asian race 1
- Exclusive breastfeeding with inadequate intake 1, 6
Predischarge Risk Assessment
- Obtain predischarge TSB/TcB and plot on Bhutani nomogram. 7
- High-risk zone (>95th percentile) requires follow-up within 24 hours. 7
- Document risk assessment, bilirubin level, and follow-up plan in discharge summary. 7
Treatment Thresholds and Phototherapy
Initiating Phototherapy
- Use AAP hour-specific phototherapy nomograms with three risk-stratified curves: 2, 7
- Low-risk: ≥38 weeks, well, no risk factors (highest threshold)
- Medium-risk: ≥38 weeks with risk factors OR 35-37 6/7 weeks, well (intermediate threshold)
- High-risk: 35-37 6/7 weeks with risk factors (lowest threshold)
Phototherapy Implementation
- Maximize exposed skin surface area by minimizing diapers, head covers, eye masks, and electrode patches. 2, 3
- Expect bilirubin decrease >2 mg/dL within 4-6 hours if phototherapy effective. 2, 3
- If TSB rises despite intensive phototherapy, hemolysis is likely occurring. 1
Monitoring During Phototherapy
- TSB ≥25 mg/dL: Recheck every 2-3 hours 2
- TSB 20-25 mg/dL: Recheck every 3-4 hours 2
- TSB <20 mg/dL: Recheck every 4-6 hours 2
- Once TSB consistently falling: Recheck every 8-12 hours 2
Feeding Management
Breastfeeding Support
- Continue frequent breastfeeding (8-12 times per 24 hours) if infant clinically well with mild-moderate jaundice. 1, 2
- Do not routinely supplement nondehydrated breastfed infants with water or dextrose water—this does not prevent hyperbilirubinemia. 1, 2
- Supplement with formula or expressed breast milk only if weight loss >12% or clinical/biochemical dehydration present. 2
- Assess adequacy of intake by monitoring weight, voiding pattern (should have 6+ wet diapers by day 4), and stooling. 1, 2
Follow-Up Schedule
Timing Based on Discharge Age
- Discharged before 24 hours: See by 72 hours 1
- Discharged 24-47.9 hours: See by 96 hours 1
- Discharged 48-72 hours: See by 120 hours 1
- Some infants discharged before 48 hours may require two follow-up visits. 1
Earlier Follow-Up Required For:
- Predischarge TSB/TcB in high-intermediate or high-risk zone (within 24 hours) 7
- Rapidly rising bilirubin crossing percentiles (within 4-12 hours) 2, 3
- Presence of risk factors 1
Delay Discharge If:
- Appropriate follow-up cannot be ensured in presence of elevated risk factors 1
- Consider delaying until 72-96 hours when risk period has passed 1
Special Situations
Jaundice Beyond 3 Weeks
- Measure total and direct/conjugated bilirubin to identify cholestasis. 1
- Check newborn thyroid and galactosemia screening results. 1
- Evaluate for urinary tract infection, sepsis, and metabolic causes. 3
Exchange Transfusion Considerations
- Obtain type and crossmatch immediately if TSB ≥25 mg/dL. 2
- Perform immediate exchange transfusion for any infant with signs of acute bilirubin encephalopathy, even if TSB falling. 2
- If isoimmune hemolytic disease with TSB rising despite intensive phototherapy, consider intravenous immunoglobulin 0.5-1 g/kg over 2 hours. 2
Rapidly Rising Bilirubin
- If TSB rises despite adequate intensive phototherapy, repeat laboratory evaluation immediately to identify unrecognized hemolytic process. 2
- Obtain blood type, Coombs' test, CBC with smear, reticulocyte count, and G6PD level. 2, 3
Critical Pitfalls to Avoid
- Never discharge infant with jaundice in first 24 hours without objective bilirubin measurement and clear follow-up plan. 3
- G6PD levels can be falsely elevated during active hemolysis—repeat testing at 3 months if strongly suspected. 3
- Do not treat 35-37 week infants as term infants—they require closer monitoring and lower phototherapy thresholds. 7
- Ensure adequate follow-up arranged before discharge; if not possible with risk factors present, delay discharge. 1, 7