From the Guidelines
Pathological jaundice in neonates requires prompt evaluation and treatment to prevent complications like kernicterus, and the most recent and highest quality study 1 recommends phototherapy as the first-line treatment.
Key Considerations
- Pathological jaundice is distinguished from physiological jaundice by its appearance within 24 hours of birth, bilirubin rising >5 mg/dL/day, total bilirubin exceeding 12 mg/dL in term infants, direct bilirubin >2 mg/dL, or jaundice persisting beyond 2 weeks.
- Phototherapy should be initiated with light wavelengths of 460-490 nm at an irradiance of 25-35 mW/cm²/nm, as recommended by the most recent study 1.
- For severe cases with bilirubin levels approaching exchange transfusion thresholds, intensive phototherapy using multiple light sources should be initiated.
- Exchange transfusion is indicated when bilirubin levels exceed 20-25 mg/dL in term infants despite phototherapy, or at lower thresholds for premature infants.
- Intravenous immunoglobulin (IVIG) at 0.5-1 g/kg over 2-4 hours may be given in cases of hemolytic disease, as suggested by earlier studies 1.
Underlying Causes and Treatment
- Underlying causes must be identified and treated, including ABO/Rh incompatibility, G6PD deficiency, sepsis, or metabolic disorders.
- Regular monitoring of bilirubin levels every 4-6 hours during treatment is essential, along with maintaining adequate hydration and nutrition to promote bilirubin excretion.
- Early identification of risk factors and prompt intervention are crucial to prevent bilirubin-induced neurological dysfunction, as emphasized by the American Academy of Family Physicians 1.
Special Considerations
- The bronze infant syndrome, a rare complication of phototherapy, may occur in infants with cholestatic jaundice, but it is not a contraindication to phototherapy, as noted in earlier studies 1.
- Congenital porphyria or a family history of porphyria is an absolute contraindication to the use of phototherapy, as it can cause severe blistering and photosensitivity.
From the Research
Pathological Jaundice in Neonates
- Pathological jaundice is a frequent condition in both term and preterm infants that can cause long-lasting neurological damage 2.
- The condition is characterized by an increase in serum bilirubin levels, largely due to the breakdown of red blood cells, and can be caused by various factors, including isoimmune hemolytic disease 3.
Treatment Options
- Phototherapy is a simple and effective way to reduce bilirubin levels in neonates with pathological jaundice 2, 3, 4.
- Bilisphere phototherapy is a novel treatment for indirect pathological hyperbilirubinemia that can lower total serum bilirubin as effectively as exchange transfusions 2.
- Phenobarbital in combination with phototherapy may be helpful in reducing total serum bilirubin levels in newborn infants with isoimmune hemolytic disease, thus decreasing the need for blood exchange transfusion 3.
- Fenofibrate as an adjuvant to phototherapy has been shown to be well-tolerated and associated with significant reduction of serum bilirubin levels, shorter duration of phototherapy, and shorter hospital stay in term neonates with pathological jaundice 4.
Management and Care
- Education programs and periodic training for medical teams can improve their performance in caring for neonates with pathological jaundice, and nurses play a significant role in providing care in the NICU 2.
- The use of a clinical pathway can improve the timeliness of care for neonates with hyperbilirubinemia, reducing the time to phototherapy, time to bilirubin result, and ED length of stay 5.
- Current management of jaundice in the UK is guided by the NICE guideline, which emphasizes the importance of urgent treatment for infants with high serum bilirubin or rapidly rising bilirubin levels to avoid neurotoxicity 6.