Iowa Neonatology Handbook: Jaundice

Management of Hyperbilirubinemia in the Newborn Period

1. Hyperbilirubinemia is an extremely common problem occurring during the newborn period. The etiology of the jaundice is quite varied; although most causes are benign, each case must be investigated to rule out an etiology with significant morbidity.
   
2. Since 97% of term babies have serum bilirubin values <13 mg/dl, all infants with a serum bilirubin level >13 mg/dl require a minimum work up. Other criteria of non-physiologic jaundice are visible jaundice on the first day of life, a total serum bilirubin level increasing by more than 5 mg/dl per day, a direct serum bilirubin level exceeding 1.5 mg/dl, and clinical jaundice persisting for more than 1 week in term babies (may persist longer in breast-fed infants).
   
3. Following the identification of an icteric infant, the maternal and preceding neonatal history are reviewed. After a complete physical examination, the following is the minimal work up necessary in each infant: serum bilirubin level (both direct and indirect) CBC with smear, and infant’s blood type and Coombs' tests; if not recorded on the maternal chart, a maternal sample should be sent for type and Coombs. A urinalysis, and urine testing for reducing substances should be done only if sepsis, urinary tract infection, or galactosemia is suspected. Be particularly aware that infants with ABO incompatibility may have extremely rapid increases in their serum bilirubin values. As such the frequency of monitoring their bilirubin levels may need to be more frequent (see table below).
   
4. Suggested guidelines for frequency of monitoring serum bilirubin in healthy term infants are as follows:
   

   		Days of Age
   		1	2	3 †
   	Visibly Jaundiced	do total & direct bilirubin	Transcutaneous Bilirubinometer	Transcutaneous Bilirubinometer
   Serum indirect	5-10	repeat in 3-5 hr	repeat x 1 in 8-12 hr	repeat Transcutaneous Bilirubinometer
   biliribuin* (mg/dL) on	10-15	repeat in 3-4hr; notify staff/fellow	repeat in 4-6 hr	repeat in 6-8 hr
   day specified	15-20	repeat in 2-3 hr	repeat in 2-4 hr; notify fellow/staff	repeat in 4-6 hr
   	>20	discuss exchange transfusion with staff	repeat in 2-3 hr;	repeat in 3-4 hr; notify fellow/staff

   * If direct bilirubin is <1.5 mg/dL, may use total bilirubin
   † Anticipates peaking of serum bilirubin at 72 hours
   Shaded area = consider institution of phototherapy
   
   In infants found to be clinically jaundiced during the first 2-3 days, it is helpful to document the rate of rise in the serum bilirubin level. A rise of >0.5 mg/dl per hour may indicate brisk hemolysis.
   
5. The need for phototherapy or exchange transfusion is an individualized decision influenced by the following factors: gestational age, weight, clinical condition, and etiology of the hyperbilirubinemia. Check a bilirubin level prior to discontinuing phototherapy and a rebound level 8-12 hours later. Phototherapy should be used sparingly in healthy term infants because they are at low risk of kernicterus. Phototherapy is used more liberally in sick, preterm infants, in whom the risk of kernicterus is less clearly defined.
   
6. Jaundice in a breast-fed infant is not normally an indication for stopping or interrupting breastfeeding. Special note must be taken of the drugs administered to the mother who is breastfeeding since it is known that drugs can be excreted in human milk and will have potential for absorption in the infant and competition for the bilirubin binding sites on albumin in the newborn. This may alter exchange criteria. Infants receiving phototherapy may continue to be breast-fed or bottle-fed by their mothers. The need for water supplementation should be decided by monitoring weight changes and urine specific gravity.
   
7. Full-term Caucasian infants in the normal newborn nursery with clinical jaundice should be screened for hyperbilirubinemia by transcutaneous bilirubinometry. When the transcutaneous bilirubinometer reading on the sternum is 19 or greater, a serum bilirubin level will be obtained. Transcutaneous bilirubinometry cannot be used in preterm infants, infants receiving phototherapy, or in non-Caucasian infants.

Management of Hyperbilirubinemia in the Healthy Term Newborn

TSB* Level, mg/dL (µmol/L)

* TSB indicates total serum bilirubin.
† Intensive phototherapy should produce a decline of TSB of 1-2 mg/dL within 4-6 hours and the TSB level should continue to fall and remain below the threshold for exchange transfusion. If this does not occur, it is considered a failure of phototherapy.
‡ Term infants who are clinically jaundiced at ≤ 24 hours old are not considered healthy and require further evaluation.

Appended from American Academy of Pediatrics, Provisional Committee on Quality Improvement. Pediatrics 94:558-565, 1994.

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