Population: Newborns, gestational age ≥35 wk, with hyperbilirubinemia.

Organization

AAP 2022

Recommendations

Evaluation

–If maternal antibody screen is positive or unknown, collect a direct antiglobulin test from the newborn as soon as possible to assess for risk of hyperbilirubinemia from hemolysis.

–For all newborns, promote breastfeeding support. Do not routinely supplement with formula.

–When hyperbilirubinemia is present, do not treat with water or dextrose supplementation. If feeding is thought to be inadequate, consider supplementation with formula or donor breast milk.

–Risk factors for significant hyperbilirubinemia include:

• Lower gestational age.

• Jaundice in first 24 h of life.

• Bilirubin close to phototherapy threshold or phototherapy prior to discharge.

• Hemolysis (verified or suspected by rate of rise ≥0.3 mg/dL/h in first 24 h, ≥0.2 mg/dL/h after).

• Parent or sibling requiring treatment for hyperbilirubinemia.

• Family history suggesting inherited RBC disorder such as G6PD deficiency.

• Exclusive breastfeeding with inadequate intake.

• Scalp hematoma or significant bruising.

• Down syndrome.

• Macrosomia, infant of diabetic mother.

–Risk factors for neurotoxicity from hyperbilirubinemia include:

• Gestational age <38 wk.

• Albumin<3.0 g/dL.

• Hemolysis (isoimmune hemolytic disease, G6PD deficiency, etc.).

• Sepsis.

• Clinical instability in prior 24 h.

–Monitor all infants for hyperbilirubinemia.

• 0–24 h of life: assess visually for jaundice at least every 12 h and measure TSB or transcutaneous bilirubin (TcB) immediately for infants with jaundice.

• 24–48 h of life: screen all infants for hyperbilirubinemia with either TSB or TcB.

• If TcB is ≥15 mg/dL or within 3 mg/dL of phototherapy threshold, measure TSB.

• Use total serum bilirubin (TSB) (not TcB or visual assessment) to guide treatment decisions.

• If rate of rise is rapid (≥0.3 mg/dL/h in first 24 h, ≥0.2 mg/dL/h after) suspect hemolysis. If not already done, collect a direct antiglobulin test.

–Prolonged jaundice: if a breastfed infant remains jaundiced after 3–4 wk of age, or formula-fed infant after 2 wk of age, measure total and direct bilirubin levels to evaluate for pathologic cholestasis and review the newborn screening test results.

Management

–Use the published nomogram to identify phototherapy thresholds based on gestational age and neurotoxicity risk factors. A free online tool is available at: https://bilitool.org/

–If TSB exceeds phototherapy threshold, treat with intensive phototherapy.

–If an infant who has already been discharged exceeds the threshold, consider home LED-based therapy rather than readmission if the following criteria are met:

• EGA ≥38 wk.

• ≥48-h old.

• Clinically well, feeding adequately.

• No neurotoxicity risk factors (see above).

• No prior phototherapy.

• TSB no more than 1 mg/dL above treatment threshold.

• Immediate availability of in-home device.

• Ability to measure TSB daily.

–If electing home LED-based therapy, admit for inpatient therapy if the TSB is ≥1 mg/dL above the phototherapy threshold.

–Maintain feeding routines. Interrupting therapy for breastfeeding does not decrease the therapy’s effectiveness. Consider formula supplementation, which may cause TSB to fall more quickly, though the risk of interfering with breastfeeding may outweigh the benefit.

–For infants in the hospital on phototherapy.

• Measure TSB within first 12 h of therapy, with timing and frequency guided by age of child, neurotoxicity risk factors, and TSB level and trajectory.

–For all infants on phototherapy, measure hemoglobin and/or hematocrit to assess for anemia and provide a baseline. Obtain direct antiglobulin test when mother had positive Ab screen, blood group O, or Rh(D)-. Measure G6PD activity if TSB increases despite intensive therapy, increases suddenly, or rises after an initial decline.

–Consider concluding phototherapy when TSB is at least 2 mg/dL below the threshold level at the initiation of therapy. Consider longer duration of treatment when risk factors for prolonged hyperbilirubinemia (EGA <38 wk, age <48 h at start of therapy, hemolytic disease).

–After concluding therapy, measure bilirubin again at least 12 h and preferably 24 h later to evaluate for rebound hyperbilirubinemia. Consider TcB instead of TSB if >24 h after phototherapy. Use phototherapy thresholds described above to decide whether to reinitiate treatment.

–Escalate to intensive care emergently if TSB is >2 mg/dL below exchange transfusion threshold despite phototherapy.

–At hospital discharge, use the difference between the most recent bilirubin level and the phototherapy threshold to determine timing of follow-up.

• 0.1–1.9 mg/dL. If age <24 h, delay discharge and measure TSB in 4–8 h. If >24 h, measure TSB in 4–24 h and either delay discharge or discharge with close follow-up or phototherapy.

• 2.0–3.4 mg/dL. TSB or TcB in 4–24 h.

• 3.5–5.4 mg/dL. TSB or TcB in 1–2 d.

• 5.5–6.9 mg/dL. F/u 2 d (or, as needed if >72 h age); TSB or TcB according to clinical judgment.

• ≥7.0 mg/dL. F/u 3d (or, as needed if >72 h age); TSB or TcB according to clinical judgment.

Source

–Pediatrics. 2022;150(3):e2022058859.