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Jaundice: NICU Handbook

Provider Education
May 18, 2022

Management of hyperbilirubinemia in the newborn period

John A. Widness, MD
Peer Review Status: Internally Peer Reviewed

  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:

    Guidelines for frequency of monitoring serum bilirubin in healthy term infants

    Section Title

    Section Title

    		 1 day old 2 days old 3 days old†
      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 epeat 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
    **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)
Age, hours Phototherapy Exchange Transfusion if Intensive Phototherapy Fails † Exchange Transfusion and Intensive Phototherapy
≤ 24 ‡ - - -
25-48 ≥ 15 (260) ≥ 20 (340) ≥ 25 (430)
49-72 ≥ 18 (310) ≥25 (430) ≥ 30 (510)
>72 ≥ 20 (340) ≥ 25 (430) ≥ 30 (510)

* 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.

Use of phototherapy

John A. Widness, MD
Peer Review Status: Internally Peer Reviewed

  1. Infant receiving phototherapy should be left unclothed except for eye protection (mask) and a diaper. Care should be taken to ensure that the mask is not too loose such that it can slip over the nose and obstruct respiration. To increase the area of skin exposed to light the diaper may be omitted by a physician's order in cases where it is desirable to lower plasma bilirubin more quickly (required because diaper protects gonads from potentially harmful exposure to light). To keep control over the mess that loose phototherapy stools can cause, a surgeon’s face mask may be used as an alternative to a diaper.
  2. To monitor the potential for increased insensible water loss occurring with the use of overhead phototherapy, daily weights and urine output should be monitored every shift.
  3. The output of the phototherapy units will be monitored by the nursing staff with a Bili-meter (Olympic Mark II ) as follows:
    1. The phototherapy unit should be placed 40 cm above the infant and have a plexiglass shield between the light bulbs and the infant.
    2. Connect sensor head to Bili-meter and set range switch to 0.1 - 19.9.
    3. Place the Bili-meter’s sensor head on the infant's abdomen (if supine) or back (if prone) and aim toward the center of the phototherapy light.
    4. Press the "READ" button and record reading in microwatts per square centimeter per nanometer. For example, if the display reads 7, the reading is recorded as 7 µw/cm2/nm. In the unusual situation where the display blinks rhythmically, it means that the reading is above 19.9. For adequate phototherapy, the display should read between 7 and 12 µw/cm2/nm.
    5. If adequate reading is not obtained, replace bulbs and repeat procedure.
    6. Monitoring of the phototherapy lights will be performed every 48 hours.
  4. Phototherapy blankets instead of phototherapy lights should be considered for extremely premature infants who require phototherapy. Use of phototherapy blankets should reduce inadvertent exposure of the developing retina to bright ambient light, a putative factor in retinopathy of prematurity.

References

Maisels MJ, Conrad S. Transcutaneous bilirubin measurements in full-term infants. Pediatrics 1982;70:464-467.

Hyperbilirubinemia. In: Guidelines for Perinatal Care, Frigoletto FD and Little GA (eds). 1992, American Academy of Pediatrics, Elk Grove, IL, pp 208-210.