Neonatal Hyperbilirubinemia/Jaundice (1-21 days)



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Neonatal Hyperbilirubinemia/Jaundice (1-21 days)

Consult neonatologist

Inclusion Criteria
  • Jaundice or concern for hyperbilirubinema
  • > 24 hours and < 21 days old
  • Born at ≥ 35 weeks gestation
Exclusion Criteria
  • Fever or any signs of sepsis
  • History of complex medical condition

Admit to NICU. Continue to encourage feeding. Do not be remove the patient from bili lights for > 20 mins in any 3 hour period.

Complete Blood Count, Serum
NS Bolus
NS infusion
Basic Metabolic Panel, Serum
Type & Screen, Serum
Phototherapy
Direct Coombs, Serum
Reticulocyte Count, Serum

Meets discharge criteria?

Treat appropriately

Discharge

IV fluids are not routinely necessary in well appear patients with hyperbilirubinema

High risk factors for severe hyperbilirubinemia

  • East Asian race
  • Gestational age 35-36 weeks
  • Jaundice within the first 24 hours of life
  • Cephalohematoma or significant bruising
  • Blood group incompatibility, positive direct Coombs or other known hemolytic disease (e.g. G6PD)
  • Exclusive breastfeeding
  • Sibling received phototherapy

Low risk factors for hyperbilirubinemia

  • Black race
  • Gestational age greater to or equal to 41 weeks
  • Nursery discharge after 72 hours of life
  • Exclusive bottle feeding

Neurotoxicity risk factors

  • Sepsis, acidosis or temperature instability
  • History of asphyxia
  • Lethargy
  • Isoimmune hemolytic disease
  • Other known hemolytic disease (e.g. G6PD)
  • Albumin < 3.0 g/dL

Any of the following features present?

  • TSB within 2 mg/dL of exchange transfusion threshold
  • Age <72 hours
  • Known/suspected hemolysis?

Continue to encourage feeding. Do not be remove the patient from bili lights for > 20 mins in any 3 hour period.

Complete Blood Count, Serum
Admit to Floor
Type & Screen, Serum
Phototherapy
Reticulocyte Count, Serum

Discontinue phototherapy when TSB is at least 3 mg/dL below the phototherapy initiation threashold.

Bilirubin Total and Fractionated, Serum
G6PD, Serum

Subsequent bili checks as clinically indicated. Discontinue phototherapy when TSB is at least 3 mg/dL below the phototherapy initiation threashold.

Bilirubin Total and Fractionated, Serum (Heelstick)

Rebound TSB is not usually necessary prior to discharge

Possible needs for a longer course of phototherapy

  • Feeding difficulties
  • Gestational age < 37 weeks
  • Hemolytic cause
  • Initial high bilirubin level

Discharge criteria

  • Patient off phototherapy if started
  • No concern for significant hemolysis
  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Bilirubin Total and Fractionated, Serum (Heelstick)

Transcutaneous bilirubin may vary based on racial and other factors and requires confirmatory serum testing

AAP Phototherapy Thresholds

  • Lower risk: ≥ 38 weeks and well appearing
  • Medium risk: ≥ 38 weeks and neurotoxicity risk factors OR 35 - 37 6/7 and well appearing
  • Higher risk: 35 - 37 6/7 and neurotoxicity risk factors

Evaluate factors for acute bilirubin encephalopathy

  • Ill appearing
  • Neurologic dysfunction
  • Evidence of hemolysis
  • Pathologic Jaundice
  • TSB level > age-specific 95th percentile
  • TSB rising by > 0.2 mg/dL per hour
  • Conjugated bilirubin (BC) > 1.5 mg/dL or > 20% of TSB

Phothotherapy MAY be a risk factor for childhood cancer (although more study is needed in this area) so the treatment should be avoided in neonates who are not at high risk.