Consult neonatologist
- Jaundice or concern for hyperbilirubinema
- > 24 hours and < 21 days old
- Born at ≥ 35 weeks gestation
- 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.
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.
Discontinue phototherapy when TSB is at least 3 mg/dL below the phototherapy initiation threashold.
Subsequent bili checks as clinically indicated. Discontinue phototherapy when TSB is at least 3 mg/dL below the phototherapy initiation threashold.
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
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.
