Admit?
If below phototherapy threshold: Discharge
- Continue phototherapy, recheck TsB in 12-24 hours
- If poor response to PTX, consider G6PD testing in males
Inpatient rebound TsB measurement is not indicated unless:
- hemolytic jaundice/evidence of hemolysis
- prematurity <37wk GA
- patient less than 24hr old
- Previously healthy
- Age < 14 days
- Gestational age > 35 weeks at delivery
- Direct hyperbilirubinemia
- Signs of acute bilirubin encephalopathy
- Above exchange transfusion threshold
Follow AAP Nomogram or Bilitool for phototherapy threshold.
- Lab follow-up schedule:
- For infants with TsB > 20 mg/dl or within 2 mg/dl of exchange transfusion or if known/suspected hemolysis, recheck TsB 4 hours after starting phototherapy. Follow every 4-6 hours until TsB level decreasing.
- For all others: recheck TsB in 12 hours or with routine AM labs
>38wk: Repeat TsB is at least 2mg/dL below threshold?
<38wk: Repeat TsB is at least 5.5mg/dL below threshold?
Risk factors for severe hyperbilirubinemia:
- High-risk TsB or TcB prior to nursery discharge
- Jaundice in first 24 hours of life
- ABO incompatibility with positive DAT
- Gestational age 35-36 weeks
- Cephalohematoma or significant bruising
- Exclusive breastfeeding
- East Asian race
- Discharge if no evidence of hemolysis
- Arrange follow up with PMD within 24 hours
- Communicate with PMD at time of discharge
Initial Assessment
- Clinical history, especially feeding and elimination
- Physical exam
- Total and direct serum bilirubin
- Consider hematocrit, retic count if concern for hemolysis
- Blood type and DAT (if not done in nursery)
Neurotoxicity risk factors:
- Isoimmune hemolytic disease
- G6PD deficiency
- Asphyxia
- Sepsis
- Acidosis
- Double source phototherapy
- Should use LED light, 460-490 nm (blue-green spectrum), irradiance of 30
- At JMH: Neoblue overhead light + NeoCozy bed blanket
Feeding during phototherapy:
- Continue breastfeeding. May remove from PTX for a maximum of 20 mins every 3 hours
- If within 2 mg/dl from exchange transfusion, do not remove from PTX until level has decreased
- Consider supplementation with EBM/Formula if weight loss, low UOP, or unable to remove from PTX
- Lactation consult
- Consider IV fluid if within 2 mg/dl of exchange transfusion and/or not feeding well and/or rapidly rising TsB
If above phototherapy threshold, and within 2 mg/dl of exchange transfusion threshold:
Consult NICU, consider NICU admission
- If excluded, admit to NICU
- Consider liver US for direct hyperbilirubinemia
References:
1) John Muir Medical Center Neonatal Hyperbilirubinemia (internal document).
2) American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004; 114(1): 297–316.
3) American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks gestation. Pediatrics. 2011; 128(4): e1046-e1052.