Hyperbilirubinemia/Jaundice — Monitoring Bilirubin, Before Phototherapy — Clinical Pathway: All Settings

Neonates with Hyperbilirubinemia/Jaundice Clinical Pathway

Monitoring Bilirubin, Before Phototherapy

Initiating Phototherapy

Discontinuing Phototherapy

Discontinue if TSB is more than 2 mg/dL below the phototherapy threshold used for initiation of phototherapy (not current hour of life phototherapy threshold).

Monitoring TSB After Discontinuing Phototherapy

Rebound Bilirubin: Monitoring TSB After Phototherapy

Pre-/Peri-Natal Maternal Screening
  • ACOG recommends blood type, ABO and Rh(D) and DAT for all mothers
  • Obtain infant blood type, DAT if maternal DAT + or unknown via cord or peripheral blood
  • Some OB/Nurseries do not test infants for Type O mothers unless visible jaundice or elevated TSB
Nursery Care at Birth Hospital
  • Infant Can Be Treated as DAT Negative If:
    • Mother was RhD antibody negative prior to receiving RhIG during pregnancy
    • and
    • Infant is DAT positive to anti-RhD only
  • Guidance for Measuring Bilirubin:
    • All infants should be visually assessed for jaundice at least every 12 hrs following delivery until discharge
    • Measure TSB or TcB as soon as possible for infants noted to be jaundiced < 24 hrs after birth
    • If not already done, measure TcB or TSB between 24 and 48 hrs after birth or before discharge if that occurs earlier
  • Determining Rate of Rise to Identify Infants at Higher Risk:
    • If > 1 TcB or TSB levels are available, determine if the rapid rate of rise is defined as:
      • > 0.3 mg/dL per hour in the 1st 24 hrs
      • > 0.2 mg/dL per hour thereafter
    • The rapid rise suggests hemolysis, obtain DAT if not already done
Primary Care
  • Infant Can Be Treated as DAT Negative If:
    • Mother was RhD antibody negative prior to receiving RhIG during pregnancy
    • and
    • Infant is DAT positive to anti-RhD only
  • Prolonged Jaundice:
    • If jaundice persists for 2 weeks in a formula-fed baby and 3-4 weeks in a breastfed baby, measure TSB and direct bilirubin
    • Review the newborn screening results for inborn errors of metabolism and hypothyroidism
ED Care
Inpatient Care
  • Phototherapy:
    • Measure TSB within 12 hrs of starting phototherapy
    • Repeat every 12 hrs until below phototherapy threshold
    • May increase frequency of TSB based on age, TSB level/trajectory, presence of neurotoxicity risk factors
  • Discontinuing Phototherapy:
    • Discontinue when TSB is > 2 mg/dL below the hour-specific threshold used to initiate phototherapy, not the current hour-of-life threshold
N/IICU Escalation
  • Infants Approaching Exchange Transfusion Levels of Hyperbilirubinemia:
    • Urgent consultation with Neonatology is recommended
      • Strong consideration for transfer to N/IICU as able
    • Stat Labs: Total and direct serum bilirubin, CBC, serum chemistries, type
      and crossmatch
    • Recommend intensive phototherapy:
      • Use double bank of phototherapy lights
      • Use bili blanket as available
      • Maximize area of skin exposed
        • E.g., small diapering area, allow feeding under phototherapy lights
    • Recommend intravenous fluids for suspected dehydration:
      • Normal saline bolus, 20 ml/kg
      • For infants feeding pumped breastmilk or formula:
        • D10, 0.45% NaCl at TFL of 100-120 ml/kg/day
      • For infants NPO:
        • D10, 0.45% NaCl at TFL of 150 ml/kg/day if significant risk of exchange transfusion
    • Place moistened gauze on umbilical stump in preparation for exchange transfusion
    • Double Volume Exchange Transfusion