Inpatient and Primary Care Clinical Pathway for Evaluation/Treatment
of Neonates with Hyperbilirubinemia/Jaundice
- Neurotoxicity Risk Factors for Phototherapy Nomograms
- Isoimmune Hemolytic Disease
- G-6-PD Deficiency
- Asphyxia
- Significant Lethargy
- Temperature Instability
- Sepsis
- Acidosis
- AAP Subcommittee on Hyperbilirubinemia
- Definition of Pathologic Jaundice
- Present in first 24 hours of life
- TSB level > age-specific 95%
- TSB rising > 0.2 mg/dL/hr
- Conjugated bili (BC) > 1.5 mg/dL or > 20% TSB
- Feeding Recommendations
- Rechecking Bili Levels
- Additional Lab Work to Consider
- Primary Care Evaluation:
- History and Physical
- Total Serum Bilirubin (TSB) level (TSB=BU+BC)
- Assess and Encourage Feeding
- Bili Recheck frequency
- Transcutaneous Bili Interpretation
Referral Considerations:
- ≥ TSB Phototherapy Threshold (TSB=BU+BC)
- Concern for Dehydration
- Other Clinical Concerns
- ED Hyperbilirubinemia Pathway
Inpatient Evaluation & Management
- History and Physical
- Assess Current TSB
- Exchange Nomogram
- Additional Lab Work
- Assess and Encourage Feeding
- Phototherapy
- Phototherapy Equipment Guidelines
- Use Highest Light Intensity Settings
- Maximize Body Surface Area Exposed to Light
- Phototherapy Equipment Guidelines
Repeat TSB 4 Hours after ED Level
TSB Rising
Consult NICU
If rate of rise
> 0.5 mg/dL/hr
OR
Within 2 mg/dL of exchange threshold
If rate of rise
> 0.5 mg/dL/hr
OR
Within 2 mg/dL of exchange threshold
Repeat every 4 hours
until falling
until falling
TSB Level Falling
Repeat every 12 hours or with morning labs
Criteria for Discontinuing Phototherapy
Low/medium risk TSB 13-14 mg/dL
High risk TSB 12 mg/dL
High risk TSB 12 mg/dL
Rebound Testing
- Routine check is NOT recommended
- Check if:
- Patient has hemolytic disease (know DAT + and retic count > 7%)
- OR
- Phototherapy stopped before 3 days of life
- TSB below phototherapy threshold
- Tolerating PO, feeding issues resolved
- Parental concerns addressed
- Follow-up plan in place
Posted: September 2016
Revised: March 2017, March 2019 (Reviewed), May 2021 (Reviewed)
Authors: L. Utidjian MD; B. Rezet MD; P. Capucilli, MD; C. Macaulay RN; M. Mai MD; M. Posencheg MD; R. Persky, MD; E. Pete Devon MD
Revised: March 2017, March 2019 (Reviewed), May 2021 (Reviewed)
Authors: L. Utidjian MD; B. Rezet MD; P. Capucilli, MD; C. Macaulay RN; M. Mai MD; M. Posencheg MD; R. Persky, MD; E. Pete Devon MD
Evidence
- Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
- The Utility of Inpatient Rebound Bilirubin Levels in Infants Readmitted After Birth Hospitalization for Hyperbilirubinemia
- Efficacy of Phototherapy Devices and Outcomes among Extremely Low Birth Weight Infants: Multi-center Observational Study
- Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
- ABM Clinical Protocol #22: Guidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation
- Preserving Breastfeeding for the Hospitalized Infant: A Clinical Pathway
- Philips (2010). BiliChek: User Manual. Amsterdam, Netherlands.
- Burgos, T., Turner, S. (2004). BiliTool™. Bilitool, Inc., Leafpath Informatics, Inc. Retrieved March 6, 2017, from bilitool.org
CHOP Program