Clinical Pathway for Evaluation/Treatment of Neonates with Hyperbilirubinemia/Jaundice
- Related Pathway
- Risk Factors for Developing Significant Hyperbilirubinemia
- Gestational age < 40 wks
- Jaundice in 1st 24 hrs after birth
- Discharge TSB or TcB close to the Phototherapy Threshold
- Hemolysis from any cause, or rapid rate of increase of TSB or TcB:
- > 0.3 mg/dL per hr in the 1st 24 hrsor
- > 0.2 mg/dL per hr thereafter
- Phototherapy before discharge from the birth hospital
- Parent, sibling requiring phototherapy or exchange transfusion
- Family hx, genetic ancestry suggest inherited RBC disorder including G6PD deficiency
- Exclusive breastfeeding with suboptimal intake
- Scalp hematoma, significant bruising
- Down syndrome
- Macrosomic infant of diabetic mother
- Hyperbilirubinemia Neurotoxicity Risk Factors Other Than Gestational Age
- Isoimmune hemolytic disease
- Other hemolytic diseases, e.g., G6PD Deficiency
- Significant clinical instability in the previous 24 hrs: e.g., sepsis, acidosis, asphyxia, significant lethargy, temperature instability
- Albumin < 3.0 g/dL
- Phototherapy Thresholds
- No Neurotoxicity Risk Factors
- One or More Neurotoxicity
Risk Factors
- Exchange Transfusion Thresholds
- No Neurotoxicity Risk Factors
- One or More Neurotoxicity
Risk Factors
- Maternal blood type, RhD, DAT
- Review risk factors
- Significant hyperbilirubinemia
- Neurotoxicity
- Differential Diagnosis for Neonatal Jaundice
- Total Serum Bilirubin (TSB):
- TSB = Conjugated + Unconjugated
- CBC, retic, infant blood type, DAT
- Escalation:
- Type and screen, albumin
- Visual jaundice assessment q12 hr after delivery
- Measure TCB or TSB 24–48 hrs after birth or prior to discharge
- Phototherapy based on TSB, risk factor
- Discharge plan, follow-up,
Rebound Testing
- Measure TcB or TSB
- Obtain TSB if:
- TcB level within 3 mg/dL of Phototherapy Threshold
- TcB > 15 mg/dL
- Determine the time of bilirubin recheck
- Refer to ED as indicated
- ED Triage
- RN standing order
- Measure TSB, apply biliblanket
- Admit or discharge with a follow-up plan
Phototherapy: Use TSB to guide the decision to initiate phototherapy
Nutrition, Hydration- Consult Neonatology if any of the following:
- TSB within 2 mg/dL of Exchange Threshold
- TSB rate of rise > 0.5 mg/dL/hr
- Evidence of hemolysis
- Intensive phototherapy, IVF
- Double Volume Exchange Transfusion, IVIG
- Consider a transfer to a hospital capable of exchange transfusion if TSB within
- 2 mg/dL of Exchange Threshold
Discontinue when TSB is > 2 mg/dL below the hour-specific threshold used to initiate phototherapy, not current hour-of-life threshold