Neonatal%20jaundice Treatment

• Consider TSB levels, infant’s age in hour & presence of risk factors to determine need for therapy

Indications for treating neonatal jaundice

• When TSB level exceeds the threshold in the nomogram
• A TSB level >25 mg/dL (428 µmol/L) at any time is a medical emergency & indicates prompt hospital admission & initiation of treatment
• For preterm infants, initiation of phototherapy or exchange transfusion depends on the gestational age

Gestational Age (weeks)	Phototherapy		Exchange Transfusion
	TSB (µmol/L)	TSB (mg/dl)	TSB (µmol/L)	TSB (mg/dl)
<28	86	>5	188-239	11-14
28-29	103-137	6-8	205-239	12-14
30-31	137-171	8-10	222-274	13-16
32-33	171-205	10-12	257-308	15-18
>34	205-239	12-14	291-325	17-19

IV immunoglobulin (IVIG)

• In an infant with isoimmune hemolytic disease, administration of IVIG is recommended if the TSB is rising in spite of intensive phototherapy or the TSB level is within 2-3 mg/dL of the exchange transfusion level
• May reduce the need for exchange transfusions in Rh & ABO hemolytic disease
• Has been shown to decrease RBC destruction & limit the rate of increase in bilirubin levels in infants with Rh & ABO isoimmunization

Tin-mesoporphyrin

• This drug prevents or treats hyperbilirubinemia by inhibiting production of heme oxygenase

Clofibrate

• May help lower bilirubin levels in term infants with hyperbilirubinemia by increasing bilirubin elimination, when used in combination with phototherapy
• Further studies are needed to further prove the efficacy of Clofibrate in neonatal jaundice

Phenobarbitone

• Has shown potential for reducing bilirubin levels by stimulation of hepatic enzymes
• There are limited studies proving Phenobarbitone’s safety & efficacy for the management of neonatal jaundice

Phototherapy

• Phototherapy creates water soluble bilirubin isomers which are excreted in the bile & urine, resulting in lower serum bilirubin levels & decreased risk of bilirubin-induced neurotoxicity
• Has been shown to be most effective in very small preterm infants & least effective in severely growth retarded full-term infants
• Conventional phototherapy in the hospital should consist of irradiance in the blue-green spectrum (400-500 nm) of at least 15 µW/cm²/nm that is delivered to as much of the infant’s surface as possible
  • The wavelength at the blue-green spectrum lets light penetrate the skin well & be maximally absorbed by bilirubin
  • The most effective light sources for phototherapy are special blue fluorescent tubes or specially designed light-emitting diode light
  • Light tubes should be placed as close to the infant as possible (30-50 cm from the infant)
  • The infant should be placed in the supine position, naked except for diapers to expose maximum body surface area, & eyes should be covered

• Intensive phototherapy, which consists of at least 30 µW/cm²/nm, should be started when TSB levels reach 3 mg/dL (51 µmol/L) above the level of conventional phototherapy or when TSB levels continuously increase by >0.5 mg/dL/hour (8.5 µmol/L/hour)
• Additional body surface area exposure may be achieved by lining the bassinet with aluminum foil or a white cloth
• Infant’s eyes should be properly protected during phototherapy to prevent retinal damage
• Fluid supplementation is not given routinely but is based on infant’s weight loss, urine output & urine specific gravity
• Complications from phototherapy are rare
  • Grayish-brown discoloration of the urine, serum & skin may develop in infants with cholestatic jaundice (bronze baby syndrome)
  • Severe blistering & photosensitivity in infants may occur in infants with congenital erythropoietic porphyria

• Sunlight exposure as a substitute for phototherapy is not recommended because sunburn is a serious danger given that exposure of a large body surface area is required
• A decrease of 30-40% in the initial bilirubin level may be expected 24 hour after start of phototherapy in infants >35 week age of gestation
• In infants with extremely high bilirubin levels, a decline of at least 0.5-1 mg/dL may be expected in the first 4-8 hour of phototherapy
• A continuing rise in bilirubin levels despite phototherapy usually means that hemolysis is present
• Frequency of TSB monitoring depends on previous measurements

TSB level in mg/dL	Repeat TSB
≥25	2-3 hour
20 to 25	3-4 hour
14 to <20	4-5 hour
Continues to decrease	8-12 hour
<14	Discontinue phototherapy & consider repeat TSB after 24 hour

Adapted from: Moerschel SK, Cianciaruso LB, Tracy LR. A practical approach to neonatal jaundice. Am Fam Physician. 2008; 77:1255-1262.

• The TSB level for discontinuing phototherapy depends on the age at which phototherapy was started & the cause of the hyperbilirubinemia

Exchange transfusion

• Exchange transfusion is recommended when an infant’s TSB level exceeds the threshold set in the nomogram (>5 mg/dL [85 µmol/L] above exchange transfusion level) or when TSB >25 mg/dL (428 µmol/L)
• Exchange transfusion should be done immediately in any infant with jaundice & signs of acute bilirubin encephalopathy which include hypotonia or hypertonia, opistothonus, fever, poor feeding & lethargy, even if the TSB level is falling
• In almost all cases, exchange transfusion is performed only when phototherapy fails to keep the bilirubin level below the exchange transfusion level
• Trained staff should perform the procedure in a neonatal intensive care unit
• Intensive phototherapy is recommended in preparation for an exchange transfusion
• Complications of exchange transfusion include infection, thromboembolization, hemolysis of transfused blood, acidosis, serum electrolyte abnormalities, bradycardia & vasospasm