Neonatal%20jaundice Treatment

• Consider TSB levels, infant’s age in hour and 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 and indicates prompt hospital admission and 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


Reference: Maisels MJ, Watchko JF, Bhutani VK, et al. An approach to the management of hyperbilirubinemia in the preterm infant less than 35 weeks of gestation. J Perinatol. 2012

Phototherapy

• Phototherapy creates water soluble bilirubin isomers which are excreted in the bile and urine, resulting in lower serum bilirubin levels and decreased risk of bilirubin-induced neurotoxicity
• Has been shown to be most effective in very small preterm infants and 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 and 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, and 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 and urine specific gravity
• Complications from phototherapy are rare
  • Grayish-brown discoloration of the urine, serum and skin may develop in infants with cholestatic jaundice (bronze baby syndrome)
  • Severe blistering and 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 and consider repeat TSB after 24 hour

Reference: Moerschel SK, Cianciaruso LB, Tracy LR. A practical approach to neonatal jaundice. Am Fam Physician. 2008

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

Exchange Transfusion

• 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)
• Should be done immediately in any infant with jaundice and signs of acute bilirubin encephalopathy which include hypotonia or hypertonia, opisthotonus, fever, poor feeding and 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 and vasospasm

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
• There is limited evidence that IVIg reduces the need for exchange transfusions in Rh and ABO hemolytic disease
• Has been shown to decrease RBC destruction and limit the rate of increase in bilirubin levels in infants with Rh and ABO isoimmunization

Tin-mesoporphyrin (Stannsoporfin)

• 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 and efficacy for the management of neonatal jaundice

Ursodeoxycholic acid (UDCA)

• Enables bile emulsification into hydrophilic forms
• More useful for obstructive jaundice from mild biliary obstruction

Vitamin Supplements (Vitamins A, D, E, and K)

• Replenishes decreased fat-soluble vitamin stores in cholestatic jaundice

• Patients presenting with predominantly conjugated hyperbilirubinemia should be assessed for need for surgery

Biliary Atresia

• Intraoperative cholangiogram
  • Gold standard for diagnosing biliary atresia
• Kasai procedure
  • Done immediately after detection of biliary atresia via intraoperative cholangiogram
• Liver transplant
  • A majority of biliary atresia patients eventually need transplant due to progressive liver disease
  • Definitive cure for biliary atresia

Choledochal Cyst

• Complete cyst excision and hepaticojejunostomy

Nutrition

• If possible, breastfeeding should be continued
  • Optimal breastfeeding 8-12 times per day increases removal of bilirubin through the gastrointestinal tract
  • Supplemental breast milk or formula may be given to infants with insufficient oral intake, dehydration or excessive weight loss
• Hydration
  • Adequacy of oral intake should be evaluated in an infant who lost >10% of birth weight
  • Infant should be referred to a specialist if with weight loss of >7% of birth weight and for close monitoring for severe hyperbilirubinemia
  • If infant’s oral intake is unreliable, give IV fluids