Neonatal Jaundice

Obtain a TSB when jaundice is clinically significant, when TcB approaches a treatment threshold, or when treatment decisions are being considered. TSB is the key parameter for starting, stopping, or restarting phototherapy; determining exchange transfusion need; and making discharge or readmission decisions. Interpret every value by postnatal age, gestational age, and clinical risk factors rather than as an isolated concentration. fda+2fdaStannsoporfin for Neonatal HyperbilirubinemiaNatureGlucose-6-phosphate dehydrogenase deficiency and neonatal indirect hyperbilirubinemia: a retrospective cohort study among 40,305 consecutively born babies | Journal of Perinatologypublications aapBilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline | Pediatrics | American Academy of Pediatrics

Treat the following as high-risk patterns: jaundice during the first 24 hours, gestational age 35–36 weeks, jaundice documented before discharge, prior sibling treated with phototherapy, bruising or cephalohematoma, and laboratory evidence or clinical concern for Rh or ABO incompatibility or G6PD deficiency. These findings increase the likelihood of severe hyperbilirubinemia and justify earlier repeat bilirubin testing and etiologic evaluation. BMJBMJIncidence and causes of severe neonatal hyperbilirubinemia in Canada

Escalate immediately for clinical features of acute bilirubin encephalopathy or a serum bilirubin concentration above 340 micromol/L (approximately 19.9 mg/dL) in infants born at 37 weeks or later. A bilirubin rise exceeding 8.5 micromol/L per hour (approximately 0.5 mg/dL per hour) also identifies increased kernicterus risk and should prompt urgent reassessment for hemolysis, treatment adequacy, and exchange-level management. nice org uknice org ukJaundice in newborn babies under 28 days | Guidance

Measure either TcB or TSB between 24 and 72 hours of life and plot the result on the applicable predictive nomogram when immediate treatment is not indicated. Record the measured value and predictive zone in the discharge documentation and arrange follow-up according to the risk of progression to severe hyperbilirubinemia. PubMedPubMedGuidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) – Summary - PMC

Confirm TcB with TSB when the TcB is close to the phototherapy threshold. This avoids using a screening measure alone at the point where a small measurement difference can change whether intensive phototherapy is started. NatureNatureGlucose-6-phosphate dehydrogenase deficiency and neonatal indirect hyperbilirubinemia: a retrospective cohort study among 40,305 consecutively born babies | Journal of Perinatology

For an infant discharged before 24 hours of life, arrange clinical review within 24 hours by a clinician able to recognize neonatal hyperbilirubinemia, obtain TcB or TSB without delay, and refer for treatment when indicated. This timing rule applies regardless of day of the week. PubMedPubMedGuidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) – Summary - PMC

In significant hyperbilirubinemia, perform a full clinical examination and obtain serum bilirubin as part of formal assessment for underlying disease. Add infant and maternal blood group assessment, direct antiglobulin testing, and complete blood count to identify Rh or ABO incompatibility and anemia consistent with hemolysis. nice org uk+1nice org ukJaundice in newborn babies under 28 days | GuidanceBMJIncidence and causes of severe neonatal hyperbilirubinemia in Canada

Test for G6PD deficiency in severe hyperbilirubinemia, particularly when the bilirubin trajectory is disproportionate to the apparent clinical findings or when hemolysis is suspected without a positive direct antiglobulin test. G6PD deficiency is a major risk factor for neonatal indirect hyperbilirubinemia and bilirubin-induced neuronal damage; affected infants may require intervention at lower TSB concentrations. Nature+1NatureGlucose-6-phosphate dehydrogenase deficiency and neonatal indirect hyperbilirubinemia: a retrospective cohort study among 40,305 consecutively born babies | Journal of PerinatologyPubMedGuidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) – Summary - PMC

A low hemoglobin concentration with reticulocytosis supports increased red-cell turnover; serial TSB behavior during intensive phototherapy is clinically useful because failure to achieve a sustained decline suggests ongoing bilirubin production or insufficient exposure. Phototherapy removes excess bilirubin but does not inhibit bilirubin production, which is particularly consequential in hemolytic disease. fda+1fdaStannsoporfin for Neonatal HyperbilirubinemiaNatureGlucose-6-phosphate dehydrogenase deficiency and neonatal indirect hyperbilirubinemia: a retrospective cohort study among 40,305 consecutively born babies | Journal of Perinatology

Measure direct as well as total bilirubin when prolonged jaundice or a cholestatic process is suspected. Early neonatal management usually targets unconjugated hyperbilirubinemia, whereas conjugated hyperbilirubinemia requires disease-specific evaluation rather than routine phototherapy escalation. BMJBMJNeonatal jaundice - Symptoms, diagnosis and treatment | BMJ Best Practice

Initiate phototherapy when the TSB crosses the applicable threshold derived from postnatal age, gestational age, and neurotoxicity risk factors. The AAP 2022 guideline applies to infants born at 35 weeks or later and uses higher phototherapy and exchange transfusion thresholds than prior AAP guidance; use a current guideline-based threshold tool rather than legacy threshold figures. publications aap+1publications aapBilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline | Pediatrics | American Academy of Pediatricspublications aapImplementing Higher Phototherapy Thresholds for Jaundice in Healthy Infants 35 Plus Weeks | Hospital Pediatrics | American Academy of Pediatrics

During intensive phototherapy, trend TSB to establish whether the concentration is falling adequately. Phototherapy converts bilirubin into excretable products and can provide a gradual, sustained bilirubin reduction in nonhemolytic hyperbilirubinemia, but it does not suppress bilirubin production and may fail to control ongoing hemolysis. fda+1fdaStannsoporfin for Neonatal HyperbilirubinemiaScienceDirectComparison of the effectiveness of phototherapy and exchange transfusion in the management of nonhemolytic neonatal hyperbilirubinemia - ScienceDirect

For severe jaundice in nondehydrated infants receiving intensive phototherapy, additional oral or intravenous fluids have been associated with reduced progression to exchange transfusion. Use fluid supplementation as an adjunct to bilirubin-directed treatment rather than as a substitute for phototherapy or exchange preparation. PubMedPubMedGuidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) – Summary - PMC

Proceed to exchange transfusion when TSB reaches the age- and gestation-specific exchange threshold unless the level decreases below that threshold while preparation is underway. Exchange transfusion is reserved for severe hyperbilirubinemia because adverse events are common, particularly in preterm infants and those with concurrent neonatal morbidity; most reported events are laboratory abnormalities that are asymptomatic and treatable. nice org uk+1nice org ukJaundice in newborn babies under 28 days | GuidanceScienceDirectAdverse events associated with neonatal exchange transfusion in the 1990s - ScienceDirect

Before discharge, document the TcB or TSB value, postnatal age at measurement, predictive risk designation when used, relevant risk factors, and the planned timing and location of reassessment. A predischarge TSB measured between 18 hours and 3 days can predict subsequent TSB above 300 micromol/L in direct antiglobulin test-negative term and late-preterm infants. PubMedPubMedGuidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) – Summary - PMC

Schedule earlier reassessment for infants with an elevated predictive-zone result, gestational age 35–36 weeks, jaundice before discharge, a sibling previously treated with phototherapy, bruising or cephalohematoma, or suspected hemolysis. The follow-up encounter must include capacity to measure TcB or TSB promptly and transfer the infant for treatment if indicated. BMJ+1BMJIncidence and causes of severe neonatal hyperbilirubinemia in CanadaPubMedGuidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) – Summary - PMC

After phototherapy, use TSB-based follow-up when rebound is a concern. Hemolytic disease materially increases rebound risk; a recurrent rise requiring repeat phototherapy has been reported in as many as 28% of affected infants. fdafdaStannsoporfin for Neonatal Hyperbilirubinemia