Neonatal Hyperbilirubinemia/Jaundice (1-21 days) - Curbside
Neonatal Hyperbilirubinemia/Jaundice (1-21 days)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Jaundice or concern for hyperbilirubinema
  • > 24 hours and < 21 days old
  • Born at ≥ 35 weeks gestation
Exclusion Criteria
  • Fever or any signs of sepsis
  • History of complex medical condition

Consult neonatologist

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Evidence
Total Notes: 7
Evidence

1 IV fluids

Supplemental IV fluids may interfere with breastfeeding and are not routinely recommended. However, they can reduce the need for exchange transfusion and patients at high risk of crossing this threshold should receive supplemental fluids.



References:
  1. Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia.
    Kaplan M, Kaplan E, Hammerman C, Algur N, Bromiker R, Schimmel MS, Eidelman AI,
    Arch. Dis. Child. 2006 Jan;91(1):31-4.

2 Rebound TSB

The use of a rebound TSB is not recommended as it is unlikely with a falling TSB 3 mg/dL below phototherapy initation level that retreatment will be necessary.



References:
  1. When should phototherapy be stopped? A pilot study comparing two targets of serum bilirubin concentration.
    Barak M, Berger I, Dollberg S, Mimouni FB, Mandel D,
    Acta Paediatr. 2009 Feb;98(2):277-81.

3 Nomogram

4 Jaundice & hyperbilirubinemia

Unconjugated hyperbilirubinemia (TSB >95th percentile) in newborns (≥35 weeks gestational age) is a normal process with almost all of them reaching a total serum bilirubin greater than 1 mg/dL (17 micromol/L). In certain populations however, the level of bilirubin may increase to levels, which after crossing the blood brain barrier and binding to brain tissue, result in bilirubin-induced neurologic dysfunction (BIND). Early identification of these populations and intervention is key to the proper care of all neonates.

Neonates have intrinsic mechanisms in bilirubin metabolism that lead to nonpathogenic jaundice;

  • An increase in the enterohepatic circulation, leading to reuptake of bilirubin from the GI tract
  • Decreased bilirubin clearance due to the deficiency of the enzyme uridine diphosphogluconurate glucuronosyltransferase (reaches adult levels at 14 weeks of age)
  • Increased bilirubin production by two to three times. This is due to the fact that neonates have higher hematocrits and increased RBC turnover

Pathologic hyperbilirubinemia

  • Increased production of bilirubin: Isoimmune-mediated hemolysis (eg, ABO or Rh(D) incompatibility), erythrocyte enzymatic defects (e.g. G6PD, inherited red blood cell membrane defects (e.g. hereditary spherocytosis), sepsis
  • Decreased clearance: Crigler-Najjar syndrome, Gilbert syndrome, etc.
  • Increased enterohepatic circulation: Breastfeeding failure jaundice, Breast milk jaundice, intestinal obstruction


References:
  1. Neonatal hyperbilirubinemia.
    Dennery PA, Seidman DS, Stevenson DK,
    N. Engl. J. Med. 2001 Feb;344(8):581-90.
  2. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

    Pediatrics 2004 Jul;114(1):297-316.
  3. The prenatal and postnatal development of UDP-glucuronyltransferase activity towards bilirubin and the effect of premature birth on this activity in the human liver.
    Kawade N, Onishi S,
    Biochem. J. 1981 Apr;196(1):257-60.
  4. Complex multifactorial nature of significant hyperbilirubinemia in neonates.
    Watchko JF, Lin Z, Clark RH, Kelleher AS, Walker MW, Spitzer AR, Spitzer AR,
    Pediatrics 2009 Nov;124(5):e868-77.

5 Transcutaneous bilirubin

Although transcutaneous bilirubin does correlate with serum values there is significant variation between different races and skin pigmentation. TCB also cannot be used after the introduction of phototherapy. Therefore, its use should be limited to screening with confirmatory testing necessary prior to treatment.



References:
  1. Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia.
    Bhutani VK, Gourley GR, Adler S, Kreamer B, Dalin C, Johnson LH,
    Pediatrics 2000 Aug;106(2):E17.
  2. Transcutaneous bilirubin measurements and serum total bilirubin levels in indigenous African infants.
    Slusher TM, Angyo IA, Bode-Thomas F, Akor F, Pam SD, Adetunji AA, McLaren DW, Wong RJ, Vreman HJ, Stevenson DK,
    Pediatrics 2004 Jun;113(6):1636-41.
  3. Transcutaneous bilirubin nomogram for prediction of significant neonatal hyperbilirubinemia.
    Varvarigou A, Fouzas S, Skylogianni E, Mantagou L, Bougioukou D, Mantagos S,
    Pediatrics 2009 Oct;124(4):1052-9.
  4. Transcutaneous bilirubin levels in the first 96 hours in a normal newborn population of > or = 35 weeks' gestation.
    Maisels MJ, Kring E,
    Pediatrics 2006 Apr;117(4):1169-73.
  5. Skin bilirubin nomogram for the first 96 h of life in a European normal healthy newborn population, obtained with multiwavelength transcutaneous bilirubinometry.
    De Luca D, Romagnoli C, Tiberi E, Zuppa AA, Zecca E,
    Acta Paediatr. 2008 Feb;97(2):146-50.
  6. An hour-specific nomogram for transcutaneous bilirubin values in term and late preterm Hispanic neonates.
    Engle WD, Lai S, Ahmad N, Manning MD, Jackson GL,
    Am J Perinatol 2009 Jun;26(6):425-30.
  7. Nomogram for prediction of the risk of neonatal hyperbilirubinemia, using transcutaneous bilirubin.
    Sanpavat S, Nuchprayoon I, Smathakanee C, Hansuebsai R,
    J Med Assoc Thai 2005 Sep;88(9):1187-93.
  8. Bhutani-based nomograms for the prediction of significant hyperbilirubinaemia using transcutaneous measurements of bilirubin.
    Bental YA, Shiff Y, Dorsht N, Litig E, Tuval L, Mimouni FB,
    Acta Paediatr. 2009 Dec;98(12):1902-8.
  9. Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates.
    Fouzas S, Mantagou L, Skylogianni E, Mantagos S, Varvarigou A,
    Pediatrics 2010 Jan;125(1):e52-7.
  10. Transcutaneous bilirubin levels in an outpatient and office population.
    Maisels MJ, Engle WD, Wainer S, Jackson GL, McManus S, Artinian F,
    J Perinatol 2011 Sep;31(9):621-4.
  11. Accuracy of neonatal transcutaneous bilirubin measurement in the outpatient setting.
    Wickremasinghe AC, Karon BS, Cook WJ,
    Clin Pediatr (Phila) 2011 Dec;50(12):1144-9.

6 Risk factors



References:
  1. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

    Pediatrics 2004 Jul;114(1):297-316.
  2. Jaundice noted in the first 24 hours after birth in a managed care organization.
    Newman TB, Liljestrand P, Escobar GJ,
    Arch Pediatr Adolesc Med 2002 Dec;156(12):1244-50.
  3. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization.
    Newman TB, Xiong B, Gonzales VM, Escobar GJ,
    Arch Pediatr Adolesc Med 2000 Nov;154(11):1140-7.
  4. Length of stay, jaundice, and hospital readmission.
    Maisels MJ, Kring E,
    Pediatrics 1998 Jun;101(6):995-8.
  5. Epidemiology of neonatal jaundice in the Jerusalem population.
    Gale R, Seidman DS, Dollberg S, Stevenson DK,
    J. Pediatr. Gastroenterol. Nutr. 1990 Jan;10(1):82-6.
  6. Hyperbilirubinemia in infants of diabetic mothers.
    Peevy KJ, Landaw SA, Gross SJ,
    Pediatrics 1980 Sep;66(3):417-9.
  7. Risk factors for severe hyperbilirubinemia among infants with borderline bilirubin levels: a nested case-control study.
    Kuzniewicz MW, Escobar GJ, Wi S, Liljestrand P, McCulloch C, Newman TB,
    J. Pediatr. 2008 Aug;153(2):234-40.

7 Childhood cancer risk

There is some observational data that phototherapy MAY be associated with an increased risk of childhood cancer. However, this risk is likely small and there are many confounders to the data that has been documented to date. Therefore, phototherapy still represents the most reasonable choice of therapy for high risk hyperbilirubinemia, but should be avoided in patients who are not in this population.



References: