Dr. Rhishikesh Thakre*
DM (Neo.), MD, DNB, DCH, FCPS, MB. Neo Clinic, 27, Samarth Nagar, Aurangabad 431001*
Jaundice occurs in most newborn infants. Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus.

Care in the Labor room:
A mother who has not had prenatal blood grouping or is Rh-negative, a direct antibody test (or Coombs' test), blood type, and an Rh (D) type on the infant's (cord) blood are strongly recommended. If the maternal blood is group O, Rh-positive, it is an option to test the cord blood for the infant's blood type and direct antibody test.

Risk Assessment:
The best documented method for assessing the risk of subsequent hyperbilirubinemia is to measure the total serum bilirubin (TSB) or Transcutaneous Bilirubin (TcB) level and plot the results on a normogram.

Clinical Assessment:
Clinicians should ensure that all infants are routinely monitored for the development of jaundice. The assessment of jaundice must be performed in a well-lit room or, preferably, in daylight at a window. A transcutaneous bili and/or total serum bili measurement should be performed if the jaundice appears excessive for the infant's age. Visual estimation of bilirubin levels from the degree of jaundice can lead to errors. Because phototherapy "bleaches" the skin, both visual assessment of jaundice and TcB measurements in infants undergoing phototherapy are not reliable. The possible cause of jaundice should be sought in an infant receiving phototherapy or whose bili level is rising rapidly and is not explained by the history and physical examination.

Lab evaluation:
Infants who have an elevation of direct-reacting bilirubin should have a urinalysis and urine culture. Additional laboratory evaluation for sepsis should be performed if indicated by history and physical examination. Sick infants and those who are jaundiced at or beyond 3 weeks should have a measurement of total and direct or conjugated bilirubin to identify cholestasis. These newborns should be subjected to thyroid and galactosemia screening. Measurement of the glucose-6-phosphate dehydrogenase (G6PD) level is recommended for a jaundiced infant who is receiving phototherapy and whose family history or geographic origin suggest the likelihood of G6PD deficiency or for an infant in whom the response to phototherapy is poor.

Management Issues:
  1. Role of IV fluids: There is no role of routine supplementation of iv fluids to jaundiced newborn. However if the infant's intake seems inadequate, weight loss is excessive, or the infant seems dehydrated iv fluids may be started.

  2. Role of breastfeeding: In infants who require phototherapy, breastfeeding should be continued. For making a diagnosis of breastfeeding in jaundice, one need not interrupt breastfeeding.

  3. Phototherapy Issues:

    1. Light source: The most effective light sources currently commercially available are those that use special blue fluorescent tubes or a specially designed light-emitting diode light. The special blue fluorescent tubes are labeled F20T12/BB or TL52/20W.

    2. Distance from the light: The phototherapy unit should be as close to the baby as possible ensuring normothermia. Hyperthermia makes the phototherapy less effective. Halogen lamp PT however needs specific distances and manufacturers instructions be followed.

    3. Surface area: In most circumstances, it is not necessary to remove the infant's diaper, but when bilirubin levels approach the exchange transfusion range, the diaper should be removed until there is clear evidence of a significant decline in the bilirubin level.

    4. Intermittent v/s Continuous phototherapy: In most circumstances, phototherapy does not need to be continuous. Phototherapy may be interrupted during feeding or brief parental visits. Individual judgment should be exercised. If the infant's bilirubin level is approaching the exchange transfusion zone, phototherapy should be administered continuously until a satisfactory decline in the serum bilirubin level occurs or exchange transfusion is initiated.

    5. Intensive phototherapy is recommended for those with "higher risk" based on age specific normograms. It implies the use of high levels of irradiance in the 430-to 490-nm band (usually 30 µW/cm2 per nm or higher) delivered to as much of the infant's surface area as possible, and delivered to as much of the infant's surface area as possible. If total serum bilirubin levels approach or exceed the exchange transfusion line, the sides of the bassinet, incubator, or warmer should be lined with aluminum foil or white material to increase the performance of phototherapy. If the total serum bilirubin does not decrease or continues to rise in an infant who is receiving intensive phototherapy, this strongly suggests the presence of hemolysis.

    6. When PT should be stopped: There is no standard for discontinuing phototherapy. The TSB level for discontinuing phototherapy depends on the age at which phototherapy is initiated and the cause of the hyperbilirubinemia. Phototherapy is used for infants with hemolytic diseases or is initiated early and discontinued before the infant is 3 to 4 days old, a follow-up bilirubin measurement within 24 hours after discharge is recommended.

    7. Contraindications to PT: Congenital porphyria or a family history of porphyria is an absolute contraindication to the use of phototherapy, as is the concomitant use of drugs or agents that are photosensitizers.

  4. Exchange Transfusion: Exchange transfusion is recommended, if the TSB rises despite intensive phototherapy. If the TSB level is above the exchange level, repeat TSB measurement every 2 to 3 hours and consider exchange if the TSB remains above the levels indicated after intensive phototherapy for 6 hours. If the TSB is at or approaching the exchange level, send blood for immediate type and crossmatch. Blood for exchange transfusion is modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant.

  5. Role of IVIG: In isoimmune hemolytic disease, administration of intravenous-globulin (0.5-1 g/kg over 2 hours), is recommended if the TSB is rising despite intensive phototherapy or the TSB level is within 2 to 3 mg/dl of the exchange level. If necessary, this dose can be repeated in 12 hours.

  6. Role of bili/albumin ratio: It is an option to measure the serum albumin level and consider an albumin level of less than 3.0 g/dL as one risk factor for lowering the threshold for phototherapy use. If an exchange transfusion is being considered, the serum albumin level should be measured and the bilirubin/albumin (B/A) ratio used in conjunction with the TSB level and other factors in determining the need for exchange transfusion.

  7. Sunlight Exposure: Although sunlight provides sufficient irradiance in the 425 to 475-nm band to provide phototherapy, the practical difficulties involved in safety exposing naked newborn to the sun either inside or outside (and avoiding sunburn) preclude the use of sunlight as a reliable therapeutic tool, and it therefore is not recommended with photo.
    Follow up Protocol: The follow-up assessment should include the infant's weight and percent change from birth weight, adequacy of intake, the pattern of voiding and stooling, and the presence or absence of jaundice.

Follow up Protocol: The follow-up assessment should include the infant's weight and percent change from birth weight, adequacy of intake, the pattern of voiding and stooling, and the presence or absence of jaundice.

Infant dischargedShould be seen by age
Before age 24 h
Between 24 and 47.9 h 
Between 48 and 72 h
72 h 
96 h 
120 h

Key messages:
  1. Promote and support successful breastfeeding.
  2. Recognize that visual estimation of the degree of jaundice and those under phototherapy can lead to errors.
  3. Interpret all bilirubin levels according to the infant's age in hours.
  4. Recognize that infants at less than 38 weeks' gestation are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring.
  5. Perform a systematic assessment on all infants before discharge for the risk of severe hyperbilirubinemia.
  6. Provide appropriate follow-up based on the time of discharge and the risk assessment.
  7. Treat newborns, when indicated, therapy or exchange transfusion.

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