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If the maternal antibody screen is positive or unknown because the mother did not have prenatal antibody screening, the infant should have a direct antiglobulin test (DAT) and the infant’s blood type should be determined as soon as possible using either cord or peripheral blood.
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Oral supplementation with water or dextrose water should not be provided to prevent hyperbilirubinemia or decrease bilirubin concentrations.
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Use TSB as the definitive diagnostic test to guide phototherapy and escalation-of-care decisions, including exchange transfusion.
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All infants should be visually assessed for jaundice at least every 12 hours following delivery until discharge. TSB or TcB should be measured as soon as possible for infants noted to be jaundiced <24 hours after birth.
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The TcB or TSB should be measured between 24 and 48 hours after birth or prior to discharge if that occurs earlier.
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TSB should be measured if the TcB exceeds or is within 3 mg/dL of the phototherapy treatment threshold or if the TcB is 15 mg/dL.
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If more than 1 TcB or TSB measure is available, the rate of increase may be used to identify higher risk of subsequent hyperbilirubinemia. A rapid rate of increase (0.3 mg/dL per hour in the first 24 hours or 0.2 mg/dL per hour thereafter) is exceptional and suggests hemolysis. In this case, obtain a DAT if not previously done.
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If appropriate follow-up cannot be arranged for an infant recommended to have an outpatient follow-up bilirubin measure, discharge may be delayed.
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For breastfed infants who are still jaundiced at 3 to 4 weeks of age, and for formula-fed infants who are still jaundiced at 2 weeks of age, the total and direct-reacting (or conjugated) bilirubin concentrations should be measured to identify possible pathologic cholestasis.
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Intensive phototherapy is recommended at the total serum bilirubin thresholds in Fig 2 (Supplemental Table 1 and Supplemental Fig 1) or Fig 3 (Supplemental Table 2 and Supplemental Figure 2) on the basis of gestational age, hyperbilirubinemia neurotoxicity risk factors, and age of the infant in hours.
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For newborn infants who have already been discharged and then develop a TSB above the phototherapy threshold, treatment with a home LED-based phototherapy device rather than readmission to the hospital is an option for select infants.
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For hospitalized infants, TSB should be measured within 12 hours after starting phototherapy. The timing of the initial TSB measure after starting phototherapy and the frequency of TSB monitoring during phototherapy should be guided by the age of the child, the presence of hyperbilirubinemia neurotoxicity risk factors, the TSB concentration, and the TSB trajectory.
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For infants receiving home phototherapy, the TSB should be measured daily. Infants should be admitted for inpatient phototherapy if the TSB increases and the difference between the TSB and the phototherapy threshold narrows or the TSB is 1mg/dL above the phototherapy threshold.
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For infants requiring phototherapy, measure the hemoglobin concentration, hematocrit, or complete blood count to assess for the presence of anemia and to provide a baseline in case subsequent anemia develops. Evaluate the underlying cause or causes of hyperbilirubinemia in infants who require phototherapy by obtaining a DAT in infants whose mother had a positive antibody screen or whose mother is blood group O regardless of Rh(D) status or whose mother is Rh(D). G6PD activity should be measured in any infant with jaundice of unknown cause whose TSB increases despite intensive phototherapy, whose TSB increases suddenly or increases after an initial decline, or who requires escalation of care.
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Discontinuing phototherapy is an option when the TSB has decreased by at least 2 mg/dL below the hour-specific threshold at the initiation of phototherapy. A longer period of phototherapy is an option if there are risk factors for rebound hyperbilirubinemia (eg, gestational age <38 weeks, age <48 hours at the start of phototherapy, hemolytic disease).
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Follow-up bilirubin measurement after phototherapy is based on the risk of rebound hyperbilirubinemia. Infants who exceeded the phototherapy threshold during the birth hospitalization and (1) received phototherapy before 48 hours of age; (2) had a positive DAT; or (3) had known or suspected hemolytic disease, should have TSB measured 6 to 12 hours after phototherapy discontinuation and a repeat bilirubin measured on the day after phototherapy discontinuation.
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Care should be escalated when an infant’s TSB reaches or exceeds the escalation-of-care threshold, defined as 2 mg/dL below the exchange transfusion threshold
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For infants requiring escalation of care, blood should be sent STAT for total and direct-reacting serum bilirubin, a complete blood count, serum albumin, serum chemistries, and type and crossmatch.
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Infants requiring escalation of care should receive intravenous hydration and emergent intensive phototherapy. A neonatologist should be consulted for transfer to a neonatal intensive care unit that can perform an exchange transfusion.
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TSB should be measured at least every 2 hours from the start of the escalation-of-care period until the escalation-of-care period ends. Once the TSB is lower than the escalation-of-care threshold, management should proceed according to the section “C. Monitoring Infants Receiving Phototherapy.”
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Intravenous immune globulin (IVIG; 0.5–1 g/kg) over 2 hours may be provided to infants with isoimmune hemolytic disease (ie, positive DAT) whose TSB reaches or exceeds escalation of care threshold. The dose can be repeated in 12 hours.
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An urgent exchange transfusion should be performed for infants with signs of intermediate or advanced stages of intermediate or advanced stages of acute bilirubin encephalopathy (eg, hypertonia, arching, retrocollis, opisthotonos, high-pitched cry, or recurrent apnea).
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An urgent exchange transfusion should be performed for infants if the TSB is at or above the exchange transfusion threshold. If, while preparing for the exchange transfusion but before starting the exchange transfusion, a TSB concentration is below the exchange transfusion threshold and the infant does not show signs of intermediate or advanced stages of acute bilirubin encephalopathy, then the exchange transfusion may be deferred while continuing intensive phototherapy and following the TSB every 2 hours until the TSB is below the escalation of care threshold.
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Beginning at least 12 hours after birth, if discharge is being considered, the difference between the bilirubin concentration measured closest to discharge and the phototherapy threshold at the time of the bilirubin measurement should be calculated and used to guide follow-up, as detailed in Fig 7.
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Before discharge, all families should receive written and verbal education about neonatal jaundice. Parents should be provided written information to facilitate postdischarge care, including the date, time, and place of the follow-up appointment and, when necessary, a prescription and appointment for a follow-up TcB or TSB.
