Major Risk Factors

Resident information about neonatal hyperbilirbinemia

Major Risk factors:

 Pre-discharge Bilirubin level in the high-risk zone on the bilirubin chart  Blood group incompatibility with positive direct anti-globulin test  Hemolytic disease (G6PD, spherocytosis )  Gestational age <37 weeks  Previous sibling received phototherapy  Cephalohematoma or significant bruising  Exclusive breastfeeding (particularly if nursing is not going well and weight loss is excessive)  East Asian race

Minor risk factors:

 Macrosomia  Infant of a Diabetic mother  Maternal age 25 y  Male gender  Pre-discharge TSB or TcB level in the high intermediate-risk zone  Gestational age 37–38 wk  Jaundice observed before discharge  Previous sibling with jaundice

For any newborn who is jaundiced at less then 24 hours of age obtain:

 Serum Bilirubin Level (total and direct)  Maternal Blood Type (look for isoimmune antibodies, Rh incompatibility)  Infants Cord Blood Type (look at Rh and look for DAT +)  CBC with manual differential  Reticulocyte count

**Determination of the rate of rise of TSB and the infant's age may help determine how often to monitor bilirubin levels and whether to begin phototherapy. (rate of rise calculated using 2 specimens drawn at a given # hrs apart)

**Continued observation may be an appropriate alternative to repeated TSB testing and phototherapy.

Phototherapy

 Minimum evaluation and documentation must include the infant’s age, maternal history, physical exam, total serum bilirubin and the rate of rise.

 Phototherapy should produce a decline in the total bilirubin level of 1 to 2 mg/dL within 4 to 6 hours, and the decline should continue thereafter. I Exchange Transfusion

The goal is to prevent kernicterus.

 If the total bilirubin level does not decline despite appropriate phototherapy, or is at or above a high level of risk on the phototherapy graph, exchange transfusion is recommended.

 Intensive phototherapy is recommended while preparations are being made for exchange transfusion. o This will hopefully prevent further elevation of the bilirubin level. o If level then drops below exchange transfusion levels during preparation, the transfusion may be avoided. .  Failure of intensive phototherapy to lower the total bilirubin level strongly suggests the presence of hemolytic disease or some other pathologic process and warrants further investigation.

Phototherapy Guidelines for infants >35weeks gestation from www. AAP.org Additional References:

Jaundice in a newborn: Answers to questions about a common clinical problem. First of two parts. http://www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?id=161376

Jaundice in a newborn: How to head off an urgent situation. Second of two parts. http://www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?id=161378

Treating acute bilirubin encephalopathy--before it's too late http://www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?id=161379