A. General Plan. Treatment for neonatal indirect hyperbilirubinemia is initiated to avoid neurologic sequelae and kernicterus, but in most instances jaundice is benign and self-limited. Mainstay of treatment for indirect hyperbilirubinemia is phototherapy, but exchange transfusion should be considered for severe cases, in consultation with a neonatologist. Initiate phototherapy if bilirubin rises rapidly or if level of jaundice is of concern because of patient's age in hours. American Academy of Pediatric (AAP) guidelines and nomograms are available. Avoid medications known to displace bilirubin bound to albumin (eg, ceftriaxone) to minimize risk for kernicterus when treating young infants with jaundice.
B. Physiologic Jaundice. Condition is self-limited, peaking at approximately 3-4 days of life for healthy term infants and resolving by 2 weeks of life.
C. Breast-Feeding Jaundice. Provide lactation support, if available. If infant is dehydrated, consider administering IV fluids or supplementing with formula by mouth. Breast-feeding should not be discontinued in most cases, particularly in the first weeks of life when not well established.
D. ABO Incompatibility. Most patients with ABO incompatibility will not have clinically significant hemolysis. For more severe cases, response to phototherapy is generally good. In very severe cases, obtain serial hematocrit and bilirubin levels. Patients with severe anemia may require packed RBC transfusions.
E. G6PD Deficiency. Provide family with educational materials regarding foods and medications to be avoided.
Erythrocyte Structural Defects. If spherocytosis is suspected, consult pediatric hematologist. Follow patients for pallor and jaundice. Some patients may require phototherapy in the newborn period.
Familial Disorders of Conjugation. Gilbert syndrome is benign, whereas Crigler-Najjar types 1 and 2 are associated with severe hyperbilirubinemia.Type 2 may respond to phenobarbital, but type 1 does not and is treated by phototherapy and liver transplantation.
VI. Problem Case Diagnosis. The 3-day-old infant was reported to be breast-feeding every 3 hours for 10 minutes on one side only. Inadequate feeding resulted in loss of 11% of birthweight and limited stooling. Final diagnosis is breast-feeding jaundice.
VII. Teaching Pearl: Questions. How does phototherapy work to decrease hyperbilirubinemia? What part of the brain is involved in kernicterus?
VIII. Teaching Pearl: Answers. Phototherapy, used to treat neonatal hyperbilirubinemia for more than 40 years, results in a number of isomers (eg, lumirubin) or photoproducts that are excreted in urine and bile. Bilirubin preferentially deposits in basal ganglia, resulting in opisthotonus, seizures, and choreoathetoid movements. The auditory system is also highly sensitive to bilirubin, and auditory neuropathy and processing disorders may be seen in patients with kernicterus.
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