Major Risk factors:



Major Risk factors:

• Predischarge Bilirubin level in the high-risk zone on the bilirubin chart

• Blood group incompatibility with positive direct antiglobulin test

• Hemolytic disease (G6PD, spherocytosis… )

• Gestational age 35–36 wk

• 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 [pic]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 photo-therapy.

**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

[pic]

Additional References:

|Jaundice in a newborn: Answers to questions about a common clinical problem. First of two parts. |

| |

Jaundice in a newborn: How to head off an urgent situation. Second of two parts.



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|Treating acute bilirubin encephalopathy--before it's too late |



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