V. Plan. See also Chapter 64.

A. Phototherapy. Phototherapy should be initiated according to the guidelines in

Tables 39-1
and 39-2. The AAP guidelines (see Table 39-1) are for healthy term infants (37
weeks)
only. Table 39-2 gives recommendations for phototherapy and exchange
transfusion in sick and well
preterm infants and sick term infants. Remember: These are guidelines only, and
each patient must be
considered individually. In infants weighing 1000 g, the guidelines may be
lowered to 5 mg/dL for
phototherapy and 10-12 mg/dL for exchange transfusion. If phototherapy is used,
perform the
following additional procedures:
1. Increase the maintenance infusion of intravenous fluids by 0.5 mL/kg/h if the
infant
weighs 1500 g and by 1 mL/kg/h if the infant weighs 1500 g. (Note: Water
supplements to breastfed
infants do not reduce serum bilirubin.) Remember that maintaining adequate
hydration and good
urine output will help the efficacy of phototherapy because the by-products
responsible for the
decline in bilirubin are partially excreted in the urine.
2. Perform total bilirubin testing every 6-12 h.
3. Attempt regular feedings if possible, and feed frequently. Feeding inhibits the
enterohepatic
from of bilirubin and helps lower the serum bilirubin level. Studies have revealed
that increasing the
frequency of breast-feeding will not have a significant effect on the serum bilirubin
level in the first 3
days of life.
4. Phototherapy can be safely discontinued once serum bilirubin levels have
fallen 2 mg/dL
below the level at which phototherapy was initiated. Once phototherapy is stopped,
the average
bilirubin rebound in infants who do not have hemolytic disease is 1 mg/dL.
B. Drug therapy
1. Phenobarbital has been shown to be effective in reducing the serum bilirubin
level by
increasing hepatic glucuronosyltransferase activity and conjugation of bilirubin. It
is not effective
immediately and is usually used in severe cases of prolonged hyperbilirubinemia
only. (For dosage
and other pharmacologic information, see Chapter 80.)
2. Studies have revealed that the tin and zinc metalloporphyrins (SnMP and
ZnMP,
respectively) are effective and in small trials show a dramatic decrease in the need
for phototherapy.
They work by decreasing the production of bilirubin by competitive inhibition of
heme oxygenase.
C. Exchange transfusion. (See Tables 39-1 and 39-2.) The procedure for
exchange transfusion is
discussed in Chapter 21. There is considerable controversy concerning the exact
level at which to
initiate exchange transfusion. The overall status (sick or well), birth weight,
gestational age, and age
of the infant are important considerations. In many cases, institutional guidelines
are established and
should be followed. The AAP guidelines for exchange transfusion are for healthy
term newborns
(37 weeks) only. Some general guidelines are listed in Table 39-2. Remember:
These are guidelines
only, and each patient must be considered individually. If the infant is sick (eg,
with signs of
hemolysis, hypoxemia, acidosis, or sepsis), has a lower gestational age, is on day 1
or 2 of life, or has
a low birth weight, this would tend to lower the threshold that is used for exchange
transfusion.
D. Breast-fed infants. The AAP does not recommend the interruption of breast-
feeding in healthy
term newborns. The AAP does encourage continued and frequent breast-feeding.
Remember that
supplementing with water or dextrose water does not lower the bilirubin level. Five
treatment options
are available. The decision as to which treatment option to use depends on the
specific infant, the
physician's judgment, and the family circumstances.
1. Observation and serial bilirubin determinations.
2. Continue breast-feeding, and administer phototherapy.
3. Continue breast-feeding but supplement with formula with or without
phototherapy.
4. Interrupt breast-feeding, and substitute formula.
5. Interrupt breast-feeding, substitute formula, and administer phototherapy.
Although
phototherapy does not reduce the serum bilirubin concentration in breast-fed
infants as quickly as it
does in formula-fed infants, it is still effective. Supplemental breast milk rather
than formula is
advocated by some.
E. Breast-fed infants with persistent jaundice after 2 weeks. About 30% of
healthy term infants
will have persistent jaundice after 2 weeks of age. Treatment is as follows:
1. If the physical examination is normal and the history of normal urine and stool is
obtained,
then the infant can be observed. An abnormal history includes pale stools or dark-
yellow urine.
2. Check the newborn screen for hypothyroidism (congenital hypothyroidism is a
cause of
indirect hyperbilirubinemia).
3. If jaundice is still present after 3 weeks, a urine bilirubin and total and direct
serum bilirubin
should be obtained.
F. Follow-up should be provided for all neonates discharged 48 h after birth to
monitor for
bilirubin problems.