Neonatal Jaundice Follow-up

  • Author: Thor WR Hansen, MD, PhD, MHA, FAAP; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Feb 1, 2012
 

Further Inpatient Care

Infants who have been treated for neonatal jaundice can be discharged when they are feeding adequately and have had 2 successive serum bilirubin levels demonstrating a trend towards lower values.

If the hospital does not routinely screen newborns for auditory function, ordering such tests prior to discharge is advisable in infants who have had severe jaundice.

The 2004 AAP guideline recommends a systematic risk assessment for hyperbilirubinemia risk in all infants before discharge.[27] Parents should be provided with verbal and written information about jaundice.

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Further Outpatient Care

In the era of early discharge, newborns released within the first 48 hours of life need to be reassessed for jaundice within 1-2 days. The use of the hour-specific bilirubin nomogram may assist in selecting infants with a high likelihood of developing significant hyperbilirubinemia. The 2004 AAP guidelines emphasize the importance of universal systematic assessment for the risk of severe hyperbilirubinemia.[27] Guidelines from the European Society for Pediatric Research reiterate the same principles.[11]

Neonatal jaundice is one of the most common reasons why neonates are brought to an emergency department after discharge from the birth hospital.[33]

Near-term infants are at higher risk than term infants of developing significant jaundice and merit closer surveillance.[34]

The question of universal bilirubin screening has received attention and is the subject of debate.

  • Some data suggest that predischarge bilirubin screening reduces the number of infants with severe jaundice, as well as the rate of hospital readmissions.[35, 36]
  • Others have found that home nurse visiting was cost-effective and prevented readmissions for jaundice and dehydration.[37] However, the cost-effectiveness of preventing kernicterus by universal screening has been questioned.[38]
  • Nevertheless, in an update to the 2004 AAP jaundice guidelines Maisels et al give a clear recommendation in favor of predischarge bilirubin screening, either by transcutaneous measurement or by serum analysis.[39]
  • These authors also recommend a more structured approach to management and follow-up according to the predischarge total serum bilirubin and transcutaneous bilirubin (TcB) levels, gestational age, and other risk factors for hyperbilirubinemia. These risk factors include the following:[39]
    • Predischarge total serum bilirubin or transcutaneous bilirubin level measurement in the high-risk or high-intermediate–risk zone
    • Lower gestational age
    • Exclusive breastfeeding, particularly if nursing is not going well and weight loss is excessive
    • Jaundice observed in the first 24 hours
    • Isoimmune or other hemolytic disease (eg, G-6-PD deficiency)
    • Previous sibling with jaundice
    • Cephalohematoma or significant bruising
    • East Asian race

Telephone consultations are not recommended because parental reports cannot be appropriately gauged. Recently, numerous infants have developed kernicterus, resulting, at least in part, from inadequate communication between practitioners or their representatives and parents.

The availability of new devices for transcutaneous measurement of bilirubin levels should facilitate follow-up evaluations of infants discharged before 48 hours of life.

Home phototherapy is used in an effort to limit the high cost of applying such therapy in hospitals.

  • Home treatment can avoid or limit parent-child separation. Home treatment should be used with caution, since prevention of neurotoxicity is the goal. Some argue that an infant at risk for neurologic damage should not be at home.
  • With effective treatment strategies, the average duration of phototherapy in the regular neonatal nursery at the author's institution is less than 17 hours. Whether the effort and cost to set up home therapy is worthwhile is debatable. This assessment may be different in different socioeconomic and health financing circumstances.

Infants who have been treated for hemolytic jaundice require follow-up observation for several weeks because hemoglobin levels may fall lower than seen in physiologic anemia. Erythrocyte transfusions may be required if infants develop symptomatic anemia.

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Inpatient & Outpatient Medications

Although drugs that impact bilirubin metabolism have been used in studies, drugs are not ordinarily used in unconjugated neonatal hyperbilirubinemia.

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Transfer

Infants in need of exchange transfusion born at or admitted to facilities not capable of performing this procedure should be transferred to the nearest facility with such capability. In addition to complete records, the infant should be accompanied by a sample of maternal blood because this is needed by the blood bank to match blood.

However, in determining the best use of time before transfer, as well as the timing of the transfer, the following factors should be considered:

  • If the infant is in imminent danger of kernicterus, or is already exhibiting signs of neurological compromise, the most efficient phototherapy possible under the circumstances should be immediately initiated and should be continued until transfer commences. If fiberoptic or any other kind of phototherapy is technically feasible during transport, it should be continued throughout the duration of the transport.
  • If the hyperbilirubinemia is due to blood group isoimmunization, an infusion of intravenous immunoglobulin (IVIG) at 500 mg/kg should be immediately started and continued before and during transfer until completed (2 h).

Even if the receiving hospital determines that an exchange transfusion should be performed, continuing optimal phototherapy until the actual exchange procedure can commence is important. If fiberoptic phototherapy is available, the infant may be left on a fiberoptic mattress while the exchange is carried out. Oral hydration with a breast milk substitute may aid the clearance of bilirubin from the gut, thus inhibiting enterohepatic circulation of bilirubin, and should be given unless clearly contraindicated by the clinical state of the infant. Although none of these suggestions have been tested in randomized controlled trials, case reports, bilirubin photobiology, and expert opinion suggest that they may be beneficial and, at the very least, are unlikely to be harmful.

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Deterrence/Prevention

Prevention of severe neonatal jaundice is best achieved through attention to the risk status of the infant prior to discharge from the birth hospital, through parent education, and through careful planning of postdischarge follow-up.[27, 11]

A predischarge bilirubin measurement, obtained by transcutaneous or serum measurement and plotted into an hour-specific nomogram, has been shown to be a useful tool in distinguishing infants with a low risk of subsequently developing high bilirubin values.

Clinical risk factors include gestational age of less than 38 weeks, the use of oxytocin or vacuum during delivery, exclusive breast feeding, an older sibling with neonatal jaundice that required phototherapy, a rise of ≥ 6 mg/dL/d (≥ 100 μ mol/L/d) in total serum bilirubin levels, and hematomas or extensive bruising. Birth weight is also associated with risk of developing significant jaundice; the higher the birthweight, the higher the risk.

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Complications

Kernicterus. Please see the main article on Kernicterus for more information.

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Prognosis

Prognosis is excellent if the patient receives treatment according to accepted guidelines.

Brain damage due to kernicterus remains a true risk, and the apparent increased incidence of kernicterus in recent years may be due to the misconception that jaundice in the healthy full-term infant is not dangerous and can be disregarded.

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Patient Education

Parents should be educated about neonatal jaundice and receive written information prior to discharge from the birth hospital. The parent information leaflet should preferably be available in several languages.

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Contributor Information and Disclosures
Author

Thor WR Hansen, MD, PhD, MHA, FAAP  Professor, Department of Neonatology, Women and Children's Division, Chair, Clinical Ethics Committee, Oslo University Hospital HC, Rikshospitalet, Norway

Thor WR Hansen, MD, PhD, MHA, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for the History of Medicine, American Pediatric Society, European Society for Paediatric Research, New York Academy of Sciences, Perinatal Research Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Oussama Itani, MD, FAAP, FACN  Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center

Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, and American Heart Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP  Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Director, Neonatal Follow-up Program, Monroe Carell Jr Children's Hospital at Vanderbilt

Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, National Hospice and Palliative Care Organization, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Carol L Wagner, MD  Professor of Pediatrics, Medical University of South Carolina

Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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The graph represents indications for phototherapy and exchange transfusion in infants (with a birthweight of 3500 g) in 108 neonatal ICUs. The left panel shows the range of indications for phototherapy, whereas the right panel shows the indications for exchange transfusion. Numbers on the vertical axes are serum bilirubin concentrations in mg/dL (lateral) and mmol/L (middle). In the left panel, the solid line refers to the current recommendation of the American Academy of Pediatrics (AAP) for low-risk infants, the line consisting of long dashes (- - - - -) represents the level at which the AAP recommends phototherapy for infants at intermediate risk, and the line with short dashes (-----) represents the suggested intervention level for infants at high risk. In the right panel, the dotted line (......) represents the AAP suggested intervention level for exchange transfusion in infants considered at low risk, the line consisting of dash-dot-dash (-.-.-.-.) represents the suggested intervention level for exchange transfusion in infants at intermediate risk, and the line consisting of dash-dot-dot-dash (-..-..-..-) represents the suggested intervention level for infants at high risk. Intensive phototherapy is always recommended while preparations for exchange transfusion are in progress. The box-and-whisker plots show the following values: lower error bar = 10th percentile; lower box margin = 25th percentile; line transecting box = median; upper box margin = 75th percentile; upper error bar = 90th percentile; and lower and upper diamonds = 5th and 95th percentiles, respectively.
Algorithm for the management of jaundice in the newborn nursery.
Guidelines for management of neonatal jaundice currently in use in most pediatric departments in Norway. The guidelines were based on previously used charts and were created through a consensus process in the Neonatal Subgroup of the Norwegian Pediatric Society. These guidelines were adopted as national at the fall meeting of the Norwegian Pediatric Society. The reverse side of the chart contains explanatory notes to help the user implement the guidelines. A separate information leaflet for parents was also created.
 
 
 
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