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.^[40]Parents should be provided with verbal and written information about jaundice.

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.

Questions

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Media Gallery

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 all 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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Author

Thor WR Hansen, MD, PhD, MHA, FAAP Professor, Department of Neonatology, Women and Children's Division, Director of Clinical Ethics, Oslo University Hospital HC, Rikshospitalet; Director of Pediatric Education, Faculty of Medicine, University of Oslo, 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, Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

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, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center

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 Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization

Disclosure: Nothing to disclose.

Chief Editor

Muhammad Aslam, MD Professor of Pediatrics, University of California, Irvine, School of Medicine; Neonatologist, Division of Newborn Medicine, Department of Pediatrics, UC Irvine Medical Center

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

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 Association for Physician Leadership, American Heart Association, American College of Nutrition

Disclosure: Nothing to disclose.

Neonatal Jaundice Follow-up

Further Inpatient Care

Transfer

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