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Guidance for follow-up of newborns undergoing bilirubin screening during birth hospitalization

Guidance for follow-up of newborns undergoing bilirubin screening during birth hospitalization
Steps of newborn bilirubin screening:
  • Step 1: Measure TSB or TcB at 24 to 48 hours after birth or before discharge, whichever is sooner.*
  • Step 2: Determine the hour-specific TSB threshold for phototherapy based upon the newborn's GA, postnatal age, and risk factors for neurotoxicity.
  • Step 3: If screening was performed with a TcB device and the value is >15 mg/dL (257 micromol/L) or is within 3 mg/dL (51 micromol/L) of the phototherapy threshold, confirm with a TSB measurement. The decision to begin phototherapy should be based upon the TSB value.
  • Step 4: If TSB is at or above the phototherapy threshold, begin treatment.Δ
  • Step 5: If the newborn's bilirubin level is below the phototherapy threshold, calculate the difference between the hour-specific phototherapy TSB threshold and newborn's bilirubin level. Decisions regarding timing and need for follow-up testing are based upon this difference.
Suggested follow-up according to the newborn's predischarge bilirubin level and age at discharge
How far below the phototherapy threshold is the newborn's bilirubin level? Age at time of discharge Suggested follow-up
0.1 to <2 mg/dL
(1 to <34 micromol/L)
<24 hours
  • Delay discharge
  • Recheck TSB in 4 to 8 hours
  • Early initiation of phototherapy may be appropriate in some cases
≥24 hours
  • Recheck TSB in 4 to 12 hours
  • Options include:
    • Delay discharge, or
    • Discharge with home phototherapy if patient meets criteria,§ or
    • Discharge without phototherapy but with earlier outpatient follow-up
2.0 to <3.5 mg/dL
(34 to <60 micromol/L)
>12 hours
  • Recheck TSB or TcB in the outpatient setting in 8 to 24 hours
3.5 to <5.5 mg/dL
(60 to <94 micromol/L)
>12 hours
  • Recheck TSB or TcB in the outpatient setting in 1 to 2 days
5.5 to <7.0 mg/dL
(94 to <120 micromol/L)
<72 hours
  • Outpatient follow-up within 2 days
  • The need for repeat TcB or TSB testing is based upon clinical assessment¥
≥72 hours
  • The timing of follow-up and need for repeat TcB or TSB testing is based upon prior bilirubin trajectory and clinical assessment¥
≥7.0 mg/dL
(≥120 micromol/L)
<72 hours
  • Outpatient follow-up within 3 days
  • The need for repeat TcB or TSB testing is based upon clinical assessment¥
≥72 hours
  • Most newborns in this category can have routine healthy newborn follow-up. Specific follow-up related to hyperbilirubinemia is not required unless new concerns arise (eg, feeding difficulties, delayed stooling, parent/caregiver concern for persistent jaundice).¥
This table summarizes our suggested approach to determining appropriate follow-up for newborns ≥35 weeks gestation undergoing routine bilirubin screening during the birth hospitalization. The guidance in this table does not apply to newborns who undergo bilirubin testing within the first 12 hours after birth or those who have received phototherapy. This table is intended for use in conjunction with other content. Refer to UpToDate's topics on neonatal hyperbilirubinemia for additional details.

TcB: transcutaneous bilirubin; TSB: total serum or plasma bilirubin; DAT: direct antiglobulin test; G6PD: glucose-6 phosphate dehydrogenase; GA: gestational age.

* Earlier testing is warranted in patients with clinical signs or risk factors for early hyperbilirubinemia, including Rh-negative mother, positive DAT, visible jaundice at <24 hours of age, or family history of hemolytic disease (eg, G6PD deficiency, hereditary spherocytosis).

¶ Refer to separate UpToDate content for the hour-specific phototherapy thresholds for newborns with and without risk factors for neurotoxicity. In addition to GA, other risk factors for neurotoxicity include hemolytic conditions, clinical instability in the previous 24 hours, sepsis, and hypoalbuminemia.

Δ The approach to using phototherapy to treat neonatal hyperbilirubinemia is beyond the scope of this table. Refer to separate UpToDate content for details of treatment. The follow-up guidance in this table applies only to infants with bilirubin values below the phototherapy threshold (ie, newborns for whom discharge is being considered).

◊ We suggest starting phototherapy early (ie, at near-threshold TSB levels) if the newborn has clinical risk factors for progressive jaundice (eg, onset of jaundice within first 24 hours after birth, ABO or Rh incompatibility, rapidly rising bilirubin levels, or significant bruising/cephalohematoma). For newborns who lack clinical risk factors for progressive hyperbilirubinemia, treatment should be individualized depending on parent/caregiver preference. Refer to UpToDate's topics on neonatal hyperbilirubinemia for additional details.

§ Treatment with home phototherapy is an option for newborns who meet all of the following criteria:
  • Gestational age ≥38 weeks
  • ≥48 hours old
  • Clinically well with adequate feeding
  • No clinical risk factors for severe hyperbilirubinemia
  • No previous need for phototherapy
  • An LED-based phototherapy device will be available in the home upon discharge
  • Bilirubin levels can be measured daily

¥ For newborns with bilirubin levels that are ≥5.5 mg/dL (94 micromol/L) below the threshold for phototherapy, decisions regarding timing for outpatient follow-up and rechecking bilirubin levels are individualized based upon the clinical assessment (signs of jaundice, feeding adequacy, weight trajectory, parent/caregiver concerns). For additional details, refer to UpToDate's topic on bilirubin screening in newborns.

Adapted from: Kemper AR, Newman TB, Slaughter JL, et al. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2022; 150:e2022058859.
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