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An approach to escalating care for term and late preterm newborns (≥35 weeks gestation) with progressive and/or severe unconjugated hyperbilirubinemia

An approach to escalating care for term and late preterm newborns (≥35 weeks gestation) with progressive and/or severe unconjugated hyperbilirubinemia

This figure summarizes our suggested approach to managing term and late preterm newborns with unconjugated hyperbilirubinemia at levels that are approaching the thresholds for exchange transfusion. These newborns are optimally managed in a NICU. If the newborn is being managed in a setting that lacks facilities for neonatal exchange transfusion, a neonatologist should be consulted and arrangements should be made to urgently transfer the newborn to the NICU. IV hydration and intensive phototherapy should be provided during transfer, if possible. This figure is intended to be used in conjunction with separate UpToDate content. Refer to UpToDate's topics on management of neonatal unconjugated hyperbilirubinemia for additional details, including a discussion of the evidence supporting our approach.

The guidance in this figure does NOT apply to preterm newborns <35 weeks gestation. Refer to separate UpToDate content for details regarding management of preterm newborns <35 weeks gestation.

AAP: American Academy of Pediatrics; ABE: acute bilirubin encephalopathy; B/A ratio: bilirubin to albumin ratio; BUN: blood urea nitrogen; CBC: complete blood count; DAT: direct antiglobulin test; G6PD: glucose-6-phosphate dehydrogenase; GA: gestational age; HDN: hemolytic disease of the newborn; IV: intravenous; IVIG: intravenous immune globulin; NICU: neonatal intensive care unit; SI: Système Internationale; TSB: total serum or plasma bilirubin.

* Signs of ABE include: lethargy, hypo- or hypertonia, poor suck, high-pitched cry, opisthotonos, retrocollis, and seizures.

¶ Hour-specific TSB thresholds for phototherapy and exchange transfusion are determined based upon the AAP nomograms, which provide risk-based guidance for intervention. The thresholds differ depending upon GA and whether the newborn has risk factors for neurotoxicity, including hemolytic conditions, hypoalbuminemia (serum albumin <3 mg/dL), clinical instability in the previous 24 hours, and/or sepsis. Refer to separate UpToDate graphics that show hour-specific phototherapy and exchange transfusion thresholds for newborns with and without neurotoxicity risk factors.

Δ Rapidly rising TSB levels are defined as levels that are increasing by ≥0.3 mg/dL (5 micromol/L) per hour in the first 24 hours after birth or ≥0.2 mg/dL (3 micromol/L) per hour thereafter.

◊ Intensive phototherapy is defined as irradiance ≥30 microW/cm2 per nm in the blue green spectrum (wavelength between 430 and 490 nM) applied to as much of the newborn's skin surface as possible, using light sources above and below the newborn. IV hydration consists of crystalloid fluid (typically 10% dextrose with one- quarter normal saline at a maintenance rate [ie, 60 to 80 mL/kg per day for newborns <48 hours old; 80 to 100 mL/kg per day for those ≥48 hours old]). Refer to separate UpToDate content for additional details of administering phototherapy and IV hydration in newborns.

§ The B/A ratio is an index of the amount of bilirubin bound to albumin. It can be calculated as a mass ratio or molar ratio. The guidance in this table is based on the mass ratio. The B/A mass ratio is calculated as follows:
  • Using conventional units: Divide TSB (in mg/dL) by serum albumin (in g/dL)
  • Using SI units: Divide TSB (in micromol/L) by serum albumin (in g/L) and then multiply by a factor of 0.585

B/A mass ratio thresholds for performing exchange transfusion are as follows:

  • For newborns with GA ≥38 weeks and no neurotoxicity risk factors: B/A ≥8.0
  • For newborns with GA ≥38 weeks and at least one neurotoxicity risk factor: B/A ≥7.2
  • For newborns with GA 35 to <38 weeks and no neurotoxicity risk factors: B/A ≥7.2
  • For newborns with GA 35 to <38 weeks and at least one neurotoxicity risk factor: B/A ≥6.8

¥ Alloimmune HDN may be suspected based upon incompatible blood type between mother and newborn and/or positive DAT. However, a negative DAT does not exclude the diagnosis of alloimmune HDN, particularly in the setting of ABO incompatibility. Refer to separate UpToDate content on alloimmune HDN for additional details.

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