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Neonatal hyperbilirubinemia

Key sources
The following summarized guidelines for the evaluation and management of neonatal hyperbilirubinemia are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2022) and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2017).


1.Diagnostic investigations

History and physical examination: as per AAP 2022 guidelines, assess all infants visually for jaundice at least every 12 hours following delivery until discharge.
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  • Bilirubin measurement

  • Direct antiglobulin test

  • Hepatobiliary imaging

  • G6PD testing

2.Diagnostic procedures

Liver biopsy
Perform an appropriately timed liver biopsy and histological examination by an experienced pediatric pathologist to elicit histopathological findings of bile duct proliferation, bile plugs, and fibrosis in the evaluation of infants with protracted conjugated hyperbilirubinemia.
Consider performing a liver biopsy and histological examination for identifying diseases causing cholestasis other than biliary atresia.
Obtain intraoperative cholangiography and histological examination of the duct remnant as the gold standard for the diagnosis of biliary atresia.

3.Medical management

Intravenous immunoglobulin: consider administering IVIG (0.5-1 g/kg) over 2 hours in infants with isoimmune hemolytic disease (positive direct antiglobulin test) if total serum bilirubin reaches or exceeds the escalation-of-care threshold. Consider repeating the dose in 12 hours.

4.Therapeutic procedures

Phototherapy, indications for initiation
Initiate intensive phototherapy at the total serum bilirubin thresholds on the basis of gestational age, hyperbilirubinemia neurotoxicity risk factors, and age of the infant in hours.
Consider offering treatment with a home LED-based phototherapy device rather than readmission to the hospital as an option in infants already discharged and then developed hyperbilirubinemia (above the phototherapy threshold) and meeting the following criteria:
gestational age ≥ 38 weeks
≥ 48 hours old
clinically well with adequate feeding
no known hyperbilirubinemia neurotoxicity risk factors
no previous phototherapy
total serum bilirubin concentration ≤ 1 mg/dL above the phototherapy treatment threshold
an LED-based phototherapy device will be available in the home without delay
total serum bilirubin can be measured daily

More topics in this section

  • Phototherapy (monitoring of treatment)

  • Phototherapy (escalation of treatment)

  • Phototherapy (indications for discontinuation)

  • Exchange transfusion

5.Patient education

Counseling before discharge: provide written and verbal education about neonatal jaundice to all families before discharge. Provide written information to facilitate postdischarge care, including the date, time, and place of the follow-up appointment and, when necessary, a prescription and appointment for a follow-up transcutaneous bilirubin or total serum bilirubin. Transmit birth hospitalization information, including the last transcutaneous bilirubin or total serum bilirubin and the age at which it was measured, and direct antiglobulin test results (if any) to the primary care provider who will see the infant at follow-up. Provide this information to families if there is uncertainty about who will provide the follow-up care.

6.Preventative measures

Primary prevention: do not offer oral supplementation of water or dextrose water to prevent hyperbilirubinemia or decrease bilirubin concentrations.

7.Follow-up and surveillance

Follow-up after discharge: calculate and use the difference between the bilirubin concentration measured closest to discharge and the phototherapy threshold at the time of the bilirubin measurement, beginning at least 12 hours after birth, to guide follow-up if patient discharge is being considered.