This handout is for neonatal hyperbilirubinemia — kernicterus prevention (aap 2022 thresholds). Your care team identified this based on: visible jaundice in neonate ≥ 35 wk ga — screening tsb or tcb indicated (kemper aap 2022 pmid 35927462).
Other reasons your team may use this plan: universal pre-discharge bilirubin screening — tsb or tcb at discharge or by 24-48 h of life (kemper aap 2022 strong recommendation); tsb at or above aap 2022 figure 2 phototherapy curve for ga + hours-age + risk factors (kemper aap 2022); tsb at or above aap 2022 figure 3 exchange-transfusion curve — emergent (kemper aap 2022).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| phototherapy_standard_or_intensive | Standard: 8-10 µW/cm²/nm at 460-490 nm blue light; Intensive: ≥ 30 µW/cm²/nm with multiple light banks + minimal swaddling | transdermal_phototherapy | continuous with breaks for feeding only if standard; uninterrupted if intensive near exchange | Mechanism: 460-490 nm blue light isomerizes bilirubin to water-soluble lumirubin excreted in bile/urine; intensive reduces TSB ~ 0.5-1 mg/dL per hour (Kemper AAP 2022) |
| ivig | 0.5-1 g/kg IV over 2-4 h; may repeat in 12 h if no response | IV | one dose, repeat at 12 h if no response | Saturates Fc receptors on reticuloendothelial macrophages, reducing antibody-coated RBC destruction in isoimmune hemolytic disease (Rh, ABO); reduces need for exchange transfusion per Cochrane + AAP 2022 |
| exchange_transfusion_double_volume | Double-volume exchange = 160 mL/kg via central / umbilical venous catheter (UVC); typically using reconstituted whole blood (RBC + FFP), irradiated, CMV-seronegative, < 7 d old | central_venous_catheter_UVC_or_central | one procedure; repeat if TSB rebounds back above exchange threshold | Removes ~ 85% of circulating bilirubin + ~ 25-50% of extravascular bilirubin; corrects anemia in isoimmune; emergent procedure for ABE or TSB above exchange curve (Kemper AAP 2022) |
| enteral_feeding_supplementation | Supplemental expressed breast milk OR formula per lactation consult; reassess weight + urine output + serum sodium | enteral_PO_or_NG | after every 2-3 h BF attempt or per lactation plan | Reduces enterohepatic recirculation of bilirubin; corrects dehydration; AAP 2022 BF + intake assessment recommendation |
| iv_fluids_maintenance_or_resuscitation | D10W or D10NS at maintenance (4-2-1 rule by weight) if dehydrated or NPO; resuscitation 10-20 mL/kg NS slowly if hypotensive (neonatal-specific slower bolus rate) | IV | continuous | Correct dehydration; phototherapy increases insensible water loss 10-20%; sepsis-associated shock requires fluid resuscitation per AAP/PALS neonatal-adapted |
Plan: Neonatal hyperbilirubinemia — by AAP 2022 threshold zone (Kemper PMID 35927462)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Outpatient peds within 24-48 h of discharge for all phototherapy-treated infants + all high-risk (Bhutani high-intermediate/high percentile) + late preterm 35-36 wk + exclusive BF cohorts. Rebound TSB check at 12-24 h post-phototherapy discontinuation if elevated risk. G6PD-positive infant: long-term outpatient counseling on trigger-medication avoidance (sulfa drugs, nitrofurantoin, primaquine, methylene blue, fava beans). Lactation support continued + weight + feeding monitoring. Universal parental kernicterus-prevention education at every visit (jaundice warning signs, when to seek evaluation). Neurodevelopmental screening at 6-12 mo if kernicterus risk factors (any ABE features, TSB approached exchange, prolonged severe hyperbilirubinemia) — Bayley III or ASQ-3; hearing screen (AABR — sensorineural hearing loss is a kernicterus sequela). Audiology referral if hearing screen abnormal.
Guideline: Kemper KJ et al — AAP 2022 Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation — Pediatrics 2022 (PMID 35927462) — substantially revised 2004 thresholds; introduced escalation-of-care concept; universal G6PD testing in all infants requiring phototherapy; universal pre-discharge screening + Bhutani 1999 nomogram (PMID 9917432). Cross-references: Watchko & Tiribelli NEJM 2013 (kernicterus pathophysiology + ABE-kernicterus spectrum); Maisels CMAJ 2015 (operational review including home phototherapy); NICE NG98 (UK parallel guideline); Kimberlin Red Book 2021 (neonatal HSV cross-ref for conjugated hyperbilirubinemia with hepatitis).