Clinical Pathway for Evaluation/Treatment of Neonates with Hyperbilirubinemia/Jaundice

Goals and Metrics
Patient Education
Provider Resources
Related Pathways
Infants ≥ 35 Weeks Gestation with Hyperbilirubinemia/Jaundice
Summary of Changes AAP 2022 Guidance
  • Risk Factors for Developing Significant Hyperbilirubinemia
  • Gestational age < 40 weeks
  • Jaundice in 1st 24 hrs after birth
  • Discharge TSB or TcB close to the Phototherapy Threshold
  • Hemolysis from any cause, or rapid rate of increase of TSB or TcB:
    • > 0.3 mg/dL per hour in the 1st 24 hrsor
    • > 0.2 mg/dL per hour thereafter
  • Phototherapy before discharge from the birth hospital
  • Parent, sibling requiring phototherapy or exchange transfusion
  • Family history, genetic ancestry suggest inherited RBC disorder including G6PD deficiency
  • Exclusive breastfeeding with suboptimal intake
  • Down syndrome
  • Macrosomic infant of diabetic mother
  • Hyperbilirubinemia Neurotoxicity Risk Factors
  • Isoimmune hemolytic disease
  • Other hemolytic diseases, e.g., G6PD Deficiency
  • Significant clinical instability in the previous 24 hours: e.g., sepsis, acidosis, asphyxia, significant lethargy, temperature instability
  • Albumin < 3.0 g/dL
Concern for other diseases: e.g., sepsis, cardiac, metabolic
History and Physical
Laboratory Studies, TcB Interpretation
  • Total Serum Bilirubin (TSB):
    • TSB = Conjugated + Unconjugated
  • CBC, retic, infant blood type, DAT
  • Consider albumin (neurotoxicity)
  • Escalation:
    • Type and screen, albumin
Nursery Care at Birth Hospital
  • Visual jaundice assessment q12 hrs after delivery
  • Measure TCB or TSB 24-48 hrs after birth or prior to discharge
  • Phototherapy based on TSB, risk factor
  • Discharge plan, follow-up,
    Rebound Testing
Primary Care
  • Measure TcB or TSB
  • Obtain TSB if:
    • TcB level within 3 mg/dL of Phototherapy Threshold
    • TcB > 15 mg/dL
    • Determine the time of bilirubin recheck
    • Refer to ED as indicated
Emergency Department Care
  • Triage
  • RN standing order
  • Measure TSB, apply biliblanket
  • Admit or discharge with a follow-up plan

Phototherapy: Use TSB to guide the decision to initiate phototherapy

Nutrition, Hydration
Home LED-based Phototherapy
Inpatient Care
N/IICU: Escalation of Care
  • Consult Neonatology if any of the following:
    • TSB within 2 mg/dL of Exchange Threshold
    • TSB rate of rise > 0.5 mg/dL/hr
    • Evidence of hemolysis
  • Intensive phototherapy, IVF
  • Double Volume Exchange Transfusion, IVIG
  • Consider a transfer to a hospital capable of exchange transfusion if TSB within
  • 2 mg/dL of Exchange Threshold
Discontinuing Phototherapy
Discontinue when TSB is > 2 mg/dL below the hour-specific threshold used to initiate Phototherapy, not current hour-of-life threshold
Monitor TSB after
Discontinuing Phototherapy

Discharge Plan and Follow-up Care

Outpatient Laboratory and ED Process for TSB on Sundays and Holidays
Posted: December 2022
Last Revised: February 2024
Editors: Clinical Pathways Team