Nomogram for designation of risk in 2840 well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks’ gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values. The serum bilirubin level was obtained before discharge, and the zone in which the value fell predicted the likelihood of a subsequent bilirubin level exceeding the 95th percentile (high-risk zone) as shown in Appendix 1, Table 4. Used with permission from Bhutani et al.31 See Appendix 1 for additional information about this nomogram, which should not be used to represent the natural history of neonatal hyperbilirubinemia.
Guidelines for phototherapy in hospitalized infants of 35 or more weeks’ gestation.
Note: These guidelines are based on limited evidence and the levels shown are approximations. The guidelines refer to the use of intensive phototherapy which should be used when the TSB exceeds the line indicated for each category. Infants are designated as “higher risk” because of the potential negative effects of the conditions listed on albumin binding of bilirubin,45–47 the blood-brain barrier,48 and the susceptibility of the brain cells to damage by bilirubin.48
“Intensive phototherapy” implies irradiance in the blue-green spectrum (wavelengths of approximately 430–490 nm) of at least 30 μW/cm2 per nm (measured at the infant’s skin directly below the center of the phototherapy unit) and delivered to as much of the infant’s surface area as possible. Note that irradiance measured below the center of the light source is much greater than that measured at the periphery. Measurements should be made with a radiometer specified by the manufacturer of the phototherapy system.
See Appendix 2 for additional information on measuring the dose of phototherapy, a description of intensive phototherapy, and of light sources used.
If total serum bilirubin levels approach or exceed the exchange transfusion line (Fig 4), the sides of the bassinet, incubator, or warmer should be lined with aluminum foil or white material.50 This will increase the surface area of the infant exposed and increase the efficacy of phototherapy.51 If the total serum bilirubin does not decrease or continues to rise in an infant who is receiving intensive phototherapy, this strongly suggests the presence of hemolysis.
Infants who receive phototherapy and have an elevated direct-reacting or conjugated bilirubin level (cholestatic jaundice) may develop the bronze-baby syndrome. See Appendix 2 for the use of phototherapy in these infants.
Guidelines for exchange transfusion in infants 35 or more weeks’ gestation.
Note that these suggested levels represent a consensus of most of the committee but are based on limited evidence, and the levels shown are approximations. See ref. 3 for risks and complications of exchange transfusion. During birth hospitalization, exchange transfusion is recommended if the TSB rises to these levels despite intensive phototherapy. For readmitted infants, if the TSB level is above the exchange level, repeat TSB measurement every 2 to 3 hours and consider exchange if the TSB remains above the levels indicated after intensive phototherapy for 6 hours.
The following B/A ratios can be used together with but in not in lieu of the TSB level as an additional factor in determining the need for exchange transfusion52:
If the TSB is at or approaching the exchange level, send blood for immediate type and crossmatch. Blood for exchange transfusion is modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant.53
Relationship between average spectral irradiance and decrease in serum bilirubin concentration. Term infants with nonhemolytic hyperbilirubinemia were exposed to special blue lights (Phillips TL 52/20W) of different intensities. Spectral irradiance was measured as the average of readings at the head, trunk, and knees. Drawn from the data of Tan.4 Source: Pediatrics. 1996;98:283-287.
Effect of light source and distance from the light source to the infant on average spectral irradiance. Measurements were made across the 425- to 475-nm band by using a commercial radiometer (Olympic Bilimeter Mark II) and are the average of measurements taken at different locations at each distance (irradiance at the center of the light is much higher than at the periphery). The phototherapy unit was fitted with eight 24-in fluorescent tubes. ▪ indicates special blue, General Electric 20-W F20T12/BB tube; ♦, blue, General Electric 20-W F20T12/B tube; ▴, daylight blue, 4 General Electric 20-W F20T12/B blue tubes and 4 Sylvania 20-W F20T12/D daylight tubes; •, daylight, Sylvania 20-W F20T12/D daylight tube. Curves were plotted by using linear curve fitting (True Epistat, Epistat Services, Richardson, TX). The best fit is described by the equation y = AeBx. Source: Pediatrics. 1996;98:283-287.
Example of a Clinical Pathway for Management of the Newborn Infant Readmitted for Phototherapy or Exchange Transfusion
Use intensive phototherapy and/or exchange transfusion as indicated in Figs 3 and 4 (see Appendix 2 for details of phototherapy use)
TSB and direct bilirubin levels
Blood type (ABO, Rh)
Direct antibody test (Coombs’)
Complete blood cell count with differential and smear for red cell morphology
ETCOc (if available)
G6PD if suggested by ethnic or geographic origin or if poor response to phototherapy
Urine for reducing substances
If history and/or presentation suggest sepsis, perform blood culture, urine culture, and cerebrospinal fluid for protein, glucose, cell count, and culture
If TSB ≥25 mg/dL (428 μmol/L) or ≥20 mg/dL (342 μmol/L) in a sick infant or infant <38 wk gestation, obtain a type and crossmatch, and request blood in case an exchange transfusion is necessary
In infants with isoimmune hemolytic disease and TSB level rising in spite of intensive phototherapy or within 2–3 mg/dL (34–51 μmol/L) of exchange level (Fig 4), administer intravenous immunoglobulin 0.5–1 g/kg over 2 h and repeat in 12 h if necessary
If infant’s weight loss from birth is >12% or there is clinical or biochemical evidence of dehydration, recommend formula or expressed breast milk. If oral intake is in question, give intravenous fluids.
For infants receiving intensive phototherapy
Breastfeed or bottle-feed (formula or expressed breast milk) every 2–3 h
If TSB ≥25 mg/dL (428 μmol/L), repeat TSB within 2–3 h
If TSB 20–25 mg/dL (342–428 μmol/L), repeat within 3–4 h. If TSB <20 mg/dL (342 μmol/L), repeat in 4–6 h. If TSB continues to fall, repeat in 8–12 h
If TSB is not decreasing or is moving closer to level for exchange transfusion or the TSB/albumin ratio exceeds levels shown in Fig 4, consider exchange transfusion (see Fig 4 for exchange transfusion recommendations)
When TSB is <13–14 mg/dL (239 μmol/L), discontinue phototherapy
Depending on the cause of the hyperbilirubinemia, it is an option to measure TSB 24 h after discharge to check for rebound
Newborns Who Subsequently Developed a TSB Level >95th Percentile, n (%)
High-risk zone (>95th percentile)
High intermediate-risk zone
Low intermediate-risk zone
Factors That Affect the Dose and Efficacy of Phototherapy
Implementation and Rationale
Spectrum of light emitted
Blue-green spectrum is most effective. At these wavelengths, light penetrates skin well and is absorbed maximally by bilirubin.
Special blue fluorescent tubes or other light sources that have most output in the blue-green spectrum and are most effective in lowering TSB.
Use special blue tubes or LED light source with output in blue-green spectrum for intensive PT.
Spectral irradiance (irradiance in certain wavelength band) delivered to surface of infant
↑ irradiance →
Irradiance is measured with a radiometer as μW/cm2 per nm. Standard PT units deliver 8–10 μW/cm2 per nm (Fig 6). Intensive PT requires >30 μW/cm2 per nm.
If special blue fluorescent tubes are used, bring tubes as close to infant as possible to increase irradiance (Fig 6). Note: This cannot be done with halogen lamps because of the danger of burn. Special blue tubes 10–15 cm above the infant will produce an irradiance of at least 35 μW/cm2 per nm.
↑ rate of decline in TSB
Spectral power (average spectral irradiance across surface area)
↑ surface area exposed
For intensive PT, expose maximum surface area of infant to PT.
Place lights above and fiber-optic pad or special blue fluorescent tubes* below the infant. For maximum exposure, line sides of bassinet, warmer bed, or incubator with aluminum foil.
→ ↑ rate of decline in TSB
Cause of jaundice
PT is likely to be less effective if jaundice is due to hemolysis or if cholestasis is present.
When hemolysis is present, start PT at lower TSB levels. Use intensive PT. Failure of PT suggests that hemolysis is the cause of jaundice. If ↑ direct bilirubin, watch for bronze baby syndrome or blistering.
(↑ direct bilirubin)
TSB level at start of PT
The higher the TSB, the more rapid the decline in TSB with PT.
Use intensive PT for higher TSB levels. Anticipate a more rapid decrease in TSB when TSB >20 mg/dL (342 μmol/L).