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)
Laboratory tests
 TSB and direct bilirubin levels
 Blood type (ABO, Rh)
 Direct antibody test (Coombs’)
 Serum albumin
 Complete blood cell count with differential and smear for red cell morphology
 Reticulocyte count
 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