GUIDELINES FOR THE MANAGEMENT OF HYPERBILIRUBINEMIA IN

PRETERM INFANTS < 35 WEEKS GESTATION

NOTE: For babies 35 weeks gestation or greater, use the American Academy of
Pediatrics guideline (published in Pediatrics July 2004)
and the Clinical Practice Guideline for
Screening and Management of Hyperbilirubinemia in Infants >= 35 weeks EGA

Check total bilirubin levels in all preterm infants at least every 24 hours in the first
few days of life
In high risk infants you may need to check earlier after birth and more frequently
(refer to table Risk Factors for Severe Hyperbilirubinemia)

Risk Factors for Severe Hyperbilirubinemia

(Adapted form Risk factors for severe hyperbilirubinemia in infants > 35 weeks EGA)

Rh isoimmunization with positive Direct Coombs Test

ABO incompatibility (positive or negative Direct Coombs Test)
Positive maternal antibody screen, other hemolytic conditions
Previous sibling requiring phototherapy or exchange transfusion
Cephalohematoma
Significant bruising
Exclusive breastfeeding planned after discharge
East Asian ethnicity

In infants with hyperbilirubinemia, assess for the presence of risk factors (ABCDE):
Acidosis, albumin level low
Blood brain barrier disruption (e.g. intracranial hemorrhage, asphyxia,
sepsis, meningitis)
Coombs positive,G6PD deficiency (i.e., hemolysis)
Displacers of bilirubin (e.g. free fatty acids from intralipid, drugs)
Encephalopathy
The presence of one or more risk factors should lower the threshold for treatment
The table below provides guidelines on when to initiate phototherapy in preterm
infants less than 35 weeks gestation at birth
Note that levels are not dependent on babys day of life
Note that total serum bilirubin is used for treatment decisions
Note that suggested treatment levels are lower in sick babies than in healthy
babies (because of greater risk of disrupted blood brain barrier).

Suggested Guidelines for Phototherapy

Total Serum Bilirubin (mg/dL)

Birthweight

Healthy Infant

Sick Infant

< 1000 g

5-7

4-6

1001 1500 g

7 - 10

6-8

1501 2000 g

10 - 12

8 - 10

2001 2500 g

12 - 15

10 - 12

Source: Martin and Fanaroff. Neonatal-Perinatal Medicine. 8th Edition p1450