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Neonatal Hyperbilirubinemia: Recommendations for Diagnosis and Management in the Emergency Department -

Neonatal Hyperbilirubinemia: Recommendations for Diagnosis and Management in the Emergency Department
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Publication Date: January 2022 (Volume 19, Number 1)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 01/01/2025.


Abdullah Khan, MD
Attending Physician, Pediatric Emergency Medicine, Dignity Health St. Rose Dominican Hospital, Sienna Campus, Henderson, NV
Tommy Y. Kim, MD
Health Science Clinical Professor, Pediatric Emergency Medicine, University of California Riverside, Department of Emergency Medicine, Riverside, CA

Peer Reviewers

Jennifer Bellis, MD, MPH
Clinical Instructor, University of Colorado/Children’s Hospital Colorado, Colorado Springs, CO
Mary Jane Piroutek, MD
Associate Clinical Professor, Department of Emergency Medicine, University of California Irvine, School of Medicine, Children’s Hospital of Orange County, Orange, California


Hyperbilirubinemia is one the most common reasons for emergency department visits for the neonate. Most cases of unconjugated hyperbilirubinemia are benign. Although rare, unrecognized or untreated pathologic unconjugated hyperbilirubinemia can lead to the development of acute bilirubin encephalopathy and, ultimately, kernicterus. This issue reviews the emergency department evaluation and management of neonatal hyperbilirubinemia and discusses how to recognize acute bilirubin encephalopathy, with the goal of preventing kernicterus. Recommendations are provided for risk stratification and determining the need for phototherapy or exchange transfusion, using nomograms to plot total serum bilirubin levels and taking into consideration hyperbilirubinemia and neurotoxicity risk factors.

Case Presentations

A 4-day-old boy born at 39 weeks’ gestation presents for evaluation of jaundice…
  • The jaundice was first noticed 2 days ago. The birth was unremarkable, with a birth weight of 2.4 kg. The baby has been exclusively breast-fed and has 2 wet diapers/day.
  • On examination, the patient has scleral icterus and generalized jaundice. His vital signs reveal a temperature of 37.2°C and a heart rate of 168 beats/min.
  • You consider the diagnosis of neonatal hyperbilirubinemia, but how do you differentiate nonpathologic from pathologic causes of hyperbilirubinemia? Based on the visual diagnosis of jaundice, should you start treatment immediately with phototherapy? What additional laboratory testing is needed to determine the need for treatment and the disposition for this neonate?
A 7-day-old boy is referred by his primary care physician for jaundice...
  • The mother states that the infant is exclusively formula-fed and is having up to 10 wet diapers/day.
  • On examination, the patient has generalized jaundice, and the liver edge is palpable approximately 4 cm below the costal margin. A transcutaneous bilirubin screen is 12.5 mg/dL.
  • What is the most likely diagnosis for this patient? Should you start phototherapy while awaiting laboratory testing results? What is the most appropriate disposition for this patient?
A 5-day-old girl presents with irritability...
  • The parents state that the girl was born full-term to a gravida 3, para 2 mother with blood type O negative. The patient was kept in the newborn nursery after birth for phototherapy and discharged after 2 days. The baby had been doing well, but now has been crying excessively and is difficult to console.
  • On examination, the baby is crying, with a high-pitched cry, with back-arching.
  • You suspect possible acute bilirubin encephalopathy. Should you start phototherapy while awaiting laboratory testing? What are the indications for exchange transfusion?


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