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Table 3 Suggested actionable treatment or referral TcB and/or TSB (mg/dL or μmol/L) levels in infants with hyperbilirubinaemia

From: Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings

Age (in hours) Repeat TcB/TSB daily if baby is not under PT Begin CPT or Refer at TcB/TSB Begin IPT or Refer at TcB/TSB Frequency of Monitoring TcB or TSB under PT Consider ET at TcB/TSB
0-12 any visible jaundice 2-3 (34–51) >3 (51)) 6 hrly 10-12 (171–205)
>12-24 ≥4 (68) 4-5 (68–86) >5 (86) 6 hrly 11-13 (188–222)
>24-36 ≥5 (86) 6-7 (103–120) >7 (120) 6 - 24 hrs 13-15 (222–257)
>36-48 ≥7 (120) 7-9 (120–154) >9 (154) 6 - 24 hrs 14-16 (239–274)
>48-60 ≥9 (154) 9-11 (154–188) >11 (188) 6 - 24 hrs 15-17 (257–291)
>60-72 ≥10 (171) 10-12 (171–205) >12 (205) 6 - 24 hrs 16-18 (274–308)
>72-84 ≥10.5 (180) 11-13 (188–222) >13 (222) 6 - 24 hrs 16-19 (274–325)
>84-96 ≥11 (188) 12-14 (205–239) >14 (239) 6 - 24 hrs 17-20 (291–342)
>96-108 ≥11.5 (197) 12-15 (205–257) >15 (257) 6 - 24 hrs 17-20 (291–351)
>108 ≥12 (205) 13-16 (222–274) >16 (274) 6 - 24 hrs 17-20 (291–351)
  1. TcB (Transcutaneous bilirubinometry), TSB (Total serum bilirubin), PT (Phototherapy), CPT (Conventional PT) ≥10 μW/cm2/nm, IPT (Intensive PT) ≥30 μW/cm2/nm, ET (Exchange transfusion).
  2. AAP (American Academy of Pediatrics), LMICs (Low and middle-income countries), G6PD (Glucose-6-Phosphate Dehydrogenase).
  3. Notes:
  4. • → The above levels are primarily adapted from the high/medium risk categories of AAP guidelines. Generally, levels of 2 mg/dL (34 μmol/L) below AAP recommendations are proposed due to multiple confounding factors such as the high risk status of many infants in LMICs, the limited facilities for clinical investigations, quality variability of phototherapy devices and the high incidence of ABE/kernicterus in many LMICs [e.g. see Guidelines #15 & 17 in Additional file 1: Table S1]. Phototherapy and especially exchange transfusion levels at or near those recommended by the AAP or NICE exchange guidelines should be strongly considered in tertiary care settings with intensive phototherapy.
  5. • → These proposals may be adjusted as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant with a view to avoiding overtreatment or under-treatment.
  6. • → Factors that place infants at higher risk in many LMICs include but are not limited to widespread exclusive breastfeeding, G6PD deficiency, unrecognised haemolysis such as blood group incompatibilities and sepsis/infection.[e.g. see Olusanya BO, Osibanjo FB, Slusher TM: Risk factors for severe hyperbilirubinaemia in low and middle-income countries: a systematic review and meta-analysis. PLoS ONE 2015,10(2):e0117229.]
  7. • → The distinction between when to begin CPT versus IPT is important in LMICs due to the sub-optimal quality of phototherapy and the limited number of IPT units in many settings. No such clear distinction exists in the AAP guidelines.
  8. • → If TcB level indicates PT, verify level using TSB measurement if available. It is acceptable to determine need for TSB with a TcB and it may be acceptable to use TcB alone (under a photo-opaque patch) to follow infants under CPT. TcB values above 12 mg/dl (205 μmol/L) should be cross-checked where possible with TSB measurement.
  9. • → All blood specimens for TSB measurement must be shielded from light to prevent photo-degradation of the sample serum bilirubin.
  10. A centre or hospital, at any level, not appropriately resourced to provide the required treatment should refer promptly to the closest suitable health facility.