Common Clinical Oversights (Mistakes)

When bilirubin is very high do not make or let your child's physician or other providers make any of the following mistakes in care:

  • Not believing an extremely high bilirubin level from the lab, and delaying treatment while it is repeated. There is no problem in repeating the test, but don't delay treatment while waiting for the repeat. You have nothing to lose by treating with phototherapy, hydration, and feeding if the baby can tolerate it, and ordering a blood type and cross match and blood for a possible exchange transfusion. If the bilirubin drops rapidly to a relatively safe level, and the child is asymptomatic (no symptoms), the exchange transfusion can be canceled.

  • Delaying treatment or interrupting phototherapy during diagnostic testing to determine other conditions and/or the risk of an exchange transfusion. If other tests such as a sepsis (infection) workup, a lumbar puncture (LP a.k.a. spinal tap), or an echocardiogram (ultrasound study of the heart) for example is needed, ask if it can be done under the phototherapy lights. If it's not possible, keep the lights on as much as possible. If the baby needs to go for a test out of the unit, the lights should go with him or her.

  • Not examining the baby for signs of acute kernicterus.

  • Using the indirect (or unconjugated) bilirubin level instead of the total bilirubin level to make treatment decisions. Experts agree to use the total bilirubin levels.

  • Allowing the bilirubin to reach potentially dangerous levels. Obtaining a transcutaneous or blood bilirubin is very easy to do. It is much easier to prevent bilirubin from rising too high than to treat it when it does.

  • Measuring the bilirubin and not comparing it to hour-specific norms - for example Bilirubin Nomogram. This is very important. A bilirubin level in a one-day-old may be normal or dangerously high depending on whether the baby is 24 or 47 hours old. A level of 9 mg/dL would be in a high-risk zone (95th percentile) in a 24-hour-old, and in a low intermediate risk zone (~40th percentile) in a 47h -hour-old old baby. Most use the Bilirubin Nomogram  although some may use their own normal values, and the BiliTool (www.bilitool.org) should give the same results as the nomogram. Note that the nomogram predicts the risk of the baby’s bilirubin rising to a level of 17 mg/dL, a level at which it is recommended that a normal term infant be treated with phototherapy to prevent the bilirubin from rising higher.