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Treatment

jaundice, were included. Existing national guidelines from Canada, Israel and the USA were
also checked for recommendations on discharge and monitoring.

Review findings
An RCT from Israel 125 compared stopping phototherapy at two different levels, one at
17 micromol/litre and the other at 51 micromol/litre below the threshold for phototherapy. The
study included 52 term babies (gestational age > 36 weeks) with birthweight > 2500 g who
were eligible for phototherapy for neonatal hyperbilirubinaemia. The mean gestational age of
the sample was 38.7 ± 1.6 weeks, mean birthweight was 3302 ± 453 g and mean serum
bilirubin at entry was 252 ± 36 micromol/litre. Twenty-five (48.1%) were male. Computer-
generated block randomisation was used and the sequence was concealed until allocation was
completed. Parents were blinded to treatment allocation. There was no statistically significant
difference between the groups in either duration of phototherapy or the number of babies
requiring a second course of phototherapy. [EL 1++]
An uncontrolled clinical study from Israel 126 examined the occurrence of post-phototherapy
rebound. A group of 226 term and near-term babies treated with phototherapy had serum
bilirubin measured 12–36 hours (mean 24 hours) after stopping phototherapy. Babies received
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phototherapy according to the 2004 AAP guideline. The mean gestational age of the sample
was 39 ± 2 weeks, mean birthweight was 3204 ± 445 g, and mean age at onset was
62.2 ± 38.3 hours. The mean bilirubin at initiation of phototherapy was 260 ± 55 micromol/litre.
In all, 134 participants (59.3%) were male. Serum bilirubin was routinely measured every
12 hours, or more often if clinically indicated. Phototherapy was discontinued when serum
bilirubin had fallen to 205 micromol/litre, or once serum bilirubin stabilised and fell below the
75th centile on the hour-specific nomogram. Rebound jaundice was defined as serum bilirubin
> 256 micromol/litre measured between 12 and 36 hours after stopping phototherapy.
Phototherapy was recommenced at the clinician’s discretion but usually not at serum bilirubin
levels below 256 micromol/litre. In all, 30 (13.3%) babies had rebound jaundice, with serum
bilirubin > 256 micromol/litre. Of these, 22 were re-treated with phototherapy up to a mean of
42 ± 26 hours after phototherapy had been discontinued. A greater number of babies rebounded
among those in whom phototherapy was initiated at < 72 hours of age (26 of 154, 16.9%)
compared with those in whom phototherapy was initiated at > 72 hours of age (4 of 74, 5.4%).
[EL 3]

Existing guidelines vary in their recommendations on discharge and monitoring of babies with
hyperbilirubinaemia. The Canadian Pediatric Society recommends that serum bilirubin should
be monitored 6–12 hours after the start of phototherapy and checked 24–48 hours after
discontinuation of phototherapy but does not specify when phototherapy should be
discontinued. 127
The AAP recommends that, for term and near-term babies (gestational age > 35 weeks), serum
bilirubin should be repeated every 2–3 hours (to coincide with feedings) until levels fall, at
which point serum bilirubin can be repeated every 8–12 hours. Phototherapy may be
discontinued at serum bilirubin < 222–239 micromol/litre, and measuring serum bilirubin
24 hours after stopping to check for rebound jaundice is optional.
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The Israel Neonatal Society guidelines recommend that, for term and near-term babies
(gestational age > 35 weeks), serum bilirubin measurement should be repeated at least twice
daily depending on clinical judgement. Phototherapy should be discontinued at 205–
222 micromol/litre. In high-risk babies, serum bilirubin should be measured 12–24 hours after
discontinuation of phototherapy. 128

Evidence summary
Two studies from Israel show that establishing a priori serum bilirubin levels for discontinuation
of phototherapy and of rebound jaundice did not make a difference to clinical practice. The
RCT of high and low threshold levels provided equal numbers of rebound jaundice cases and
did not lead to significant reduction in duration of phototherapy. While the uncontrolled study
identified 30 cases of rebound jaundice (serum bilirubin > 256 micromol/litre), only 22 of
these were considered by the clinician to need a second course of phototherapy.

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