Written by Kimiko Dunbar
Spoon Feed
Additional fluid supplementation for preterm infants with severe hyperbilirubinemia helps speed the rate of decline of serum bilirubin levels but does not reduce duration of phototherapy.
How to mellow the yellow
Approximately 80% of preterm infants develop hyperbilirubinemia and are at higher risk of long-term complications. The AAP endorses fluid supplementation for severe hyperbilirubinemia in infants ≥35 weeks; however, data are limited on the use of fluids in more preterm infants. This open-label randomized controlled trial investigated whether intravenous fluid supplementation accelerates bilirubin decline in preterm neonates (29 to 33w6d) with severe unconjugated hyperbilirubinemia. Seventy-two neonates were randomized to receive phototherapy with or without IV fluids. The fluid group showed significantly greater reductions in total serum bilirubin at 6, 18, and 24 hours (i.e., 24h: 2.96 vs. 1.56 mg/dL; p=0.001) but no difference in phototherapy duration or adverse events. It’s important to note that nearly all infants in the study, both control and treatment, were receiving some sort of fluid supplementation to meet their maintenance needs; however, those in the treatment group received additional IVF (extra fluid run at 25% maintenance with a max of 30 mg/kg/day). The study is further limited by lack of blinding (impossible given the intervention) and lack of generalizability (single site, exclusion of extremely preterm infants, sick infants, and those with evidence of hemolytic disease).
How does this change my practice?
Volume of additional fluid supplementation was small, but it seems that running babies at 1.25x maintenance makes a meaningful impact without adverse events. Driving bilirubin levels down faster, even if overall duration of phototherapy remains the same, has an important impact in preventing bilirubin-related neuronal injury. While I’m not a neonatologist, it seems reasonable to up the fluids a bit in these babies, especially if monitoring for downstream side effects such as fluid overload and hyponatremia.
Source
Intravenous fluid supplementation in management of severe unconjugated hyperbilirubinemia in preterm neonates-a randomized controlled trial. Eur J Pediatr. 2025 Jun 2;184(6):383. doi: 10.1007/s00431-025-06226-1. PMID: 40455331
