AMERICAN ACADEMY OF PEDIATRICS

Subcommittee on HyperbilirubinemiaClinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant >

35 Weeks of GestationPediatrics 2004 (July);114:297

AAP Jaundice Guideline The 10 Key Elements

1. Promote and support successful breastfeeding.

2. Establish nursery protocols–include circumstances in which nurses can order a bilirubin.

3. Measure TSB or TcB if jaundiced in the first 24 hours.

4. Visual estimation of jaundice can lead to errors, particularly in darkly pigmented infants.

5. Interpret bilirubin levels according to the infant’s age in hours.

AAP Jaundice Guideline The 10 Key Elements (cont)

6. Infants <38 weeks, particularly if breastfed, are high risk

7. Perform risk assessment prior to discharge.8. Give parents written and oral information .9. Provide appropriate follow-up based on time

of discharge and risk assessment.10. Treat newborns, when indicated, with

phototherapy or exchange transfusion.

Risk assessment and follow up will prevent

disasters

We need to assess jaundice risks the way we assess other risks

Risk Assessment

Do this on every babyRisk factors and/or measure TcB or TSBBest to use both

Risk Factors for Developing Hyperbilrubinemia

TSB or TCB >75%Jaundice <24hr or before dischargeABO with +ve DAT or other hemolytic disease (G6PD)Gestation <39wkPrevious sibling jaundicedCephalhematoma or bruising (vacuum)Exclusive breastfeedingEast AsianMaleDischarge <72hr

Predictive Ability of a Predischarge Hour-specific Serum

Bilirubin for Subsequent Significant Hyperbilirubinemia in

Healthy Term and Near-Term Newborns

Bhutani VK, Johnson L, Sivieri EM. Pediatrics 1999;103:6-14

Newman Arch Ped Adolesc Med 2005;159:113

Predischarge Bilirubin Levels and Risk of Subsequent Hyperbilirubinemia

TSB after dischargeTSB before discharge

126 (4.4%)2840TOTAL

68/172 (39.5%)46/356 (12.9%)12/556 (2.15%)0/1756

172 (6.1%)356 (12.5%)556 (19.6%)1756 (61.8%)*

95th

76th – 95th

40th – 75th

< 40th

> 95th percentileNPercentile

* Newborn TSB were obtained between 18 and 72 hours and 61.8% of all values obtained were below the 40th percentile.

Bhutani, et al. Pediatrics 1999;103:6-14.

Give Physicians the Tools to Implement the Guidelines

Risk assessment tool at bedside

Predischarge Assessment for the Risk of Hyperbilirubinemia inInfants >35 wk Gestation (Pediatrics 2004;114:257-313)

Postnatal Age (hours)0 12 24 36 48 60 72 84 96 108 120 132 144

Seru

m B

iliru

bin

(mg/

dl)

0

5

10

15

20

25

High Intermediate Risk Zone

Low Intermediate Risk Zone

95 th%ile

75 th%ile

40 th%ile

High Risk Zone

Low Risk Zone

*The more risk factors present, the greater the risk of developing severe hyperbilirubinemia

Follow-up should be provided as followsAny infant discharged before age 72 hours should be seen

within 2 days of discharge.*If an infant is discharged before age 72 hours AND if you plan to follow up in more than 2 days, please document your reasons in the chart.

**If considering phototherapy or exchange transfusion please refer to the back of this page for guidelines and information.

Date Time Age (hrs)

TcB TS B

Initials

TcB – Transcutaneous BilirubinTSB – Total Serum Biilirubin/Direct

Risk Factors for Development of Severe HyperbilirubinemiaRisk Factors Major Risk Minor Risk Decreased Risk

Predischarge TSB or TcB(see nomogram above)

In high zone (>95%) In high intermediate zone (>75%)

Low risk zone (<40%)

Visible Jaundice First 24 hrs. Before discharge

Gestational age 35-36 wks 37-38 wks. >41 wk

Previous sibling Received phototherapy Jaundiced, no phototherapy

Blood GroupsHemolytic disease

Blood grp. incompatibility with +DAT. Other known hemolytic disease (eg. G^PD deficiency)

Feeding Exclusive breast (↑risk if poor feeder or ↑

wt. loss )Breast fed, nursing well Exclusive formula

feeding.Race East Asian Hispanic (Mexican)? African American

*unless G^PD def.~12% are G6PD deficient

Other factors Cephalhematoma or significant bruising

Macrosomic infant of IDM,male gender, maternal age >25 yr.

Discharged from hospital after 72 hrs.

Bhutani, Pediatrics1999;103:6

Implementation tools (low tech)

Wallet-sized nomogram and guidelines

Tony Burgos, MD, MPH Chris Longhurst, MD, MS Stuart Turner, DVMStanford University and Stanford University and University of California DavisPackard Children’s Hospital Packard Children’s Hospital