Jaundice in the Healthy Term Infant - Debok.net · Jaundice in the Healthy Term Newborn April 2002...

British Columbia Reproductive Care Program

April 1993 ndash OriginalFebruary 1994 - RevisedApril 2002 - Revised of 20

Newborn Guideline 4

JAUNDICE IN THE HEALTHY TERM NEWBORN

INTRODUCTION

During the first week of life all newborns have increased bilirubin levels by adult standards withapproximately 50 of term infants having visible jaundice Despite progress in neonatal care and thevirtual absence of classic bilirubin encephalopathy safe bilirubin levels have not been established withabsolute certainty There has been an increase in the number of term infants reported withkernicterus12 and the number of readmissions to hospital for jaundice has increased in recent years3This has been attributed to shorter length of postpartum hospital stays without comprehensive follow-up45

When carefully reviewed the data from numerous studies of bilirubin toxicity are so complex that it isdifficult to derive a single rational approach to jaundiced neonates6 One principle is well accepted ifthere is any evidence that a neonatersquos jaundice is not physiologic the cause should be investigatedprior to the initiation of treatment6

SIGNIFICANCE

Neonatal Jaundice is of concern due to

bull The risk of bilirubin encephalopathykernicturusbull The possibility that the jaundice may be a sign of a serious underlying illness

RISK FACTORS 7

bull family history of newborn jaundice (especially sibling) anemia liver disease or inborn errors ofmetabolism

bull plethora polycythemia bruising cephahematomabull poor feeding vomiting delayed passage of meconiumbull excessive weight lossbull sepsisbull asphyxiabull relative prematurity or small for gestational agebull hypothyroidism hypopituitarismbull certain ethnic groups ie East Asian Native Americanbull infant of a diabetic motherbull maternal ingestion of sulfonamides or antimalarial drugs

Vad menar folk naumlr de Say Naringgon kan inte se skogen foumlr alla traumld

Jaundice in the Healthy Term Newborn

April 2002 Page 2 of 20

CAUSES

I PHYSIOLOGIC JAUNDICE

Increased bilirubin load due to

bull Increased red blood cell volumebull Immaturity of bilirubin conjugation in the liver at birthbull Increased enterohepatic circulation of bilirubinbull Decreased red blood cell survivalbull Decreased uptake of bilirubin from the plasma by the liver

II INCREASED BREAKDOWN OF RED BLOOD CELLS

bull Blood group and Rh incompatibilitybull Red blood cell defects (G6PD deficiency spherocytosis)bull Rare blood group incompatibilitiesbull Polycythemiabull Sequestered blood (bruising hematoma)bull Infection

III DECREASED CONJUGATION OF BILIRUBIN

bull Prematuritybull Rare inherited defects

IV INCREASED REABSORPTION OF BILIRUBIN FROM THE GI TRACT

bull Asphyxiabull Delayed feedingsbull Bowel obstructionbull Delayed passage of meconium

V IMPAIRMENT OF BILE EXCRETION

bull Sepsisbull Intrauterine infectionsbull Hepatitisbull Cholestatic syndromesbull Biliary atresiabull Cystic fibrosis

VI BREAST MILK JAUNDICE

The association between breastfeeding and higher bilirubin levels is well established however thecause for this has not been determined with certainty6



A Early Breastfeeding Jaundice

bull Develops within 2 to 4 days of birthbull Most likely related to infrequent breastfeeding with a limited fluid intakebull May be related to increased reabsorption of bilirubin from the bowel

B Late Breast Milk Jaundice

bull Much less commonbull Develops 4 to 7 days after birth peaks day 7 to 15 bull Cause remains unknown despite numerous theories and studies

STRATEGIES TO DECREASE INCIDENCE

I LABOR AND DELIVERY

bull avoid trauma during labor and delivery8

II BREASTFEEDING

bull provide early assistance education and support for breastfeedingbull ensure parental education regarding signs of adequate hydration signs of jaundice and feeding1 bull initiate early and frequent feedings ndash at least 8 feeds in 24 hours68 Avoid separation of mother

and babybull encourage the ingestion of colostrum to increase stooling which prevents reabsorption of bilirubinbull supplementation with water does not affect bilirubin levels and is not recommended If

supplementation is necessary due to inadequate intake the mother should pump her breasts andgive expressed breastmilk andor formula rather than water

III DISCHARGEFOLLOW-UP

bull ensure adherence to evidence-based and current postpartum discharge criteria9

bull initiate early postpartum follow-up once discharged from hospital All infants discharged prior to48 hours of age should be evaluated by a health care professional within 48 hours after discharge69

bull ensure community mechanisms for follow-up and referral between health care providers (Seeexample in Appendix 1 Management of Newborn Jaundice at Home Program)

SCREENING

I TRANSCUTANEOUS

Use of an icterometer or transcutaneous jaundice meter is sometimes used as a screening device inhealthy term infants810 Accuracy may be limited by the changing pigmentation of the skin theduration of jaundice and the effect of phototherapy11


April 2002

II BILIRUBIN MEASUREMENT

Several studies have looked at the predictive ability of predischarge serum bilirubin testing121314 Todate routine bilirubin investigation for healthy term newborns is not indicated However if theinfantrsquos level of jaundice is a concern at discharge it may be prudent and helpful to obtain a bilirubinlevel at the time that the PKU specimen is collected Reference to the Bhutani Graph (Appendix 3page 17) may then help to determine whether further bilirubin levels should be obtained

ASSESSMENT

I COLOUR

Kramer15 described the cephalocaudal progression of jaundice in term infants He drew attention tothe observation that jaundice starts on the head and extends towards the feet as the level rises This isuseful in deciding whether or not a baby needs to have the serum bilirubin (SBR) measured Kramerdivided the infant into 5 zones The SBR range associated with progression to the zones is as follows

Zone 1 2 3 4 5SBR

(umolL)100 150 200 250 gt250

Adapted from the Department of Neonatal Medicine Protocol Book Royal Prince Alfred Hospital University of Sydney Australia 199816

The colour of the skin should be evaluated after the skin has been blanched by pressure from the thumb in a well lit room (or natural daylight if in the home)

II AGE

Jaundice before 24 hours of age is always pathological

III FEEDING BEHAVIOUR

bull as bilirubin levels rise the baby may become more lethargicbull after the first 1-2 days of life newborns should breastfeed at lebull if baby is sleepy during feeds utilize waking techniques

IV HYDRATION

Adequate intake can be determined by the babyrsquos bull Skin turgorbull Moistness of mouthbull Weightbull Energy levelsbull Feeding patternbehavior

Page 4 of 20

ast 8 times in 24 hours



bull Elimination (See guide below)

Guide for Healthy Term Newborn Output

Day Number of Stools24 hours Number of Wet diapers24 hours

1 at least one meconium at least 1 2 at least one meconium at least 2 3 at least 1 transitional at least 3 4 at least 2 + yellowseedy at least 4 5 at least 2 + yellowseedy 5 - 6

See BCRCP British Columbia Newborn Care Path Outcomes Teaching amp Interventions document for norms27

V OTHER ILLNESS

In association with other findings jaundice may be a sign of serious illness Each jaundiced infantshould be assessed to see whether the following danger signs are present

bull Family history of significant hemolytic diseasebull Onset of jaundice within 24 hoursbull Pallor bruising petechiaebull Lethargybull Poor feedingbull Feverbull Vomitingbull Dark urine and light stoolsbull Hepatosplenomegalybull High pitched cry

CLINICAL MANAGEMENT

Clinical management is aimed at avoiding bilirubin encephalopathy with itrsquos long term neurologicalcomplications Adequate hydration is an important consideration in the infant with moderate to highbilirubin levels

Fundamental to management is a good history and physical examination together with appropriateinvestigations including

bull Unconjugated and conjugated bilirubinbull Blood group determination with a direct antibody test (Coombrsquos test)bull Hemoglobin and hematocritbull Other lab investigations (eg T4 G6PD) may be required depending on the patient assessment1

Once the serum bilirubin reaches ldquoriskrdquo levels11217 the standard treatment is the use of phototherapyandor exchange transfusion Several expert bodies have developed guidelines to assist care providers



determine the appropriate time to implement each therapy as well as how to provide the therapy mosteffectively11217

The most common guidelines utilized in risk identification and management of hyperbilirubinemia arelisted below

Appendix 2 Approach to the management of hyperbilirubinemia in term newborn infants1 A Joint Statement Canadian Paediatric Society amp College of Family

Physicians of Canada (February 2001) Appendix 3 Hyperbilirubinembia risk designation for term and near-term well newborns12 Bhutani at al (1999) Pediatrics Vol 103 No 1 p6-12

Appendix 4 Management of hyperbilirubinemia in healthy term newborns17 American Academy of Pediatrics (1994)

OTHER ISSUES IN THE MANAGEMENT OF JAUNDICE

I BREASTFEEDING AND PHOTOTHERAPY

bull Interruption of breastfeeding is usually not indicated6bull An adequate intake of milk minimizes the bilirubin level by stimulating bowel emptying

Encourage frequent and effective breastfeeding (as least 8X in 24 hours)618

bull Breastfeeding may be interrupted for diagnostic or therapeutic purposes when the bilirubin is highand there is the risk of an exchange transfusion Should this occurbull continue phototherapybull consider discontinuing breastfeeding for 24 hours or bull alternate breastfeeding with formula feeding if fluid intake is of concernbull offer positive support for breastfeeding Encourage maintenance of lactation by using a breast

pump or manual expression during the period of interrupted breastfeeding6bull Glucose water will not reduce serum bilirubin levels and may interfere with breastfeeding6 II DAYLIGHT TREATMENT

Exposing infants to indirect sunlight via a window to decrease bilirubin levels has been a longstanding practice19 Controlled studies on this treatment have not been done Mild jaundice requiresno sunlight exposure as it sends a false note to parents that their baby has a significant problem whenin fact (s)he has not If an infant has jaundice that needs treatment according to accepted guidelinesthen it should be investigated further

III FIBROPTIC PHOTOTHERAPY

Use of fibroptic or ldquobili blanketsrdquo is gaining increased interest A Cochrane Database Review20 foundthat fibroptic phototherapy was more effective at lowering serum bilirubin than no treatment but less



effective than conventional phototherapy A combination of fibroptic and conventional phototherapywas more effective than conventional phototherapy alone No conclusion could be made on thesuperiority of one fibroptic device over another No trials have been identified which support the viewthat fibroptic devices interfere less with infant care or impact less on parent-child bonding

At this time ldquobili blanketsrdquo should not be used alone to treat non-physiologic causes of jaundice orthose infants at risk of requiring an exchange transfusion

IV HOME PHOTOTHERAPY

There are few articles in the literature which address this issue21-24 With the advent of fibropticblankets and portable bilibeds home phototherapy has been implemented in a few communitiesthroughout Canada25-27 To date there are no published evidence-based guidelines on the use of homephototherapy

CLINICAL INDICATORS FOR EVALUATION

bull Serum bilirubin levels at which phototherapy is initiated (age specific in hours of life) bull Bilirubin levels at which the infant is readmitted bull Numbers of readmissions for jaundice

REFERENCES

1 Canadian Paediatric Society amp the College of Family Physicians of Canada (1999) Approach tothe management of hyperbilirubinemia in term newborn infants Paediatrics and Child Health 4(2)161-164 Access from wwwcpscaenglishstatementsFNfn98-02htm

2 Maisels J amp Newman T (1998) Jaundice in full-term and near-term babies who leave thehospital within 36 hours Clinics in Perinatology 25(2) 295-302

3 Maisels J amp Kring E (1998) Length of stay jaundice and hospital readmission Pediatrics101(6) 995-998

4 Gurpp-Phelan J Taylor J Liu L amp Davis R (1999) Early newborn hospital discharge andreadmission for mild and severe jaundice Archive of Pediatric and Adolescent Medicine 153 1283-1288)

5 Liu S Wen S McMillan D Trouton K Fowler D amp McCourt C (2000) Increasedneonatal readmission rate associated with decreased length of hospital stay at birth in CanadaCanadian Journal of Public Health 91(1) 46-50

6 American Academy of Pediatrics amp American College of Obstetricians and Gynecologists(1997) Guidelines for Perinatal Care (4rd Edition) American College of Obstetricians andGynecologists Elk Grove Village IL American Academy of Pediatrics Washington DC

7 Banks J Montgomer D Coody D amp Yetman R (1996) Hyperbilirubinemia in the termnewborn Journal of Pediatric Health Care 10(5) 228-230



8 Blackburn S (1995) Hyperbilirubinemia and neonatal jaundice Neonatal Network 14 (7)15-24

9 Canadian Paediatric Society amp the Society of Obstetricians and Gynaecologists of Canada (1996)Joint Policy Statement Facilitating discharge home following a normal term birth Paediatric amp ChildHealth1(2) 165-168Access from httpwwwcpscaenglishstatementsFNfn96-02htm

10 Bhutani V Gourley G Adler S Kreamer B Dalin C Johnson L (2000) NoninvasiveMeasurement of Total Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Riskof Severe Hyperbilirubinemia Pediatrics (106) NO 2 Part 1 of 3

11 Schwoebel A amp Sakraida (1997) Hyperbilirubinemia New approaches to an old problemJournal of Perinatal and Neonatal Nursing 11(3) 78-97

12 Bhutani V Johnson L amp Sivieri E (1999) Predictive ability of a predischarge hour-specificserum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newbornsPediatrics 103(1) 6-14

13 Seidman D Ergaz Z Paz I Laor A Revel-Vilk S Stevenson D amp Gale R (1999)Predicting the risk of jaundice in fullterm healthy newborns A prospective population-based studyJournal of Perinatology 19(8) 564-567

14 Alpay F Sarici U Tosuncuk D Serdar M Inanc N amp Gokcay E (2000) The value offirst-day bilirubin measurement in predicting the development of significant hyperbilirubinemia inhealth term newborns Pediatrics 106(2)

15 Kramer L 1969 Advancement of dermal icterus in the jaundiced newborn American Journal ofDiseases in Children 118 454-458

16 Royal Prince Alfred Hospital 1998 The department of neonatal medicine protocol bookjaundice Sydney Author Accessed May 2001 fromwwwcsnswgovaurpaneonatalhtmlnewprotjaund2htm

17 American Academy of Pediatrics (1994) Practice parameter Management ofhyperbilirubinemia in the healthy term newborn Pediatrics 94(4) 558-565) httpwwwaaporgpolicyhyperbhtm

18 International Lactation Consultant Association (1999) Evidence-Based Guidelines forBreastfeeding Management During the First Fourteen Days Raleigh NC Author

19 Mohrbacher N amp Stock J (1997) The Breastfeeding Answer Book Illinois La Leche League

20 Mills J amp Tudehope D (2001) The Cochrane Database of Systemic Reviews Fibreopticphototherapy for neonatal jaundice Volume (Issue 1)

21 Ludwig M (1990) Phototherapy in the home setting Journal of Pediatric Health Care 4(6)304-308



22 Hamelin K amp Seshia M (1998) Home phototherapy for uncomplicated neonatal jaundiceCanadian Nurse Jan 39-40

23 Murphy B amp Welch R (1992) Home phototherapy for the jaundiced full-term newbornJournal of Home Health Care Practitioner 5(1) 26-33

24 British Columbia Reproductive Care Program (2001) British Columbia Newborn Care PathOutcomes Teaching amp Interventions Vancouver Author

25 Campbell River Hospital (2000) Protocol Hyperbilirubinemia ndash Home PhototherapyManagement Campbell River BC Author

26 Mississauga Hospital (1994) Protocol Home Phototherapy Programme Mississauga ONAuthor

27 University of Manitoba Health Science Centre () Protocol Home Phototherapy ProgramWinnepeg Author Access from httpwwwumanitobacawomens_healthhschomethtm

WEB RESOURCES

httpwwwaaporgpolicyhyperbhtm

wwwcpscaenglishstatementsFNfn98-02htm

httpwwwcpscaenglishstatementsFNfn96-02htm

wwwcsnswgovaurpaneonatalhtmlnewprotjaund2htm

httpwwwumanitobacawomens_healthhschomethtm



Management of Newborn Jaundice at Home Program

Referral for the Healthy Term Infant

PHN Identifies jaundice in the newborn

1 Preterm Infant RhABO incompatibility2 Look or act ill (eg lethargic apnea tachycardia

temperature unstable poor feeding changed behaviorpersistant vomiting insufficient voidingstooling)

No

Family hx of early or severejaundice Ethnicity relevant(Mediterranean SE Asian)

No

Infant less than24 hrs

No

Is jaundiceclinically

significant

No

Jaundice persistedgt 2 weeks

Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes

Refer to MD forinvestigationeg

G6PD SpherocytosisYes

Refer to MD fornon - isoimmune

hemolyticdisease

investigation

Yes

Refer to MD forfollow-up with total

serum bilirubinYes

Any abnormal physicalfindings Dark urine

light stoolsRefer to MDYes Yes

Refer to MDYes

APPENDIX 1 (Example)

Developed by the Coordinated Maternity Standards Committee South FraserHealth Region and Dr K Danso Pediatrician Surrey Memorial Hospital

Revised 1997 Copied with permission



APPENDIX 2

Approach to the Management of Hyperbilirubinemiain Term Newborn Infants

A Joint Statement with the College of Family Physicians of CanadaPaediatrics amp Child Health 19994(2)161-164Reference No FN98-02Reaffirmed February 2001

Reprints of this position statement are available from the Canadian Paediatric Society100-2204 Walkley Road Ottawa ON K1G 4G8 phone (613) 526-9397 fax (613) 526-3332

Contents bull Background bull Phototherapy bull Clinical management of hyperbilirubinemia in infants bull Exchange transfusion bull Conclusions bull References

Conflicting reports have led to confusion about the optimal management of jaundice in otherwise healthy terminfants (1-9) The lsquokinder gentler approachrsquo to neonatal hyperbilirubinemia proposed in 1992 by Newman andMaisels (8) resulted in a 1994 statement by the American Academy of Pediatrics (2) that addressed themanagement of healthy term infant without risk factors Recently there has been an increase in the number ofterm infants reported with kernicterus (10) It is important to note that while some of the infants reported withkernicterus had features that would place them in a high risk category some presented with severe jaundiceonly and no identifiable risk factors (10) The infants reported were commonly breastfed and frequentlydischarged from hospital very soon after birth (10) Nonetheless the current standards (2) for the managementof hyperbilirubinemia in the healthy term infant have become controversial This document updates information previously published by the Canadian Paediatric Society (1) It provides anoverview of the proposed management of hyperbilirubinemia based on available evidence even thoughrandomized controlled trials are not available to allow a conclusive assessment of the risk associated withhyperbilirubinemia in the clinical situations encountered in practice The objective of this overview is toestablish a management plan that will minimize the risk of kernicterus in term infants both with and withoutrisk factors Although scientific evidence has not established a clear link between specific bilirubinconcentrations and the development of kernicterus in healthy term babies information to date has beenincorporated into the following guidelines Background

Kernicterus is a neurological condition characterized by deep yellow staining of the basal nuclei Theaccompanying clinical syndrome results from the destructive changes of these neuronal populations Initiallythe signs are lethargy hypotonia and seizures later the infants may develop athetoid cerebral palsy mentalretardation and deafness When neurological signs evident in the infant permanent damage has alreadyoccurred leading to death or long term disability Therefore management strategies are aimed at preventingkernicterus



Until recently these strategies suggested maintaining serum unconjugated bilirubin concentrations below 340micromolL (20 mgdL) in healthy term infants through the use of phototherapy or exchange transfusion (11) Whileexchange transfusions had been a frequent occurrence from the 1950s to the 1970s and may sometimes still berequired phototherapy has become the mainstay of medical management of hyperbilirubinemia since that time

The cases of kernicterus originally described occurred mainly in infants with hemolytic disease Higher serumunconjugated bilirubin concentrations may be safe in healthy term infants without hemolytic disease It is notpossible to predict at what level an individual infant may develop kernicterus

Several authors have expressed serious concerns over the approach of allowing higher serum unconjugatedbilirubin concentrations to occur before investigating and treating these term infants (11-16) Brown andJohnson (10) have reported 23 cases of kernicterus occurring since 1989 16 in term and seven in near terminfants In these infants peak unconjugated bilirubin concentrations of 375 to 860 micromolL (22 to 50 mgdL)were seen All but one infant was breastfed Other associations found in these infants with kernicterus weredehydration (seven infants) glucose-6-phosphate dehydrogenase (G6PD) deficiency (five infants) ABOalloimmunization (one infant) hemolysis of unknown cause (five infants) familial etiology (one infant) andotherwise unexplained early jaundice clinically evident before 24 h of age (six infants) Similar cases have beenreported by others (1718) Although many of these babies were subsequently found to have additional riskfactors these factors were not often identified at the time the baby was noted to be jaundiced

Since the introduction in the 1990s of the kinder gentler approach to the management of hyperbilirubinemia agreat deal of confusion has arisen about approaches to the management of hyperbilirubinemia in healthy terminfants This confusion has extended to the care of borderline preterm infants who have often been treated asterm infants A recently published international survey reported considerable variability in the approach tohyperbilirubinemia and the use of phototherapy among neonatal units worldwide (3)

PhototherapyThe goal of hyperbilirubinemia treatment is to avoid bilirubin concentrations that may result in kernicterusPhototherapy remains an effective therapeutic intervention that decreases bilirubin concentrations therebypreventing elevated bilirubin levels associated with permanent sequelae

The effectiveness of phototherapy is related to the area of skin exposed and the radiant energy and thewavelength of the light (19-23) Phototherapy acts on unconjugated bilirubin to a depth of 2 mm from theepidermis Phototherapy changes the bilirubin through structural photoisomerization into water-solublelumirubin that is excreted in the urine (19) The fall in bilirubin level is proportionately greater in the skin thanin the serum (20) Therefore the infant receiving phototherapy should have as much skin as possible exposed tothe lights More intense phototherapy may be achieved by using multiple sources of phototherapy double ortriple phototherapy is recommended to optimize the skin surface exposed and therefore the efficacy ofphototherapy More detailed discussion of the physics of phototherapy has been published (124) It is important to recognize the relationship between dehydration and hyperbilirubinemia Dehydration may beassociated with increased serum bilirubin concentrations and may be exacerbated by phototherapy Alljaundiced infants should be adequately hydrated before and during phototherapy Breastfeeding is notcontraindicated in the presence of hyperbilirubinemia and should be continued More frequent breastfeedingsmay be beneficial (25)

The concentrations of bilirubin at which phototherapy might be initiated in healthy term infants and those withrisk factors are shown in Figure 1 Guidelines for phototherapy in low birth weight infants remain as previouslypublished (1) The bilirubin concentrations at which phototherapy is suggested by the Canadian PaediatricSociety in the present statement are more conservative than the current recommendations of the AmericanAcademy of Pediatrics (2) If the infant is a healthy term newborn phototherapy should be started as indicated



in the upper curve of Figure 1 If the infant has one or more risk factors a clinical decision should be made toinitiate phototherapy at the concentration indicated by the lower curve

Figure 1 Guidelines for initiation of phototherapy for hyperbilirubinemia in term infants with and without riskfactors Some risk factors include gestional age younger than 37 weeks birth weight less than 2500 ghemolysis jaundice at younger than 24 h of age sepsis and the need for resuscitation at birth

The timely recognition of risk factors is essential to minimize the danger of kernicterus The risk factors are asfollows

bull gestational age younger than 37 weeks and birth weight less than 2500 g bull hemolysis due to maternal isoimmunization G6PD deficiency spherocytosis or other causes bull jaundice at less than 24 h of age bull sepsis and bull the need for resuscitation at birth



Clinical management of hyperbilirubinemia in infants

A bilirubin level that justifies consideration of phototherapy should mandate the investigation of the cause ofhyperbilirubinemia Investigation should include a clinically pertinent history of the mother family historydescription of labour and delivery and infantrsquos clinical course (26) A physical examination should besupplemented by laboratory investigations (Table 1) including determination of unconjugated and conjugatedserum bilirubin concentrations and blood group with direct antibody test (Coombsrsquo test) and hemoglobin andhematocrit levels A complete blood count including differential white cell count and a blood smear for red cellmorphology may be indicated Further tests (eg reticulocyte count G6PD screen) may be indicated based oninitial results ethnicity or clinical presentation Testing for serum electrolytes and albumin or protein areindicated in some situations such as suspected dehydration or when bilirubin levels approach exchange valuesIn the absence of drugs or clinical states that alter the binding of bilirubin by albumin the bilirubin to albuminor the bilirubin to protein ratio reflects the free bilirubin concentration and the binding capacity of the serum(27-29) At a bilirubin concentration close to exchange transfusion levels some clinicians may wish to ensurethat serum bilirubin binding is normal (albumin 25 gL or greater protein 54 gL or greater) Values belowthese levels may be associated with low bilirubin binding and may be used by the clinician when decidingwhether further intervention (eg exchange transfusion) should take place (27)

TABLE 1 Laboratory investigation for hyperbilirubinemia in term newborn infants

Indicated (if bilirubin concentrations reach phototherapy levels) Serum total or unconjugated bilirubin concentration Serum conjugated bilirubin concentration Blood group with direct antibody test (Coombsrsquo test) Hemoglobin and hematocrit determinations

Optional (in specific clinical circumstances) Complete blood count including manual differential white cell count Blood smear for red cell morphology Reticulocyte count Glucose-6-phosphate dehydrogenase screen Serum electrolytes and albumin or protein concentrations

For infants with prolonged jaundice (lasting longer than seven days) or with conjugated hyperbilirubinemia(greater than 30 micromolL) additional investigation and management may be required and a consultation with aspecialist may be needed (30)

During the past decade most nurseries have shortened the time of hospital stay for term healthy newborninfants Early discharge of neonates means that jaundice is not often recognized at discharge (31) The CanadianPaediatric Society reiterates the importance of allowing early discharge only if a healthy status is confirmed foreach baby and appropriate follow-up is provided (32) Appropriate parental education about feeding signs ofdehydration and jaundice must be implemented in hospital nurseries Testing for serum bilirubin concentrationsmust be readily available for newborns on an out-patient basis Readmission to hospital (usually the hospital ofbirth) may be necessary for the investigation and management of hyperbilirubinemia

Exchange transfusion If phototherapy fails to control the rising bilirubin levels exchange transfusion is indicated to lower serumbilirubin concentrations For healthy term infants without risk factors exchange transfusion should beconsidered at serum unconjugated bilirubin concentrations of 400 to 430 micromolL For term infants with riskfactors the level should be 340 micromolL For infants who initially present with serum bilirubin concentrations in



excess of exchange levels intensive phototherapy should produce a decline of serum unconjugated bilirubinfrom 20 to 35 micromolL within 4 to 6 h and levels should continue to fall thereafter and remain below thethreshold for exchange transfusion If the bilirubin concentration does not decrease after adequate rehydrationand 4 to 6 h of intensive phototherapy exchange transfusion should be considered Preparation for thisincluding ensuring availability of blood should occur shortly after the admission of babies whose bilirubinconcentrations exceed exchange levels Appropriate consultation should be obtained if the etiology ofhyperbilirubinemia is unclear the infant is ill and particularly if bilirubin concentrations are approachingexchange levels Because the risks of exchange transfusion are significant the best management may bereviewed with an expert opinion from a neonatologist

Conclusions Hyperbilirubinemia in apparently healthy term newborn infants continues to hold the potential threat ofcomplications from bilirubin encephalopathy and kernicterus Careful assessment of risk factors judicious useof phototherapy appropriate laboratory monitoring and specific treatment of other disorders (eg sepsis) areessential for the optimal management of hyperbilirubinemia Appropriate laboratory facilities must be availableto measure bilirubin concentrations for out-patients in required clinical situations Readmission to hospital maybe required if phototherapy is necessary Guidelines for phototherapy are presented for term babies with andwithout identifiable risk factors

References

1 Fetus and Newborn Committee Canadian Paediatric Society Use of phototherapy for neonatalhyperbilirubinemia Can Med Assoc J 19861341237-45 2 American Academy of Pediatrics Practice parameter Management of hyperbilirubinemia in the healthy termnewborn Pediatrics 199494558-65 3 Hansen TWR Therapeutical approaches to neonatal jaundice an international survey Clin Pediatr199635309-16 4 Valaes T Koliopoulos C Koltsidopoulos A The impact of phototherapy in the management of neonatalhyperbilirubinemia comparison of historical cohorts Acta Paediatrica 199685273-6 5 Gustafson PA Boyle DW Bilirubin index a new standard for intervention Med Hypotheses 199545409-16 6 Torres-Torres M Tayaba R Weintraub A Holzman IR New perspectives on neonatal hyperbilirubinemiaMount Sinai J Med 199461424-8 7 Lazar L Litwin A Merlob P Phototherapy for neonatal nonhemolytic hyperbilirubinemia analysis ofrebound and indications for discontinuing therapy Clin Pediatr 199332264-7 8 Newman TB Maisels MJ Evaluation and treatment of jaundice in the term newborn Pediatrics 199289809-18 9 McMillan DD Lockyer JM Magnan L Akierman A Parboosingh JT Effect of educational program andinterview on adoption of guidelines for the management of neonatal hyperbilirubinemia Can Med Assoc J1991144707-12 10 Brown AK Johnson L Loss of concern about jaundice and the reemergence of kernicterus in full-terminfants in the era of managed care In Fanaroff AA Klaus MH eds The Year Book of Neonatal and PerinatalMedicine Philadelphia Mosby Yearbook 199617-28 11 Valaes T Bilirubin toxicity The problem was solved a generation ago Pediatrics 199289819-21 12 Wennberg RP Bilirubin recommendations present problems New guidelines simplistic and untestedPediatrics 199289821-2 13 Merenstein GB lsquoNewrsquo bilirubin recommendations questioned Pediatrics 199289822-3 14 Poland RL In search of a lsquogold standardrsquo for bilirubin toxicity Pediatrics 199289823-4 15 Brown AK Seidman DS Stevenson DK Jaundice in healthy term neonates Do we need new action levelsor new approaches Pediatrics 199289827-9 16 Johnson L Yet another expert opinion on bilirubin toxicity Pediatrics 199289829-31



17 MacDonald MG Hidden risks Early discharge and bilirubin toxicity due to glucose-6-phosphatedehydrogenase deficiency Pediatrics 199596734-8 18 Maisels MJ Newman TB Kernicterus in otherwise healthy breast-fed newborns Pediatrics 199596730-3 19 Vogl TP Phototherapy of neonatal hyperbilirubinemia bilirubin in unexposed areas of the skin J Pediatr197485707-1020 Rubaltelli FF Carli M The effect of light on cutaneous bilirubin Biol Neonate 197118457-62 21 Sisson TR Kendall N Shaw E et al Phototherapy of jaundice in the newborn infant 2 Effect of variouslight intensities J Pediatr 19738135-8 22 Bonta BW Warshaw JB Importance of radiant flux in the treatment of hyperbilirubinemia failure ofoverhead phototherapy units in intensive care units Pediatrics 197657502-5 23 Warshaw JB Gagliardi J Patel A A comparison of fluorescent and non-fluorescent light source forphototherapy Pediatrics 198065795-8 24 Ennever JF Blue light green light white light more light treatment of neonatal jaundice Clin Perinatol199017467-8125 Auerbach KG Gartner LM Breastfeeding and human milk their association with jaundice in the neonateClin Perinatol 19871489-108 26 Maisels MJ Jaundice in the newborn Pediatr Rev 19823305-20 27 Ahlfors CE Criteria for exchange transfusion in jaundiced newborns Pediatrics 199493488-94 28 Odell GB Storey GNB Rosenberg LA Studies in kernicterus III The saturation of serum protein withbilirubin during neonatal life and its relationship to brain damage at 5 years J Pediatr 19707612-21 29 Wirth FH Goldberg KE Lubchenco LO The neurologic outcome of infants evaluated for unboundbilirubin Pediatr Res 19759385-91 30 Haber BA Lake AM Cholestatic jaundice in the newborn Clin Perinatol 199017483-506 31 Maisels MJ Newman TB Jaundice in full-term and near-term babies who leave the hospital within 36hours The pediatricianrsquos nemesis Clin Perinatol 199825295-302 32 Fetus and Newborn Committee Canadian Paediatric Society and Society of Obstetricians andGynaecologists of Canada Facilitating discharge home following a normal term birth Paediatr Child Health19961165-8

Fetus and Newborn Committee Members Drs John Watts Department of Paediatrics Childrenrsquos Hospital ndash Hamilton Health Sciences CentreHamilton Ontario (director responsible) Douglas McMillan Department of Pediatrics Foothills HospitalCalgary Alberta (chair) Arne Ohlsson Department of Paediatrics Mount Sinai Hospital Toronto Ontario(co-chair) Deborah Davis Childrenrsquos Hospital of Eastern Ontario Ottawa Ontario Daniel Faucher RoyalVictoria Hospital Montreal Quebec (principal author) John Van Aerde Stollery Childrenrsquos Health CentreEdmonton Alberta Michael Vincer IWK-Grace Health Centre Halifax Nova ScotiaConsultant Dr Michael C Klein University of British Columbia Vancouver British Columbia (College ofFamily Physicians of Canada)Liaisons Drs James Lemon Riley Childrenrsquos Hospital Indiana University Medical Center IndianapolisIndiana (American Academy of Pediatrics) Saroj Saigal Department of Paediatrics McMaster UniversityMedical Centre Childrenrsquos Hospital ndash Hamilton Health Sciences Centre Hamilton Ontario (CPS Neonatal-Perinatal Medicine Section) Cheryl Levitt Department of Family Medicine Childrenrsquos Hospital ndash HamiltonHealth Sciences Centre Hamilton Ontario (College of Family Physicians of Canada) Catherine McCourtDirector Bureau of Reproductive amp Child Health Laboratory Centre for Disease Control Ottawa Ontario(Health Canada) Mrs Debbie Fraser-Askin Winnipeg Manitoba (Neonatal Nurses) Dr Line LeducDepartment of Obstetrics-Gynecology Hocircpital Sainte-Justine Montreal Quebec (Society of Obstetricians andGynaecologists of Canada)

Disclaimer The recommendations in this position statement do not indicate an exclusive course oftreatment or procedure to be followed Variations taking into account individual circumstances may beappropriate



APPENDIX 3Hyperbilirubinemia Risk Designation for Term and Near-Term Well Newborns



APPENDIX 4

American Academy of Pediatrics 1994 Practice parameter Management ofHyperbilirubinemia in the Healthy Term Newborn Pediatrics 94(4) 558-565

(Chart and Algorithm)



AlgorithmPediatric clinician evaluatesterm newborn with jaundice

Does the infant have signs of underlyingserious illness (lethargy apnea tachypneatemperature instability behavior changeshepatosplenomegaly persistant vomiting

or persistent feeding difficulty)

1

2

Exit this algorithm to individualizedclinical evaluation including

assessment of jaundice and underlyingdisease

Yes

3

No

Is the infant lt 37 weeks gestational age

4 Exit this algorithm to individualizedclinical evaluation including

assessment of jaundice in light ofprematurity

5

Yes

Is the mothersABO and Rh

blood typing andisoimmune

antibody screenstatus known

Is the mothersblood Rhpositive

Does themothers blood

have anyimmune

antibodies

Consider holding the infantscord blood in the blood bank incase future testing is necessary

6 7 8 9No

Yes Yes No

(Go to Box 10) (Go to Box 10) (Go to Box 10) (Go to Box 13)

No No Yes

Perform blood typing (ABO and Rh) and direct Coombs testingon the infants cord (preferably) or venous blood

10

Is the infantsblood direct

Coombs testpositive

Exit this algorithm to individualized clinical evaluationincluding assessment of jaundice and isoimmune

hemolytic disease

11 12

Yes

Are any of the following risk factors present tosuggest that nonisoimmune hemolytic disease

is possible in this infant(1) Family history of hemolytic anemia

OR(2) Family history of early or severe jaundice

OR(3) Ethnicity or geographic originassociated with hemolytic anemia

OR(4) Early or severe jaundice

Perform appropriate laboratoryassessment of infant including

(but not limited to consideration of)(1) Complete blood count differentialsmear reticulocyte count(2) G6PD screen(3) Hemoglobin electrophoresis

1314

No

No

No

(Go to Box 16)

Does the evaluation suggesthemolytic disease

15

Yes

(Go to Box 17)(Go to Box 16)

No



AlgorithmIs the infant

jaundiced andlt 24 hours of

age

Exit this algorithm to individualizedclinical evaluation includingassessment of jaundice and

nonisoimmune hemolytic disease

Is jaundiceclinicallysignificant by medical

judgment

(1) Measure infantstotal serum bilirubin(2) Go to Box 27

Healthy term infant with jaundice not clinicallysignificant by medical judgment

Follow infant in routine clinical supervision

1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No

Is jaundicepersisting

gt 2 weeks

Does this infant haveabnormal physicalexam results dark

urine or light stools

Is jaundice persistinggt 3 weeks

Perform appropriate physical andlaboratory assessment of theinfant including possibility of

cholestatic jaundice

Provide routine carerecommend routine

feeding and follow-up Table 2 Management of Hyperbilirubinemia in the Healthy Term NewbornAgehours TSB Level mgdL (umolL)

Consider Phototherapy Exchange ExchangePhototherapy Transfusion Transfusion

if Intensive and IntensivePhototherapy PhototherapyFails

lt24 25-48 gt 12 (170) gt15 (260) gt 20 (340) gt 25 (430)49-72 gt 15 (260) gt 18 (310) gt 25 (430) gt 30 (510)gt 72 gt 17 (290) gt 20 (340) gt 25 (430) gt 30 (510)

TSB indicates total serum bilirubinPhototherapy at these TSB levels is a clinical option meaning that the intervention is availableand may be used on the basis of individual clinical judgement For a more detailed descriptionof phototherapy see the AppendixIntensive phototherapy (Appendix) should produce a decline of TSB of 1 to 2 mgdL within 4 to 6hours and the TSB level should continue to fall and remain below the threshold level for exchangetransfusion If this does not occur it is considered a failure of phototherapyTerm infants who are clinically jaundiced at lt 24 hours old are not considered healthy andrequire further evaluation (see text)

22 23

24

25

26

YesYes

No

YesNo

No 27

Algorithm Management of hyperbilirubinemia inthe healthy term infant

(From Box 19)

Adapted from the Department of Neonatal Medicine Protocol Book Royal Prince

Alfred Hospital University of Sydney Australia 199816


WEB RESOURCES






APPENDIX 2

Phototherapy

Exchange transfusion

Conclusions

References

American Academy of Pediatrics 1994 Practice parameter Management of Hyperbilirubinemia in the Healthy Term Newborn Pediatrics 94(4) 558-565



April 2002 of 20

CAUSES

I PHYSIOLOGIC JAUNDICE

Increased bilirubin load due to

bull Increased red blood cell volumebull Immaturity of bilirubin conjugation in the liver at birthbull Increased enterohepatic circulation of bilirubinbull Decreased red blood cell survivalbull Decreased uptake of bilirubin from the plasma by the liver

II INCREASED BREAKDOWN OF RED BLOOD CELLS

bull Blood group and Rh incompatibilitybull Red blood cell defects (G6PD deficiency spherocytosis)bull Rare blood group incompatibilitiesbull Polycythemiabull Sequestered blood (bruising hematoma)bull Infection

III DECREASED CONJUGATION OF BILIRUBIN

bull Prematuritybull Rare inherited defects

IV INCREASED REABSORPTION OF BILIRUBIN FROM THE GI TRACT

bull Asphyxiabull Delayed feedingsbull Bowel obstructionbull Delayed passage of meconium

V IMPAIRMENT OF BILE EXCRETION

bull Sepsisbull Intrauterine infectionsbull Hepatitisbull Cholestatic syndromesbull Biliary atresiabull Cystic fibrosis

VI BREAST MILK JAUNDICE

The association between breastfeeding and higher bilirubin levels is well established however thecause for this has not been determined with certainty6










II BREASTFEEDING








SCREENING

I TRANSCUTANEOUS



April 2002



ASSESSMENT

I COLOUR


Zone 1 2 3 4 5SBR

(umolL)100 150 200 250 gt250



II AGE




IV HYDRATION


Page 4 of 20









V OTHER ILLNESS



CLINICAL MANAGEMENT





























REFERENCES
































WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20








II BREASTFEEDING








SCREENING

I TRANSCUTANEOUS



April 2002



ASSESSMENT

I COLOUR


Zone 1 2 3 4 5SBR

(umolL)100 150 200 250 gt250



II AGE




IV HYDRATION


Page 4 of 20









V OTHER ILLNESS



CLINICAL MANAGEMENT





























REFERENCES
































WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002



ASSESSMENT

I COLOUR


Zone 1 2 3 4 5SBR

(umolL)100 150 200 250 gt250



II AGE




IV HYDRATION


of 20









V OTHER ILLNESS



CLINICAL MANAGEMENT





























REFERENCES
































WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20






V OTHER ILLNESS



CLINICAL MANAGEMENT





























REFERENCES
































WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20























REFERENCES
































WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20







REFERENCES
































WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20























WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20







WEB RESOURCES













No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20






No


No


No


significant

No


Jaundice gt3weeks

Routinecare and

feedsNo

Routinecare and

feedsNo

RoutineClinical

Supervis-ion

No

Refer to MD ASAPYes




hemolyticdisease

investigation

Yes


serum bilirubinYes



Refer to MDYes






APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20

APPENDIX 2




































References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20




























References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20



















References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20













References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20



References












APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20









APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20




APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20

APPENDIX 4








1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20




1

2



Yes

3

No




5

Yes






have anyimmune

antibodies


6 7 8 9No

Yes Yes No


No No Yes


10


Coombs testpositive


hemolytic disease

11 12

Yes








1314

No

No

No

(Go to Box 16)


15

Yes


No





age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References




April 2002 of 20



age




judgment




1617

18 19

20

21

(Go to Box 22)

Yes

Yes

No

No


gt 2 weeks












22 23

24

25

26

YesYes

No

YesNo

No 27


(From Box 19)




WEB RESOURCES






APPENDIX 2

Phototherapy


Conclusions

References



Jaundice in the Healthy Term Infant - Debok.net · Jaundice in the Healthy Term Newborn April 2002...

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Transcript of Jaundice in the Healthy Term Infant - Debok.net · Jaundice in the Healthy Term Newborn April 2002...