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
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