AMERICAN ACADEMY OF PEDIATRICS Subcommittee on Hyperbilirubinemia

Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant > 35 Weeks of Gestation
Pediatrics 2004 (July);114:297

AAP Jaundice Guideline The 10 Key Elements

1. Promote and support successful breastfeeding. 2. Establish nursery protocolsinclude 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 infants 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 baby Risk factors and/or measure TcB or TSB Best to use both

Risk Factors for Developing Hyperbilrubinemia

TSB or TCB >75% Jaundice <24hr or before discharge ABO with +ve DAT or other hemolytic disease (G6PD) Gestation <39wk Previous sibling jaundiced Cephalhematoma or bruising (vacuum) Exclusive breastfeeding East Asian Male Discharge <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 before discharge Percentile
95th 76th 95th 40th 75th < 40th

TSB after discharge

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

> 95th percentile

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

TOTAL

2840

126 (4.4%)

* 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 in Infants >35 wk Gestation (Pediatrics 2004;114:257-313)
25

Date

Time

Age (hrs)

TcB

TS B

Initials
20

Serum Bilirubin (mg/dl)

High Risk Zone 15

h Hig In te In rm e d iate Ris R k e Zon e

95 th%ile 75 th%ile
th

10

L ow

e te rm

dia te

Z on isk

40 %ile

Low Risk Zone 5

Bhutani, Pediatrics1999;103:6 TcB Transcutaneous Bilirubin TSB Total Serum Biilirubin/Direct

0 0 12 24 36 48 60 72 84 96 108 120 132 144

Postnatal Age (hours)

Risk Factors for Development of Severe Hyperbilirubinemia

Risk Factors Predischarge TSB or TcB (see nomogram above) Visible Jaundice Gestational age Previous sibling Blood Groups Hemolytic disease Feeding Race Other factors Major Risk In high zone (>95%) 3 Minor Risk In high intermediate zone (>75%) Before discharge 37-38 wks. Jaundiced, no phototherapy >41 wk 3 Decreased Risk Low risk zone (<40%) 3

First 24 hrs. 35-36 wks Received phototherapy Blood grp. incompatibility with +DAT. Other known hemolytic
disease (eg. G^PD deficiency)

Exclusive breast (risk if poor feeder or wt. loss ) East Asian Cephalhematoma or significant bruising

Breast fed, nursing well Hispanic (Mexican)? Macrosomic infant of IDM,male gender, maternal age >25 yr.

Exclusive formula feeding. African American

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

Discharged from hospital after 72 hrs.

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

Follow-up should be provided as follows

Any 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.

Implementation tools (low tech)

Wallet-sized nomogram and guidelines

Tony Burgos, MD, MPH Stanford University and Packard Childrens Hospital

Chris Longhurst, MD, MS Stanford University and Packard Childrens Hospital

Stuart Turner, DVM University of California Davis