Management of Hyperbilirubinemia in the Newborn
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AMERICAN ACADEMY OF PEDIATRICS
CLINICAL PRACTICE GUIDELINE
Subcommittee on Hyperbilirubinemia
Management of Hyperbilirubinemia in the Newborn Infant 35 or MoreWeeks of Gestation
ABSTRACT. Jaundice occurs in most newborn infants.Most jaundice is benign, but because of the potentialtoxicity of bilirubin, newborn infants must be monitoredto identify those who might develop severe hyperbili-rubinemia and, in rare cases, acute bilirubin encephalop-athy or kernicterus. The focus of this guideline is toreduce the incidence of severe hyperbilirubinemia andbilirubin encephalopathy while minimizing the risks ofunintended harm such as maternal anxiety, decreasedbreastfeeding, and unnecessary costs or treatment. Al-though kernicterus should almost always be prevent-able, cases continue to occur. These guidelines provide aframework for the prevention and management ofhyperbilirubinemia in newborn infants of 35 or moreweeks of gestation. In every infant, we recommend thatclinicians 1) promote and support successful breastfeed-ing; 2) perform a systematic assessment before dischargefor the risk of severe hyperbilirubinemia; 3) provideearly and focused follow-up based on the risk assess-ment; and 4) when indicated, treat newborns with pho-totherapy or exchange transfusion to prevent the devel-opment of severe hyperbilirubinemia and, possibly,bilirubin encephalopathy (kernicterus). Pediatrics 2004;114:297316; hyperbilirubinemia, newborn, kernicterus,bilirubin encephalopathy, phototherapy.
ABBREVIATIONS. AAP, American Academy of Pediatrics; TSB,total serum bilirubin; TcB, transcutaneous bilirubin; G6PD, glu-cose-6-phosphate dehydrogenase; ETCOc, end-tidal carbon mon-oxide corrected for ambient carbon monoxide; B/A, bilirubin/albumin; UB, unbound bilirubin.
In October 1994, the Provisional Committee forQuality Improvement and Subcommittee on Hy-perbilirubinemia of the American Academy ofPediatrics (AAP) produced a practice parameterdealing with the management of hyperbilirubinemiain the healthy term newborn.1 The current guidelinerepresents a consensus of the committee charged bythe AAP with reviewing and updating the existingguideline and is based on a careful review of theevidence, including a comprehensive literature re-view by the New England Medical Center Evidence-Based Practice Center.2 (See An Evidence-BasedReview of Important Issues Concerning Neonatal
Hyperbilirubinemia3 for a description of the meth-odology, questions addressed, and conclusions ofthis report.) This guideline is intended for use byhospitals and pediatricians, neonatologists, familyphysicians, physician assistants, and advanced prac-tice nurses who treat newborn infants in the hospitaland as outpatients. A list of frequently asked ques-tions and answers for parents is available in Englishand Spanish at www.aap.org/family/jaundicefaq.htm.
DEFINITION OF RECOMMENDATIONSThe evidence-based approach to guideline devel-
opment requires that the evidence in support of apolicy be identified, appraised, and summarized andthat an explicit link between evidence and recom-mendations be defined. Evidence-based recommen-dations are based on the quality of evidence and thebalance of benefits and harms that is anticipatedwhen the recommendation is followed. This guide-line uses the definitions for quality of evidence andbalance of benefits and harms established by theAAP Steering Committee on Quality ImprovementManagement.4 See Appendix 1 for these definitions.
The draft practice guideline underwent extensivepeer review by committees and sections within theAAP, outside organizations, and other individualsidentified by the subcommittee as experts in thefield. Liaison representatives to the subcommitteewere invited to distribute the draft to other represen-tatives and committees within their specialty organi-zations. The resulting comments were reviewed bythe subcommittee and, when appropriate, incorpo-rated into the guideline.
BILIRUBIN ENCEPHALOPATHY ANDKERNICTERUS
Although originally a pathologic diagnosis charac-terized by bilirubin staining of the brainstem nucleiand cerebellum, the term kernicterus has come tobe used interchangeably with both the acute andchronic findings of bilirubin encephalopathy. Biliru-bin encephalopathy describes the clinical central ner-vous system findings caused by bilirubin toxicity tothe basal ganglia and various brainstem nuclei. Toavoid confusion and encourage greater consistencyin the literature, the committee recommends that ininfants the term acute bilirubin encephalopathy beused to describe the acute manifestations of bilirubin
The recommendations in this guideline do not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, taking intoaccount individual circumstances, may be appropriate.PEDIATRICS (ISSN 0031 4005). Copyright 2004 by the American Acad-emy of Pediatrics.
PEDIATRICS Vol. 114 No. 1 July 2004 297 by guest on February 13, 2018http://pediatrics.aappublications.org/Downloaded from by guest on February 13, 2018http://pediatrics.aappublications.org/Downloaded from by guest on February 13, 2018http://pediatrics.aappublications.org/Downloaded from
toxicity seen in the first weeks after birth and that theterm kernicterus be reserved for the chronic andpermanent clinical sequelae of bilirubin toxicity.
See Appendix 1 for the clinical manifestations ofacute bilirubin encephalopathy and kernicterus.
FOCUS OF GUIDELINEThe overall aim of this guideline is to promote an
approach that will reduce the frequency of severeneonatal hyperbilirubinemia and bilirubin encepha-lopathy and minimize the risk of unintended harmsuch as increased anxiety, decreased breastfeeding,or unnecessary treatment for the general populationand excessive cost and waste. Recent reports of ker-nicterus indicate that this condition, although rare, isstill occurring.2,510
Analysis of these reported cases of kernicterussuggests that if health care personnel follow the rec-ommendations listed in this guideline, kernicteruswould be largely preventable.
These guidelines emphasize the importance of uni-versal systematic assessment for the risk of severehyperbilirubinemia, close follow-up, and prompt in-tervention when indicated. The recommendationsapply to the care of infants at 35 or more weeks ofgestation. These recommendations seek to furtherthe aims defined by the Institute of Medicine asappropriate for health care:11 safety, effectiveness,efficiency, timeliness, patient-centeredness, and eq-uity. They specifically emphasize the principles ofpatient safety and the key role of timeliness of inter-ventions to prevent adverse outcomes resulting fromneonatal hyperbilirubinemia.
The following are the key elements of the recom-mendations provided by this guideline. Cliniciansshould:
1. Promote and support successful breastfeeding.2. Establish nursery protocols for the identification
and evaluation of hyperbilirubinemia.3. Measure the total serum bilirubin (TSB) or trans-
cutaneous bilirubin (TcB) level on infants jaun-diced in the first 24 hours.
4. Recognize that visual estimation of the degree ofjaundice can lead to errors, particularly in darklypigmented infants.
5. Interpret all bilirubin levels according to the in-fants age in hours.
6. Recognize that infants at less than 38 weeksgestation, particularly those who are breastfed,are at higher risk of developing hyperbiliru-binemia and require closer surveillance andmonitoring.
7. Perform a systematic assessment on all infantsbefore discharge for the risk of severe hyperbil-irubinemia.
8. Provide parents with written and verbal infor-mation about newborn jaundice.
9. Provide appropriate follow-up based on the timeof discharge and the risk assessment.
10. Treat newborns, when indicated, with photo-therapy or exchange transfusion.
PRIMARY PREVENTIONIn numerous policy statements, the AAP recom-mends breastfeeding for all healthy term and near-term newborns. This guideline strongly supports thisgeneral recommendation.RECOMMENDATION 1.0: Clinicians should advisemothers to nurse their infants at least 8 to 12 times perday for the first several days12 (evidence quality C: benefitsexceed harms).
Poor caloric intake and/or dehydration associatedwith inadequate breastfeeding may contribute to thedevelopment of hyperbilirubinemia.6,13,14 Increasingthe frequency of nursing decreases the likelihood ofsubsequent significant hyperbilirubinemia in breast-fed infants.1517 Providing appropriate support andadvice to breastfeeding mothers increases the likeli-hood that breastfeeding will be successful.
Additional information on how to assess the ade-quacy of intake in a breastfed newborn is provided inAppendix 1.RECOMMENDATION 1.1: The AAP recommendsagainst routine supplementation of nondehydrated breast-fed infants with water or dextrose water (evidence qualityB and C: harms exceed benefits).
Supplementation with water or dextrose waterwill not prevent hyperbilirubinemia or decrease TSBlevels.18,19
SECONDARY PREVENTIONRECOMMENDATION 2.0: Clinicians should performongoing systematic assessments during the neonatal pe-riod for the risk of an infant developing severe hyperbil-irubinemia.
Blood TypingRECOMMENDATION 2.1: All pregnant women shouldbe tested for ABO and Rh (D) blood types and have aserum screen for unusual isoimmune antibodies (evidencequality B: benefits exceed harms).RECOMMENDATION 2.1.1: If a mother has not hadprenatal blood grouping or is Rh-negative, a direct anti-body test (or Coombs test), blood type, and an Rh (D) typeon the infants (cord) blood are strongly recommended(evidence quality B: benefits exceed