Practice Guideline


Pediatrics Volume 94, Number 4 October, 1994

Management of Hyperbilirubinemia in the Healthy Term Newborn

AMERICAN ACADEMY OF PEDIATRICS

Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia

Each year approximately 60% of the 4 million newborns in the United States become clinically jaundiced. Many receive various forms of evaluation and treatment. Few issues in neonatal medicine have generated such long-standing controversy as the possible adverse consequences of neonatal jaundice and when to begin treatment. Questions regarding potentially detrimental neurologic effects from elevated serum bilirubin levels prompt continuing concern and debate, particularly with regard to the management of the otherwise healthy term newborn without risk factors for hemolysis.[1-16] Although most data are based on infants with birth weights >2500 g, "term" is hereafter defined as 37 completed weeks of gestation.

Under certain circumstances, bilirubin may be toxic to the central nervous system and may cause neurologic impairment even in healthy term newborns. Most studies, however, have failed to substantiate significant associations between a specific level of total serum bilirubin (TSB) during nonhemolytic hyperbilirubinemia in term newborns and subsequent IQ or serious neurologic abnormality (including hearing impairment).[3-5] Other studies have detected subtle differences in outcomes associated with TSB levels, particularly when used in conjunction with albumin binding tests and/or duration of exposure.[5,15,17,18] In almost all published studies, the TSB concentration has been used as a predictor variable for outcome determinations.

Factors influencing bilirubin toxicity to the brain cells of newborn infants are complex and incompletely understood; they include those that affect the serum albumin concentration and those that affect the binding of bilirubin to albumin, the penetration of bilirubin into the brain, and the vulnerability of brain cells to the toxic effects of bilirubin. It is not known at what bilirubin concentration or under what circumstances significant risk of brain damage occurs or when the risk of damage exceeds the risk of treatment. Concentrations considered harmful may vary in different ethnic groups or geographic locations and may be lower outside North America or northern Europe. Reasons for apparent geographic differences in risk for kernicterus are not clear; the following practice parameter may not apply worldwide.

There are no simple solutions to the management of jaundiced neonates. Continuing uncertainties about the relationship between serum bilirubin levels and brain damage as well as differences in patient populations and practice settings contribute to variations in the management of hyperbilirubinemia. Early postpartum discharge from the hospital further complicates the management of jaundiced newborns, because it places additional responsibilities on parents or guardians to recognize and respond to developing jaundice or clinical symptoms.

Some conditions significantly increase the risk of hyperbilirubinemia, including history of a previous sibling with hyperbilirubinemia, decreasing gestational age, breast-feeding, and large weight loss after birth. Although newborns of 37 weeks' gestation and above are considered "term," infants 37 to 38 weeks of gestation may not nurse as well as more mature infants, and there is a strong correlation between decreasing gestational age and risk for hyperbilirubinemia. Infants born at 37 weeks' gestation are much more likely to develop a serum bilirubin level of 13 mg/dL or higher than are those born at 40 weeks' gestation.[19-22]

METHODOLOGY

The Task Force on Quality Assurance (now designated the Provisional Committee on Quality Improvement) selected the management of hyperbilirubinemia as a topic for practice parameter development and appointed a subcommittee that performed a comprehensive literature review. Two independent MEDLINE searches identified primarily retrospective epidemiologic data derived almost exclusively from North American and European literature. The subcommittee also relied heavily on both the data and analyses contained in a 1990 report by Newman and Maisels.[3] Moreover, the total experience analyzed involved a relatively limited number of healthy term infants with bilirubin levels in excess of 25 mg/dL (428 µmol/L) making it difficult to draw firm conclusions from the published data. The recommendations that follow stem from careful consideration of currently available information, as analyzed and interpreted by subcommittee members and consultants, and are based on evidence when appropriate data exist and derived from consensus when data are lacking. The subcommittee's recommendations are supported by a technical report containing a world literature search and analysis, and updated literature review. The technical report is available from the Publications Department of the American Academy of Pediatrics (AAP).

RECOMMENDATIONS

The following recommendations were developed by the AAP to aid in the evaluation and treatment of the healthy term infant with hyperbilirubinemia. Important in the development of these guidelines is the general belief that therapeutic interventions for hyperbilirubinemia in the healthy term infant may carry significant risk relative to the uncertain risk of hyperbilirubinemia in this population. In these guidelines, the AAP has attempted to describe a range of acceptable practices, recognizing that adequate data are not available from the scientific literature to provide more precise recommendations.

Evaluation

1. Maternal prenatal testing should include ABO and Rh(D) typing and a serum screen for unusual isoimmune antibodies.[23]

2. A direct Coombs' test, a blood type, and an Rh(D) type on the infant's (cord) blood are recommended when the mother has not had prenatal blood grouping or is Rh-negative.

3. Institutions are encouraged to save cord blood for future testing, particularly when the mother's blood type is group O. Appropriate testing may then be performed as needed.

4. When family history, ethnic or geographic origin, or the timing of the appearance of jaundice suggests the possibility of glucose-6-phosphate dehydrogenase deficiency or some other cause of hemolytic disease, appropriate laboratory assessment of the infant should be performed.

5. A TSB level needs to be determined in infants noted to be jaundiced in the first 24 hours of life.

6. In newborn infants, jaundice can be detected by blanching the skin with digital pressure, revealing the underlying color of the skin and subcutaneous tissue. The clinical assessment of jaundice must be done in a well-lighted room. Dermal icterus is seen first in the face and progresses caudally to the trunk and extremities. As the TSB level rises, the extent of cephalocaudad progression may be helpful in quantifying the degree of jaundice; use of an icterometer or transcutaneous jaundice meter may also be helpful.[24-26]

7. Evaluation of newborn infants who develop abnormal signs such as feeding difficulty, behavior changes, apnea, or temperature instability is recommended--regardless of whether jaundice has been detected--to rule out underlying illness (Table 1).

8. Follow-up should be provided to all neonates discharged less than 48 hours after birth by a health care professional in an office, clinic, or at home within 2 to 3 days of discharge.[23]

9. Approximately one third of healthy breast-fed infants have persistent jaundice after 2 weeks of age.[27] A report of dark urine or light stools should prompt a measurement of direct serum bilirubin. If the history (particularly the appearance of the urine and stool) and physical examination results are normal, continued observation is appropriate. If jaundice persists beyond 3 weeks, a urine sample should be tested for bilirubin, and a measurement of total and direct serum bilirubin obtained.

Treatment

Decisions about therapeutic intervention are tempered by clinical judgment based on the infant's history, course, and physical findings and are balanced by comparing the potential benefits with the risks. As appropriate, physicians are encouraged to discuss management options and their recommendations with parents or other guardians. The guidelines in Table 2 are recommended for infants initially seen with elevated TSB levels, as well as for infants who have been followed up for clinical jaundice. Similar guidelines have been used in Great Britain.[28,29] Direct bilirubin measurements vary substantially as a function of individual laboratories and their instrumentation. For the purposes of the otherwise healthy appearing jaundiced newborn, it is recommended that the direct bilirubin measurement not be subtracted from the TSB level and that the TSB level be relied on as the relevant criterion.

Determination of the rate of rise of TSB and the infant's age may help determine how often to monitor bilirubin levels and whether to begin photo-therapy. Continued observation may be an appropriate alternative to repeated TSB testing and phototherapy.

There is continuing uncertainty about what specific TSB levels warrant exchange transfusion. Intensive phototherapy (Appendix) is recommended in infants initially seen with a TSB concentration in the exchange transfusion range (Table 2) while preparations are being made for exchange transfusion. Intensive phototherapy should produce a decline in the TSB level of 1 to 2 mg/dL within 4 to 6 hours, and the decline should continue thereafter. If the TSB level does not decline but persists above the level recommended for exchange transfusion, most experts recommend exchange transfusion (Table 2). Exchange transfusion is also indicated in infants whose TSB levels rise to exchange transfusion levels in spite of intensive phototherapy. In any of the above situations, failure of intensive phototherapy to lower the TSB level strongly suggests the presence of hemolytic disease or some other pathologic process and warrants further investigation.

These guidelines apply to infants without signs of illness or apparent hemolytic disease. It may be difficult to rule out ABO hemolytic disease as well as rarer causes of hemolysis.

The evaluation and treatment of hyperbilirubinemia in the healthy term infant is presented in the clinical Algorithm.[30]

Management of Hyperbilirubinemia in the Healthy Term Newborn by Age (in Hours)

1. Infants <24 hours old are excluded from Table 2 , because jaundice occurring before age 24 hours is generally considered "pathologic" and requires further evaluation. Although some healthy infants appear slightly jaundiced by 24 hours, the presence of jaundice before 24 hours requires (at least) a serum bilirubin measurement and, if indicated, further evaluation for possible hemolytic disease or other diagnoses. Phototherapy and/or exchange transfusion may be indicated for rapidly rising TSB levels in the first 24 hours of life.

2. For the treatment of the 25- to 48-hour-old infant, phototherapy may be considered (see Table 2 for definition) when the TSB level is >12 mg/dL (210 µmol/L). Phototherapy should be implemented when the TSB level is >15 mg/dL (260 µmol/L). If intensive phototherapy fails to lower a TSB level of >20 mg/dL (340 µmol/L), exchange transfusion is recommended. If the TSB level is >25 mg/dL (430 µmol/L) when the infant is first seen, intensive phototherapy is recommended while preparations are made for an exchange transfusion. If intensive phototherapy fails to lower the TSB level, exchange transfusion is recommended. The higher TSB levels in a 25- to 48-hour-old infant suggest that the infant may not be healthy and indicate the need for investigation into the cause of hyperbilirubinemia, such as hemolytic disease.

3. Phototherapy may be considered for the 49- to 72-hour-old jaundiced infant when the TSB level is >15 mg/dL (260 µmol/L). Phototherapy is recommended when the TSB level reaches 18 mg/dL (310 µmol/L). If intensive phototherapy fails to lower the TSB level when it reaches or is predicted to reach 25 mg/dL (430 µmol/L), an exchange transfusion is recommended. If the TSB level is >30 mg/dL (510 µmol/L) when the infant is first seen, intensive phototherapy is recommended while preparations are made for exchange transfusion. If intensive phototherapy fails to lower the TSB level, an exchange transfusion is recommended.

4. For the infant >72 hours old, phototherapy may be considered if the TSB level reaches 17 mg/dL (290 µmol/L). Phototherapy needs to be implemented at a TSB level of >20 mg/dL (340 µmol/L). If intensive phototherapy fails to lower a TSB level of >25 mg/dL (430 µmol/L), exchange transfusion is recommended. If the TSB level is > 30 mg/dL (510 µmol/L) when the infant is first seen, intensive phototherapy is recommended while preparations are made for an exchange transfusion. If intensive phototherapy fails to lower the TSB level, an exchange transfusion is recommended.

In all of the above situations, intensive phototherapy (Appendix) should be used if the TSB level does not decline under conventional phototherapy. Intensive phototherapy should produce a steady decline in the concentration of TSB. If this does not occur, the presence of hemolytic disease or some other pathologic process is suggested and warrants further investigation.

Treatment of Jaundice Associated With Breast-feeding in the Healthy Term Newborn

The AAP discourages the interruption of breast-feeding in healthy term newborns and encourages continued and frequent breast-feeding (at least eight to ten times every 24 hours). Supplementing nursing with water or dextrose water does not lower the bilirubin level in jaundiced, healthy, breast-feeding infants.[31] Depending on the mother's preference and the physician's judgment, however, a variety of options are presented in Table 3 for possible implementation beyond observation, including supplementation of breast-feeding with formula or the temporary interruption of breast-feeding and substitution with formula, either of which can be accompanied by phototherapy.

DOCUMENTATION

This practice parameter is designed to assist the pediatrician and other health care providers by providing a framework for the management of hyperbilirubinemia in the healthy term newborn. It is not intended to replace the physician's clinical judgment or to establish a single protocol applicable to all such newborns with hyperbilirubinemia. It is understood that some clinical problems may not be adequately addressed by the practice parameter, which cannot be considered to represent an exclusive standard of care. Physicians are urged to document their management strategies, including any significant deviation from these or other guidelines and the rationale for the course of action taken.

Finally, all physicians and other health care providers caring for jaundiced newborns are encouraged to continue appraising and incorporating into their practices new scientific and technical advances as clinical evidence of their effectiveness becomes established.

PROVISIONAL COMMITTEE ON QUALITY IMPROVEMENT, 1993 TO 1994
David A. Bergman, MD, Chairman
James R. Cooley, MD
John B. Coombs, MD
Michael J. Goldberg, MD, Sections Liaison
Charles J. Homer, MD, Section on Epidemiology Liaison
Lawrence F. Nazarian, MD
Thomas A. Riemenschneider, MD
Kenneth B. Roberts, MD
Daniel W. Shea, MD
Thomas F. Tonniges, MD, AAP Board of Directors Liaison

SUBCOMMITTEE ON HYPERBILIRUBINEMIA, 1992 TO 1994
William O. Robertson, MD, Chairman
Jon R. Almquist, MD
Irwin J. Light, MD
M. Jeffrey Maisels, MD
Thomas B. Newman, MD, MPH, Consultant
Ronald W. Poland, MD

IN CONSULTATION WITH:
Gerald B. Merenstein, MD
James A. Lemons, MD
Lawrence M. Gartner, MD
Lois Johnson, MD
Audrey K. Brown, MD
David K. Stevenson, MD
Avroy Fanaroff, MD
James Cooley, MD, Clinical Algorithm

REFERENCES

1. Behrman RE, ed. Nelson's Textbook of Pediatrics. 14th ed. Philadelphia: WB Saunders; 1992, pp 476-481

2. Watchko JF, Oski FA. Bilirubin 20 mg/dL = vigintiphobia. Pediatrics. 1983;71:660-663

3. Newman TB, Maisels MJ. Does hyperbilirubinemia damage the brain of healthy newborn infants? Clin Perinatol. 1990;17:331-358

4. Newman TB, Maisels MJ. Evaluation and treatment of jaundice in the term infant: a kinder, gentler approach. Pediatrics. 1992;89:809-818

5. Newman TB, Klebanoff M. Peak serum bilirubin in normal-sized infants and neurodevelopmental outcome at age 7: a closer look at the collaborative perinatal study. Pediatrics. 1993;92:651-657

6. Valaes T. Bilirubin toxicity: the problem was solved a generation ago. Pediatrics. 1992;89:819-820

7. Wennberg RP. Bilirubin recommendations present problems: new guidelines simplistic and untested. Pediatrics. 1992;89:821-822

8. Merenstein GB. "New" bilirubin recommendations questioned. Pediatrics. 1992;89:822-823

9. Poland RL. In search of a "gold standard" for bilirubin toxicity. Pediatrics. 1992;89:823-824

10. Cashore WJ. Hyperbilirubinemia: should we adopt a new standard of care? Pediatrics. 1992;89:824-826

11. Gartner LM. Management of jaundice in the well baby. Pediatrics. 1992;89:826-827

12. Brown AK, Seidman DS, Stevenson DK. Jaundice in healthy term neonates: do we need new action levels or new approaches? Pediatrics. 1992;89:827-828

13. Johnson L. Yet another expert opinion on bilirubin toxicity! Pediatrics. 1992;89:829-830

14. Newman TB, Maisels MJ. Response to commentaries re: evaluation and treatment of jaundice in the term newborn: a kinder, gentler approach. Pediatrics. 1992;89:831-833

15. Seidman DS, Paz I, Stevenson DK, et al. Neonatal hyperbilirubinemia and physical and cognitive performances at 17 years of age. Pediatrics. 1991;88:828-833

16. Martinez JC, Maisels MJ, Otheguy L, et al. Hyperbilirubinemia in the breast-fed newborn: controlled trial of four interventions. Pediatrics. 1993;91:470-473

17. Johnson LH, Boggs TR. Bilirubin-dependent brain damage: incidence indications for treatment. In: O'Dell GB, Schaffer R, Simopoulous AP, eds. Phototherapy in the Newborn: An Overview. Washington, DC: National Academy of Sciences; 1974;122-149

18. Johnson LH. Hyperbilirubinemia in the term infant: when to worry, when to treat. NY State J Med. 1991;91:483-489

19. Gale R, Seidman DS, Dollberg S, Stevenson DK. Epidemiology of neonatal jaundice in the Jerusalem population. J Pediatr Gastroenterol Nutr. 1990;10:82-86

20. Friedman L, Lewis PJ, Clifton P, et al. Factors influencing the incidence of neonatal jaundice. Br Med J. 1978;1:1235-1237

21. Linn S, Schoenbaum SC, Monson RR, et al. Epidemiology of neonatal hyperbilirubinemia. Pediatrics. 1985;75:770-774

22. Maisels MJ, Gifford KL, Antle CE, Lieb GR. Jaundice in the healthy newborn infant: a new approach to an old problem. Pediatrics. 1988;81:505-511

23. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1992

24. Kramer LI. Advancement of dermal icterus in the jaundiced newborn. AJDC. 1969;118:454

25. Ebbesen F. The relationship between the cephalopedal progress of clinical icterus and the serum bilirubin concentration in newborn infants without blood type sensitization. Obstet Gynecol Scand. 1975;54:329-332

26. Schumacher RE. Noninvasive measurements of bilirubin in the newborn. Clin Perinatol. 990;17:417-435

27. Alonso EM, Whitington PF, Whitington SH, Rivard WA, Given G. Enterohepatic circulation of non-conjugated bilirubin in rats fed with human milk. J Pediatr. 1991;118:425-430

28. Dodd KL. Neonatal jaundice--a lighter touch. Arch Dis Child. 1993;68:529-533

29. Finlay HVL, Tucker SM. Neonatal plasma bilirubin chart. Arch Dis Child. 1978;53:90-91

30. Pearson SD, Margolis CZ, Davis S, Schreier LK, Gottlieb LK. The clinical algorithm nosology: a method for comparing algorithmic guidelines. Med Decision Making. 1992;12:123-131

31. Nicoll A, Ginsburg R, Tripp JH. Supplementary feeding and jaundice in newborns. Acta Pediatr Scand. 1982;71:759-761

APPENDIX

Phototherapy
There is no standardized method for delivering phototherapy. Phototherapy units vary widely, as do the types of lamps used in these units. The following factors strongly influence the efficacy of phototherapy:

The energy output (or irradiance) of the phototherapy light in the blue spectrum, measured in µW/cm²;

The spectrum of light delivered by the phototherapy unit, determined by the type of light source.

The surface area of the infant exposed to phototherapy.

Commonly used phototherapy units contain a number of daylight, cool white, blue, or "special blue" fluorescent tubes. Other units use tungsten-halogen lamps in different configurations, either free-standing or as part of a radiant warming device. Most recently, fiberoptic systems have been developed that deliver light from a high-intensity lamp to a fiberoptic blanket. Most of these devices deliver enough output in the blue-green region of the visible spectrum to be effective for standard phototherapy use. When bilirubin levels approach the range at which exchange transfusion might be indicated, maximal efficacy should be sought. This can be achieved in the following manner.

The use of special blue tubes in standard fluorescent phototherapy units. Note that special blue (narrow spectrum) tubes carry the designation F20 T12/BB are not the same as blue tubes (F20 T12/B).[1] Special blue lights have the disadvantage of making the infant look blue, but in healthy newborns this is generally not a concern during the relatively brief period that phototherapy is necessary. To mitigate this effect, four special blue tubes may be used in the central portion of a standard phototherapy unit and two daylight fluorescent tubes may be used on either side.[2]

Regardless of the type of light used, its maximum irradiance should be employed. Standard fluorescent lamps accomplish this by bringing the light as close to the baby as possible. In the full-term nursery, this is most easily achieved by placing the infant in a bassinet (not an incubator) and lowering the lamps to within 15 to 20 cm of the infant. If this treatment causes slight warming of the infant, the lamps need to be elevated slightly. With halogen phototherapy lamps, however, there are no data to indicate how close to the baby the lamp can be positioned without incurring the risk of a burn. When halogen lamps are used, manufacturers' recommendations should be followed. The reflectors, light source, and transparent light filters (if any) should be kept clean.

The third way to improve phototherapy efficiency is to increase the surface area of the infant exposed to the lights. This is done, most simply, by placing the infant on a fiberoptic blanket while using a standard phototherapy system described above.[3] If fiberoptic units are not available, several phototherapy lamps can be placed around the infant. When a single phototherapy unit is used, the area of exposure can be increased by placing a white reflecting surface (such as a sheet) around the bassinet so that light is reflected onto the baby's skin. Removing diapers will also increase the exposed surface area.

Intermittent Versus Continuous Phototherapy
Clinical studies comparing intermittent with continuous phototherapy have produced conflicting results.[4-6] Because all light exposure increases bilirubin excretion (compared with darkness), no plausible scientific rationale exists for using intermittent phototherapy. In the majority of circumstances, however, phototherapy does not need to be continuous. Phototherapy may be interrupted during feeding or brief parental visits. Individual judgment should be exercised. If the infant is admitted to the hospital with a bilirubin level >25 mg/dL(428 µmol/L), intensive phototherapy should be administered continuously until a satisfactory decline in the serum bilirubin level occurs or exchange transfusion is initiated.

Intensity of Phototherapy
The intensity of the phototherapy (number of lights, distance from infant, and use of double phototherapy, use of special lights) should also be tailored to the infant's needs. In many circumstances intensive phototherapy is not necessary. However, if the serum bilirubin level is rising in spite of conventional phototherapy or the infant is admitted with a serum bilirubin concentration within the exchange transfusion range, the necessary steps should be taken to increase the intensity of phototherapy during preparation for exchange transfusion. With the light sources commonly used, it is impossible to overdose the patient.

Hydration
To our knowledge, no evidence exists that excess fluid administration affects the serum bilirubin concentration. Some infants who are admitted with high bilirubin levels are also mildly dehydrated, however, may need supplemental fluid intake to correct their dehydration. As these infants are almost always breast-fed, the best fluid to use in these circumstances is a milk-based formula, because it inhibits the enterohepatic circulation of bilirubin and helps lower the serum bilirubin level. Because the photoproducts responsible for the decline in serum bilirubin are excreted in both urine and bile, maintaining adequate hydration and good urine output should help improve the efficacy of phototherapy.[7] Routine supplementation (with dextrose water) of infants receiving phototherapy is not indicated.

When Should Phototherapy Be Stopped?
A recent study found that, in infants who do not have hemolytic disease, the average bilirubin rebound after phototherapy is less than 1 mg/dL (17 µmol/L).[8] Phototherapy may be discontinued when the serum bilirubin level falls below 14 to 15 mg/dL. Discharge from the hospital need not be delayed in order to observe the infant for rebound and, in most cases, no further measurement of bilirubin is necessary. If phototherapy is initiated early and discontinued before the infant is 3 to 4 days old, additional outpatient follow-up may be necessary.

APPENDIX REFERENCES

1. Ennever JF. Blue light, green light, white light, more light: treatment of neonatal jaundice. Clin Perinatol. 1990;17:407-478

2. Hammerman C, Eidelman A, Lee K-S, et al. Comparative measurements of phototherapy: a practical guide. Pediatrics. 1981;67:368-372

3. Holtrop PC, Ruedisueli K, Maisels MJ. Double versus single phototherapy in low birthweight infants. Pediatrics. 1992;90:674-677

4. Maurer HM, Shumway C, Draper DA, et al. Controlled trial comparing agar, intermittent phototherapy, and continuous phototherapy for reducing neonatal hyperbilirubinemia. J Pediatr. 1973;82:73-76

5. Rubaltelli FF, Zanardo V, Granati B. Effect of various phototherapy regimens on bilirubin decrement. Pediatrics. 1978;61:838-841

6. Lau SP, Fung KP. Serum bilirubin kinetics in intermittent phototherapy of physiological jaundice. Arch Dis Child. 1984;59:892-894

7. Wu PYK, Hodgman JE, Kirkpatrick BV, et al. Metabolic aspects of phototherapy. Pediatrics. 1985;75:427-433

8. Lazar L, Litwin A, Nerlob P. Phototherapy for neonatal nonhemolytic hyperbilirubinemia. Analysis of rebound and indications for discontinuing phototherapy. Clin Pediatr. 1993;32:264-267

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The practice parameter, "Management of Hyperbilirubinemia in the Healthy Term Newborn," was reviewed by the appropriate committees and sections of the American Academy of Pediatrics (AAP), including the Chapter Review Group, a focus group of office-based pediatricians representing each AAP District: Gene R. Adams, MD; Robert M. Corwin, MD; Lawrence C. Pakula, MD; Barbara M. Harley, MD; Howard B. Weinblatt, MD; Thomas J. Herr, MD; Kenneth E. Matthews, MD; Diane Fuguay, MD; Robert D. Mines, MD; and Delosa A. Young, MD. The clinical algorithm was developed by Carmie Margolis, MD; Agnatha Golan, MD; Professor Michael Karplus, Ben Gurion University of Negev, Beer Sheva, Israel; and James R. Cooley, MD, Harvard Community Health Plan.

The American Medical Association (AMA) Specialty Society Practice Parameter Partnership reviewed the neonatal hyperbilirubinemia practice parameter and found it to be in conformance with AMA attributes for practice parameter development.

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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

PEDIATRICS (ISSN 0031 4005). Copyright © 1994 by the American Academy of Pediatrics.

No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use.


Table 1. Factors To Be Considered When Assessing a Jaundiced Infant*

Factors that suggest the possibility of hemolytic disease
Family history of significant hemolytic disease
Onset of jaundice before age 24 h
A rise in serum bilirubin levels of more than 0.5 mg/dL/h
Pallor, hepatosplenomegaly
Rapid increase in the TSB level after 24-48 h (consider G6PD deficiency)
Ethnicity suggestive of inherited disease (G6PD deficiency, etc)
Failure of phototherapy to lower the TSB level
Clinical signs suggesting the possibility of other diseases

such as sepsis or galactosemia in which jaundice may be one

manifestation of the disease

Vomiting
Lethargy
Poor feeding
Hepatosplenomegaly
Excessive weight loss
Apnea
Temperature instability
Tachypnea
Signs of cholestatic jaundice suggesting the need to rule out

biliary atresia or other causes of cholestasis

Dark urine or urine positive for bilirubin
Light-colored stools
Persistent jaundice for >3 wk

* TSB indicates total serum bilirubin; G6PD, glucose-6-phosphate dehydrogenase.

 

 

 

Table 2. Management of Hyperbilirubinemia in the Healthy Term Newborn*

Age,hours

TSB Level, mg/dL (pmol/L)

 

Consider Phototherapy†

Phototherapy

Exchange Transfusion if Intensive Photo therapy Fails‡

Exchange Transfusion and Intensive Phototherapy

<=24§

...

...

...

...

25-48

> 12 (210)

> 15 (260)

> 20 (340)

> 25 (430)

49-72

> 15 (260)

> 18 (310)

> 25 (430)

> 30 (510)

>72

> 17 (290)

> 20 (340)

> 25 (430)

> 30 (510)

* TSB mdicates total serum bilirubin.

† Phototherapy at these TSB levels is a clinical option, meaning that the intervention is available and may be used on the basis of individual clinical judgment. For a more detailed description of phototherapy, see the Appendix.

‡ Intensive phototherapy (Appendix) should produce a decline of TSB of 1 to 2 mg/dL within 4 to 6 hours and the TSB level should continue to fall and remain below the threshold level for exchange transfusion. If this does not occur, it is considered a failure of phototherapy.

§ Term infants who are clinically jaundiced at <=24 hours old are not considered healthy and require further evaluation (see text).

 

 

 

Table 3. Treatment Options for Jaundiced Breast-fed Infants

Observe
Continue breast-feeding; administer phototherapy
Supplement breast-feeding with formula with orwithout phototherapy
Interrupt breast-feeding; substitute formula
Interrupt breast-feeding; substitute formula;administer phototherapy

 

 

ALGORITHM

FIGURE. Management of hyperbilirubinemia in the healthy term newborn.