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AMERICAN ACADEMY of PEDIATRICS Management of Hyperbilirubinemia in the Newborn Infant 35 Or More Weeks of Gestation

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AMERICAN ACADEMY of PEDIATRICS Management of Hyperbilirubinemia in the Newborn Infant 35 Or More Weeks of Gestation AMERICAN ACADEMY OF PEDIATRICS CLINICAL PRACTICE GUIDELINE Subcommittee on Hyperbilirubinemia Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation ABSTRACT. Jaundice occurs in most newborn infants. Hyperbilirubinemia”3 for a description of the meth- Most jaundice is benign, but because of the potential odology, questions addressed, and conclusions of toxicity of bilirubin, newborn infants must be monitored this report.) This guideline is intended for use by to identify those who might develop severe hyperbili- hospitals and pediatricians, neonatologists, family rubinemia and, in rare cases, acute bilirubin encephalop- physicians, physician assistants, and advanced prac- athy or kernicterus. The focus of this guideline is to tice nurses who treat newborn infants in the hospital reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of and as outpatients. A list of frequently asked ques- unintended harm such as maternal anxiety, decreased tions and answers for parents is available in English breastfeeding, and unnecessary costs or treatment. Al- and Spanish at www.aap.org/family/jaundicefaq. though kernicterus should almost always be prevent- htm. able, cases continue to occur. These guidelines provide a framework for the prevention and management of DEFINITION OF RECOMMENDATIONS hyperbilirubinemia in newborn infants of 35 or more The evidence-based approach to guideline devel- weeks of gestation. In every infant, we recommend that clinicians 1) promote and support successful breastfeed- opment requires that the evidence in support of a ing; 2) perform a systematic assessment before discharge policy be identified, appraised, and summarized and for the risk of severe hyperbilirubinemia; 3) provide that an explicit link between evidence and recom- early and focused follow-up based on the risk assess- mendations be defined. Evidence-based recommen- ment; and 4) when indicated, treat newborns with pho- dations are based on the quality of evidence and the totherapy or exchange transfusion to prevent the devel- balance of benefits and harms that is anticipated opment of severe hyperbilirubinemia and, possibly, when the recommendation is followed. This guide- bilirubin encephalopathy (kernicterus). Pediatrics 2004; line uses the definitions for quality of evidence and 114:297–316; hyperbilirubinemia, newborn, kernicterus, balance of benefits and harms established by the bilirubin encephalopathy, phototherapy. AAP Steering Committee on Quality Improvement Management.4 See Appendix 1 for these definitions. ABBREVIATIONS. AAP, American Academy of Pediatrics; TSB, The draft practice guideline underwent extensive total serum bilirubin; TcB, transcutaneous bilirubin; G6PD, glu- peer review by committees and sections within the cose-6-phosphate dehydrogenase; ETCOc, end-tidal carbon mon- AAP, outside organizations, and other individuals oxide corrected for ambient carbon monoxide; B/A, bilirubin/ albumin; UB, unbound bilirubin. identified by the subcommittee as experts in the field. Liaison representatives to the subcommittee BACKGROUND were invited to distribute the draft to other represen- n October 1994, the Provisional Committee for tatives and committees within their specialty organi- Quality Improvement and Subcommittee on Hy- zations. The resulting comments were reviewed by perbilirubinemia of the American Academy of the subcommittee and, when appropriate, incorpo- I rated into the guideline. Pediatrics (AAP) produced a practice parameter dealing with the management of hyperbilirubinemia in the healthy term newborn.1 The current guideline BILIRUBIN ENCEPHALOPATHY AND represents a consensus of the committee charged by KERNICTERUS the AAP with reviewing and updating the existing Although originally a pathologic diagnosis charac- guideline and is based on a careful review of the terized by bilirubin staining of the brainstem nuclei evidence, including a comprehensive literature re- and cerebellum, the term “kernicterus” has come to view by the New England Medical Center Evidence- be used interchangeably with both the acute and Based Practice Center.2 (See “An Evidence-Based chronic findings of bilirubin encephalopathy. Biliru- Review of Important Issues Concerning Neonatal bin encephalopathy describes the clinical central ner- vous system findings caused by bilirubin toxicity to the basal ganglia and various brainstem nuclei. To The recommendations in this guideline do not indicate an exclusive course avoid confusion and encourage greater consistency of treatment or serve as a standard of medical care. Variations, taking into in the literature, the committee recommends that in account individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- infants the term “acute bilirubin encephalopathy” be emy of Pediatrics. used to describe the acute manifestations of bilirubin Downloaded from www.aappublications.org/news by guest PEDIATRICSon September 29,Vol. 2021 114 No. 1 July 2004 297 toxicity seen in the first weeks after birth and that the PRIMARY PREVENTION term “kernicterus” be reserved for the chronic and In numerous policy statements, the AAP recom- permanent clinical sequelae of bilirubin toxicity. mends breastfeeding for all healthy term and near- See Appendix 1 for the clinical manifestations of term newborns. This guideline strongly supports this acute bilirubin encephalopathy and kernicterus. general recommendation. RECOMMENDATION 1.0: Clinicians should advise mothers to nurse their infants at least 8 to 12 times per FOCUS OF GUIDELINE day for the first several days12 (evidence quality C: benefits The overall aim of this guideline is to promote an exceed harms). approach that will reduce the frequency of severe Poor caloric intake and/or dehydration associated neonatal hyperbilirubinemia and bilirubin encepha- with inadequate breastfeeding may contribute to the lopathy and minimize the risk of unintended harm development of hyperbilirubinemia.6,13,14 Increasing such as increased anxiety, decreased breastfeeding, the frequency of nursing decreases the likelihood of or unnecessary treatment for the general population subsequent significant hyperbilirubinemia in breast- and excessive cost and waste. Recent reports of ker- fed infants.15–17 Providing appropriate support and nicterus indicate that this condition, although rare, is advice to breastfeeding mothers increases the likeli- still occurring.2,5–10 hood that breastfeeding will be successful. Analysis of these reported cases of kernicterus Additional information on how to assess the ade- suggests that if health care personnel follow the rec- quacy of intake in a breastfed newborn is provided in ommendations listed in this guideline, kernicterus Appendix 1. would be largely preventable. RECOMMENDATION 1.1: The AAP recommends These guidelines emphasize the importance of uni- against routine supplementation of nondehydrated breast- versal systematic assessment for the risk of severe fed infants with water or dextrose water (evidence quality hyperbilirubinemia, close follow-up, and prompt in- B and C: harms exceed benefits). tervention when indicated. The recommendations Supplementation with water or dextrose water apply to the care of infants at 35 or more weeks of will not prevent hyperbilirubinemia or decrease TSB gestation. These recommendations seek to further levels.18,19 the aims defined by the Institute of Medicine as appropriate for health care:11 safety, effectiveness, SECONDARY PREVENTION efficiency, timeliness, patient-centeredness, and eq- RECOMMENDATION 2.0: Clinicians should perform uity. They specifically emphasize the principles of ongoing systematic assessments during the neonatal pe- patient safety and the key role of timeliness of inter- riod for the risk of an infant developing severe hyperbil- ventions to prevent adverse outcomes resulting from irubinemia. neonatal hyperbilirubinemia. The following are the key elements of the recom- Blood Typing mendations provided by this guideline. Clinicians RECOMMENDATION 2.1: All pregnant women should should: be tested for ABO and Rh (D) blood types and have a serum screen for unusual isoimmune antibodies (evidence 1. Promote and support successful breastfeeding. quality B: benefits exceed harms). 2. Establish nursery protocols for the identification RECOMMENDATION 2.1.1: If a mother has not had and evaluation of hyperbilirubinemia. prenatal blood grouping or is Rh-negative, a direct anti- 3. Measure the total serum bilirubin (TSB) or trans- body test (or Coombs’ test), blood type, and an Rh (D) type cutaneous bilirubin (TcB) level on infants jaun- on the infant’s (cord) blood are strongly recommended diced in the first 24 hours. (evidence quality B: benefits exceed harms). 4. Recognize that visual estimation of the degree of RECOMMENDATION 2.1.2: If the maternal blood is jaundice can lead to errors, particularly in darkly group O, Rh-positive, it is an option to test the cord blood pigmented infants. for the infant’s blood type and direct antibody test, but it 5. Interpret all bilirubin levels according to the in- is not required provided that there is appropriate surveil- fant’s age in hours. lance, risk assessment before discharge, and follow-up20 6. Recognize that infants at less than 38 weeks’ (evidence quality C: benefits exceed harms). gestation, particularly those who are breastfed, are at higher risk of developing hyperbiliru- Clinical Assessment binemia and require closer
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