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 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 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 TSB after discharge

Percentile N > 95th percentile

95th 172 (6.1%) 68/172 (39.5%)
76th – 95th 356 (12.5%) 46/356 (12.9%)
40th – 75th 556 (19.6%) 12/556 (2.15%)
< 40th 1756 (61.8%)* 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 TcB TS Initials
(hrs) B
20

95 th%ile
High Risk Zone

Serum Bilirubin (mg/dl)

e 75 th%ile
k Zon
15 Ris
d iate
rm e e th
h In te Z on
40 %ile
Hig R isk
e dia te
In te rm
10 L ow

Low Risk Zone

Bhutani, Pediatrics1999;103:6
0
TcB – Transcutaneous Bilirubin
0 12 24 36 48 60 72 84 96 108 120 132 144
TSB – Total Serum Biilirubin/Direct Postnatal Age (hours)

Risk Factors for Development of Severe Hyperbilirubinemia

3 3
Risk Factors Major Risk 3 Minor Risk Decreased Risk
Predischarge TSB or In high zone (>95%) In high intermediate zone Low risk zone (<40%)
TcB (>75%)
(see nomogram above)
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 Groups Blood grp. incompatibility with
Hemolytic disease +DAT. Other known hemolytic
disease (eg. G^PD deficiency)
Feeding Exclusive breast (↑risk if poor Breast fed, nursing well Exclusive formula
feeder or ↑ wt. loss ) feeding.
Race East Asian Hispanic (Mexican)? African American
*unless G^PD def.~12% are
G6PD deficient
Other factors Cephalhematoma or significant Macrosomic infant of Discharged from
bruising IDM,male gender, maternal hospital after 72 hrs.
*The more risk factors present, the greater the risk of developing severe hyperbilirubinemia
age >25 yr.

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 Chris Longhurst, MD, MS Stuart Turner, DVM
Stanford University and Stanford University and University of California Davis
Packard Children’s Hospital Packard Children’s Hospital