New Hyperbilirubinemia Guidelines

Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Subcommittee on Hyper-bilirubinemia. PEDIATRICS (July 2004); 114:297-316.

Jaundice occurs in most newborn infants. Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus.

Objective: The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment. Although kernicterus should almost always be preventable, cases continue to occur. These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 35 or more weeks of gestation. In every infant, we recommend that clinicians 1) promote and support successful breastfeeding; 2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia; 3) provide early and focused follow-up based on the risk assessment; and 4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus).

Comments: These guidelines on preventing severe hyperbilirubinemia in infants born at or after 35 weeks gestation unambiguously in newborn care. In my reading, the three recommendations that will result in the most significant modifications to current practice are as follows: (1) every infant should be screened before discharge for the risk of severe hyperbilirubinemia; (2) sufficient outpatient follow-up (at least one visit) should be accomplished by 5 days of age to assess for hyperbilirubinemia; and (3) phototherapy (when indicated by hour-specific and risk-stratified nomograms) should be provided only in the hospital with equipment that provides high levels of total spectral irradiance. I predict that compliance with these guidelines will result in more transcutaneous bilirubinometry, more serum bilirubin tests, less home phototherapy, longer newborn stays (consequent to the difficulty of insuring outpatient follow-up within 48 hours of discharge), and a greater percentage of normal newborn infants who receive their initial newborn care (and perhaps even their initial outpatient follow-up visit) courtesy of a neonatologist. Essentially these guidelines reflect a zero-tolerance level for kernicterus. Because kernicterus is still very rare (estimated incidence is between 1:200,000 and 1:500,000 cases per year in the U.S.) and because there is currently no single predictor that can economically identify all at-risk infants, these guidelines will impact the care of every infant. MH

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