This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

Rating schemes for strength of evidence and recommendation follow the Major Recommendations.

Primary Prevention

1. Clinicians should advise mothers to nurse their infants at least 8 to 12 times per day for the first several days (American Academy of Pediatrics [AAP], 2002) (evidence quality C: benefits exceed harms).
2. The AAP recommends against routine supplementation of nondehydrated breastfed infants with water or dextrose water (evidence quality B and C: harms exceed benefits).

Secondary Prevention

1. Clinicians should perform ongoing systematic assessments during the neonatal period for the risk of an infant developing severe hyperbilirubinemia.

Blood Typing

1. All pregnant women should be tested for ABO and Rh (D) blood types and have a serum screen for unusual isoimmune antibodies (evidence quality B: benefits exceed harms).
2. If a mother has not had prenatal blood grouping or is Rh-negative, a direct antibody test (or Coombs’ test), blood type, and an Rh (D) type on the infant’s (cord) blood are strongly recommended (evidence quality B: benefits exceed harms).
3. If the maternal blood is group O, Rh-positive, it is an option to test the cord blood for the infant’s blood type and direct antibody test, but it is not required provided that there is appropriate surveillance, risk assessment before discharge, and follow-up (Madlon-Kay, 1992) (evidence quality C: benefits exceed harms).

Clinical Assessment

1. Clinicians should ensure that all infants are routinely monitored for the development of jaundice, and nurseries should have established protocols for the assessment of jaundice. Jaundice should be assessed whenever the infant’s vital signs are measured but no less than every 8 to 12 hours (evidence quality D: benefits versus harms exceptional).
2. Protocols for the assessment of jaundice should include the circumstances in which nursing staff can obtain a transcutaneous bilirubin (TcB) level or order a total serum bilirubin (TSB) measurement (evidence quality D: benefits versus harms exceptional).

Laboratory Evaluation

1. A TcB and/or TSB measurement should be performed on every infant who is jaundiced in the first 24 hours after birth (refer to Figure 1 and Table 1 in the original guideline document) (Newman, Liljestrand, & Escobar, 2002) (evidence quality C: benefits exceed harms). The need for and timing of a repeat TcB or TSB measurement will depend on the zone in which the TSB falls (refer to Fig 2 in the original guideline document) (Bhutani et al., 2000; Bhutani, Johnson, & Sivieri, 1999), the age of the infant, and the evolution of the hyperbilirubinemia. Recommendations for TSB measurements after the age of 24 hours are provided in Figure 1 and Table 1 in the original guideline document.
2. A TcB and/or TSB measurement should be performed if the jaundice appears excessive for the infant’s age (evidence quality D: benefits versus harms exceptional). If there is any doubt about the degree of jaundice, the TSB or TcB should be measured. Visual estimation of bilirubin levels from the degree of jaundice can lead to errors, particularly in darkly pigmented infants (evidence quality C: benefits exceed harms).
3. All bilirubin levels should be interpreted according to the infant’s age in hours (Figure 2 in the original guideline document) (evidence quality C: benefits exceed harms).

Cause of Jaundice

1. The possible cause of jaundice should be sought in an infant receiving phototherapy or whose TSB level is rising rapidly (i.e., crossing percentiles [Figure 2 in the original guideline document]) and is not explained by the history and physical examination (evidence quality D: benefits versus harms exceptional).
2. Infants who have an elevation of direct-reacting or conjugated bilirubin should have a urinalysis and urine culture.(Garcia & Nager, 2002) Additional laboratory evaluation for sepsis should be performed if indicated by history and physical examination (evidence quality C: benefits exceed harms).
3. Sick infants and those who are jaundiced at or beyond 3 weeks should have a measurement of total and direct or conjugated bilirubin to identify cholestasis (Table 1 in the original guideline document) (evidence quality D: benefit versus harms exceptional). The results of the newborn thyroid and galactosemia screen should also be checked in these infants (evidence quality D: benefits versus harms exceptional).
4. If the direct-reacting or conjugated bilirubin level is elevated, additional evaluation for the causes of cholestasis is recommended (evidence quality C: benefits exceed harms).
5. Measurement of the glucose-6-phosphate dehydrogenase (G6PD) level is recommended for a jaundiced infant who is receiving phototherapy and whose family history or ethnic or geographic origin suggest the likelihood of G6PD deficiency or for an infant in whom the response to phototherapy is poor (Figure 3 in the original guideline document) (evidence quality C: benefits exceed harms).

Risk Assessment Before Discharge

1. Before discharge, every newborn should be assessed for the risk of developing severe hyperbilirubinemia, and all nurseries should establish protocols for assessing this risk. Such assessment is particularly important in infants who are discharged before the age of 72 hours (evidence quality C: benefits exceed harms).
2. The AAP recommends 2 clinical options used individually or in combination for the systematic assessment of risk: predischarge measurement of the bilirubin level using TSB or TcB and/or assessment of clinical risk factors. Whether either or both options are used, appropriate follow-up after discharge is essential (evidence quality C: benefits exceed harms).

Hospital Policies and Procedures

1. All hospitals should provide written and verbal information for parents at the time of discharge, which should include an explanation of jaundice, the need to monitor infants for jaundice, and advice on how monitoring should be done (evidence quality D: benefits versus harms exceptional).

Follow-up

1. All infants should be examined by a qualified health care professional in the first few days after discharge to assess infant well-being and the presence or absence of jaundice. The timing and location of this assessment will be determined by the length of stay in the nursery, presence or absence of risk factors for hyperbilirubinemia (Table 2 and Figure 2 in the original guideline document), and risk of other neonatal problems (evidence quality C: benefits exceed harms).

Timing of Follow-up

1. Follow-up should be provided as follows:
   1. Infant discharged before age 24 h should be seen by age 72 h
   2. Infant discharged between 24 and 47.9 h should be seen by age 96 h
   3. Infant discharged between 48 and 72 h should be seen by age 120 h

   For some newborns discharged before 48 hours, 2 follow-up visits may be required, the first visit between 24 and 72 hours and the second between 72 and 120 hours. Clinical judgment should be used in determining follow-up. Earlier or more frequent follow-up should be provided for those who have risk factors for hyperbilirubinemia (see Table 2 in the original guideline document), whereas those discharged with few or no risk factors can be seen after longer intervals (evidence quality C: benefits exceed harms).

2. If appropriate follow-up cannot be ensured in the presence of elevated risk for developing severe hyperbilirubinemia, it may be necessary to delay discharge either until appropriate follow-up can be ensured or the period of greatest risk has passed (72 to 96 hours) (evidence quality D: benefits versus harms exceptional).

Follow-up Assessment

1. The follow-up assessment should include the infant’s weight and percent change from birth weight, adequacy of intake, the pattern of voiding and stooling, and the presence or absence of jaundice (evidence quality C: benefits exceed harms). Clinical judgment should be used to determine the need for a bilirubin measurement. If there is any doubt about the degree of jaundice, the TSB or TcB level should be measured. Visual estimation of bilirubin levels can lead to errors, particularly in darkly pigmented infants (evidence quality C: benefits exceed harms).

Treatment

Phototherapy and Exchange Transfusion

1. Recommendations for treatment are given in Table 3 and Figures 3 and 4 in the original guideline document (evidence quality C: benefits exceed harms). If the TSB does not fall or continues to rise despite intensive phototherapy, it is very likely that hemolysis is occurring. The committee’s recommendations for discontinuing phototherapy can be found in Appendix 2 in the original guideline document.
2. In using the guidelines for phototherapy and exchange transfusion (Figures 3 and 4 in the original guideline document), the direct-reacting (or conjugated) bilirubin level should not be subtracted from the total (evidence quality D: benefits versus harms exceptional).
3. If the TSB is at a level at which exchange transfusion is recommended (Figure 4 in the original guideline document) or if the TSB level is 25 mg/dL (428 micromoles/L) or higher at any time, it is a medical emergency and the infant should be admitted immediately and directly to a hospital pediatric service for intensive phototherapy. These infants should not be referred to the emergency department, because it delays the initiation of treatment (Garland et al., 1994) (evidence quality C: benefits exceed harms).
4. Exchange transfusions should be performed only by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities (evidence quality D: benefits versus harms exceptional).
5. In isoimmune hemolytic disease, administration of intravenous gamma-globulin (0.5–1 g/kg over 2 hours) is recommended if the TSB is rising despite intensive phototherapy or the TSB level is within 2 to 3 mg/dL (34–51micromoles/L) of the exchange level (Figure 4 in the original guideline document) (Gottstein & Cooke, 2003). If necessary, this dose can be repeated in 12 hours (evidence quality B: benefits exceed harms).

Serum Albumin Levels and the Bilirubin/Albumin Ratio

1. It is an option to measure the serum albumin level and consider an albumin level of less than 3.0 g/dL as one risk factor for lowering the threshold for phototherapy use (see Figure 3 in the original guideline document) (evidence quality D: benefits versus risks exceptional).
2. If an exchange transfusion is being considered, the serum albumin level should be measured and the bilirubin/albumin (B/A) ratio used in conjunction with the TSB level and other factors in determining the need for exchange transfusion (see Figure 4 in the original guideline document) (evidence quality D: benefits versus harms exceptional).

Acute Bilirubin Encephalopathy

1. Immediate exchange transfusion is recommended in any infant who is jaundiced and manifests the signs of the intermediate to advanced stages of acute bilirubin encephalopathy (Volpe, 2001; Harris et al., 2001) (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) even if the TSB is falling (evidence quality D: benefits versus risks exceptional).

Phototherapy

1. All nurseries and services treating infants should have the necessary equipment to provide intensive phototherapy (see Appendix 2 in the original guideline document) (evidence quality D: benefits exceed risks).

Outpatient Management of the Jaundiced Breastfed Infant

1. In breastfed infants who require phototherapy (Figure 3 in the original guideline document), the AAP recommends that, if possible, breastfeeding should be continued (evidence quality C: benefits exceed harms). It is also an option to interrupt temporarily breastfeeding and substitute formula. This can reduce bilirubin levels and/or enhance the efficacy of phototherapy (Osborn & Bolus, 1985; Martinez et al., 1993; Amato, Howald, & von Muralt, 1985) (evidence quality B: benefits exceed harms). In breastfed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infant’s intake seems inadequate, weight loss is excessive, or the infant seems dehydrated.

Definitions:

Rating Scheme for Strength of Evidence

1. Well-designed, randomized, controlled trials or diagnostic studies on relevant populations
2. Randomized, controlled trials or diagnostic studies with minor limitations; overwhelming, consistent evidence from observational studies
3. Observational studies (case-control and cohort design)
4. Expert opinion, case reports, reasoning from first principles

Rating Scheme for Strength of Recommendation

• Strong recommendation: the committee believes that the benefits of the recommended approach clearly exceed the harms of that approach and that the quality of the supporting evidence is either excellent or impossible to obtain. Clinicians should follow these recommendations unless a clear and compelling rationale for an alternative approach is present.
• Recommendation: the committee believes that the benefits exceed the harms, but the quality of evidence on which this recommendation is based is not as strong. Clinicians should also generally follow these recommendations but should be alert to new information and sensitive to patient preferences. In this guideline, the term "should" implies a recommendation by the committee.
• Option: either the quality of the evidence that exists is suspect or well-performed studies have shown little clear advantage to one approach over another. Patient preference should have a substantial role in influencing clinical decision-making when a policy is described as an option.
• No recommendation: there is a lack of pertinent evidence and the anticipated balance of benefits and harms is unclear.

A clinical algorithm is provided for the management of jaundice in the newborn nursery.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

1994 Oct (revised 2004 Jul)

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Subcommittee on Hyperbilirubinemia

Subcommittee on Hyperbilirubinemia: M. Jeffrey Maisels, MB, BCh, Chairperson; Richard D. Baltz, MD; Vinod K. Bhutani, MD; Thomas B. Newman, MD, MPH; Heather Palmer, MB, BCh; Warren Rosenfeld, MD; David K. Stevenson, MD; Howard B. Weinblatt, MD

Consultant: Charles J. Homer, MD, MPH, Chairperson, American Academy of Pediatrics Steering Committee on Quality Improvement and Management

Staff: Carla T. Herrerias, MPH

M. Jeffrey Maisels received grant support from Natus Medical, Inc, for multinational study of ambient carbon monoxide; WellSpring Pharmaceutical Corporation for study of Stannsoporfin (tin-mesoporphyrin); and Minolta, Inc, for study of the Minolta/Hill-Rom Air-Shields transcutaneous jaundice meter model JM-103.

Vinod K. Bhutani received grant support from WellSpring Pharmaceutical Corporation for study of Stannsoporfin (tin-mesoporphyrin) and Natus Medical, Inc, for multinational study of ambient carbon monoxide and is a consultant (volunteer) to SpectrX (BiliChek transcutaneous bilirubinometer).

David K. Stevenson is a consultant to and holds stock options through Natus Medical, Inc.

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

None available

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on August 9, 2004. The updated information was verified by the guideline developer on September 27, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.