Editor’s note: A solicited commentary, “Applying an Equity Lens to Clinical Practice Guidelines: Getting Out of the Gate,” will be published in the September issue of Pediatrics at https://doi.org/10.1542/peds.2022-058918.
Updated AAP guidance emphasizes the need for early identification of newborns of 35 or more weeks’ gestation at risk for hyperbilirubinemia who might require treatment to prevent kernicterus. This includes identification of newborns with maternal anti-erythrocyte antibodies and other risk factors such as lower gestational age, jaundice in the first 24 hours after birth and poor feeding.
Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation and a companion technical report are available at https://doi.org/10.1542/peds.2022-058859 and https://doi.org/10.1542/peds.2022-058865. They will be published in the September issue of Pediatrics.
The clinical practice guideline (CPG) highlights the challenge of identifying infants with glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is among the
most important causes of hyperbilirubinemia leading to kernicterus in the U.S. and worldwide.
Even with a careful history and physical examination, it is hard to predict which newborns are at greatest risk for hyperbilirubinemia. Therefore, all newborns should have either a transcutaneous bilirubin measurement or a total serum bilirubin measurement 24 to 48 hours after birth or prior to discharge, if that occurs earlier.
Follow-up testing, evaluation
One major change from the 2004 AAP guidance is that decisions about the timing of and need for follow-up bilirubin testing and evaluation should be based on the difference between the pre-discharge bilirubin level and the hour-specific phototherapy threshold.
The phototherapy threshold considers the baby’s age in hours as well as gestational age and the presence of any risk factors for neurotoxicity from hyperbilirubinemia. The closer the newborn’s bilirubin level is to the newborn’s risk-based phototherapy threshold, the closer follow-up will need to be.
Change in thresholds
The thresholds for phototherapy and exchange transfusion also have increased slightly in the new guideline. These treatment thresholds take into account gestational age and whether there are additional risk factors for neurotoxicity related to hyperbilirubinemia, including a low albumin level, isoimmune or other hemolytic disease, and sepsis or clinical instability. Additional new recommendations address follow-up care after discontinuing phototherapy to assess for rebound hyperbilirubinemia.
Timely identification of hyperbilirubinemia and the appropriate use of intensive phototherapy can almost always prevent the need for an exchange transfusion. The guidance offers recommendations on how to provide intensive phototherapy and the circumstances in which home phototherapy is an option.
The new guidance introduces the term “escalation of care” to address serum bilirubin levels that exceed 2 milligrams per deciliter below the exchange transfusion level. This is a medical emergency. Specific recommendations, such as when it is appropriate to provide an urgent exchange transfusion, are included.
The new guidance underscores the importance of ensuring timely follow-up, even for low-risk infants. Prior to discharge, all families should receive written and verbal education about neonatal jaundice and information specific to their baby, including the infant’s pre-discharge bilirubin level along with details about follow-up after discharge.
As with any CPG, it is important to personalize care based on the unique clinical situation. However, the new guidance is based on the best available evidence and was developed to prioritize patient safety.
Drs. Kemper and Newman are lead authors of the clinical practice guideline and technical report. Dr. Kemper was chair and Dr. Newman was vice chair of the guideline authoring subcommittee.
- Key driver diagram to guide quality improvement (QI) efforts to eliminate kernicterus
- Examples of QI metrics to help pediatricians measure progress on the key action statements in the guideline
- Graphs show follow-up recommendations by gestational age and presence of neurotoxicity risk factors