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Raising the Bar on Neonatal Hyperbilirubinemia Care

September 27, 2022

Written by Jacob Altholz

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The American Academy of Pediatrics (AAP) updated clinical guidelines for management of term infants presenting with hyperbilirubinemia. Relevant sections for ED providers include slightly raising phototherapy treatment thresholds, removing race as a consideration, and giving courses of action for infants requiring higher levels of care.

Why does this matter?
Hyperbilirubinemia is a common neonatal concern, with the potential for devastating consequences if left untreated. Though commonly a concern identified by pediatricians, ED providers must also be aware of the presentation and management of these infants.

Bilirubin Boundaries Boosted, Racial Discrepancies Recognized
The AAP organized a committee-led systematic review of the literature related to hyperbilirubinemia in infants. The near-decade long effort reviewed over 40 articles published since the most recent major revision in 2004. Areas of focus included prevention of jaundice, assessment/monitoring, treatment, and follow-up planning. A total of 25 “Key Action Statements” were made, scaling recommendations based on strength of evidence.

Given the non-zero risks associated with phototherapy and the acknowledgement that previous thresholds were conservative, the boundaries for treatment were elevated slightly. When treating jaundiced infants, keep in mind that tools many of us use, such as BiliTool, have yet to be updated.

Management of a jaundiced neonate includes specialized care not every center may have; thus, the article specifically recommends transfer to a NICU at certain bilirubin levels (defined as 2 mg/dL below exchange transfusion threshold). Infants requiring this escalation are recommended to undergo intensive phototherapy and IV hydration. Providers should consider IVIG for those with isoimmune hemolysis.

Two companion pieces were published at the same time, one laying out technical details of the review and the other commenting on the removal of racial considerations. The latter demonstrated that previously identified “protective” black racial identity was misaligned with demonstrable health disparities.

Here are the new phototherapy levels. Note, this is only infants with no risk factors for neurotoxicity. Click here for light levels with risk factors for neurotoxicity and for exchange transfusion levels.

From Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation, click image to view source

Peer reviewed by Dr. Ketan Patel

Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022 Aug 5;e2022058865. doi: 10.1542/peds.2022-058865. Online ahead of print.




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