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New AAP guidelines for hyperbilirubinemia

Most pediatricians who care for newborns meet babies with some degree of hyperbilirubinemia, or jaundice, daily. Eighty percent of newborns are born with elevated levels of bilirubin, which causes skin and the whites of eyes to look yellow. It’s so common that it can be easy to forget the importance of adequate screening and treatment for jaundice – and in some cases this can lead to serious, life-changing complications. 

Recently, the American Academy of Pediatrics (AAP) published revised clinical guidelines for treating hyperbilirubinemia in newborns. In the Talking Pediatrics episode, “Code Yellow: New Guidelines for Hyperbilirubinemia,” host Dr. Gabi Hester discusses the new guidelines for diagnosis and treatment with Dr. Jordan Blessing, a pediatric hospitalist at St. Luke’s Hospital in Duluth, Minnesota.

Gabrielle Hester, MD, MS, Hospitalist, Jordan Blessing, MD

Refresher: Bilirubin and hyperbilirubinemia

Bilirubin is a waste product that is produced when red blood cells are broken down. Normally, once bilirubin gets to the liver it becomes conjugated (water-soluble) so it can leave the body in the stool.  

Babies are born with a different form of hemoglobin that very rapidly breaks down after birth. This generates higher than normal levels of bilirubin that must be filtered out of the bloodstream by the liver and sent to the intestine for excretion. However, newborn livers can take several days to start effectively processing bilirubin.

Hyperbilirubinemia, or neonatal jaundice, occurs when the liver is not ready or able to process the bilirubin. In most cases, jaundice in infants is not severe and the symptoms resolve naturally as regular feeding and digestion are established. But for some newborns, high levels of bilirubin in the blood require interventions to help break it down because bilirubin can be toxic in elevated levels. This can lead to serious complications, including kernicterus, a condition that can lead to brain damage, intellectual disabilities, and issues with hearing or vision. 

AAP guidelines emphasize standardized screening processes

Central to the AAP guidelines for hyperbilirubinemia is having systems in place to standardize screening for all newborns. “The new AAP guidelines help define some of the gray zones in terms of screening, intervention and timeframes,” said Dr. Blessing. “Making the process automatic reduces the need for a conversation every time a standard screening or treatment intervention is needed.” It also makes sure every newborn is adequately screened. 

For example, the nursing order set for newborns should include a transcutaneous bilirubin reading at 24 to 48 hours of life or prior to hospital discharge, whichever is sooner. In cases of infants with higher risk factors (e.g., premature birth, significant bruising during birth, baby’s blood type different than mother’s, etc.), the transcutaneous reading should be done at 12 hours of life. A total serum (blood) test should be done if the transcutaneous bilirubin reading is 3 mg/dL or greater than the 15 mg/dL standard treatment threshold. 

Jaundice is also more common in infants who are breastfeeding, so they will require more monitoring. There are two main causes of jaundice due to breastfeeding: suboptimal intake and breast milk jaundice. Suboptimal intake can happen if the baby doesn’t feed well or if the mother’s milk is slow to come in; a lactation consultation can be helpful in these cases. Breast milk jaundice means there’s something in the breast milk that’s interfering with the enzymatic processes in the liver and not allowing the bilirubin to break down. 

Red flags for a more serious cause of hyperbilirubinemia include: jaundice within the first 24 hours of life, a marked elevation of bilirubin levels such as reaching exchange transfusion levels, family history of hemolytic disease or G6PD, and prematurity. 

Treatment for hyperbilirubinemia

While most cases of hyperbilirubinemia resolve on their own, some infants need interventions to help break down the bilirubin. A standard treatment called phototherapy exposes the baby to a special kind of blue-green light that converts the bilirubin to a different form to make it more easily excreted by the liver and kidney. The new AAP guidelines raised the phototherapy use threshold by a narrow range in some circumstances and warned against overtreatment.

“The AAP guidelines help sort out two things: they recognized most of our treatment thresholds are well below the dangerous levels that cause neurologic injury, and largely we have an infrastructure where testing and treatment is readily available,” said Dr. Blessing. “Oftentimes we’re getting information about [bilirubin levels] before newborns leave the hospital… so I incorporate the family’s wishes, values and needs into the conversation in terms of deciding how we safely start treatment or safely arrange follow up with a plan B if needed.”

A rebound bilirubin level should be checked at approximately 12 to 24 hours after stopping phototherapy for well newborns without additional risk factors for hyperbilirubinemia. If bilirubin levels remain elevated or increase rapidly, an exchange transfusion might be necessary to prevent kernicterus.

“If you check the bilirubin level and it’s at the exchange transfusion threshold as defined by the AAP algorithms, you should still start with the basics, which is initiating high-intensity phototherapy [with] IV fluids [as needed] to help with dehydration and then monitoring very closely for the next four to six hours,” said Dr. Blessing. “If you’re unable to bring it below the exchange transfusion threshold, we then consider transferring to a NICU where they can undergo exchange transfusion or at least have that option of exchange transfusion in a neonatal intensive care unit.” 

Listen to the full podcast or read the transcript: “Code Yellow: New Guidelines for Hyperbilirubinemia.” 

Alexandra Rothstein