AMERICAN ACADEMY OF PEDIATRICS Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant > 35 Weeks of Gestation Pediatrics 2004 (July);114:297 AAP Jaundice Guideline The 10 Key Elements 1. Promote and support successful breastfeeding. 2. Establish nursery protocols–include circumstances in which nurses can order a bilirubin. 3. Measure TSB or TcB if jaundiced in the first 24 hours. 4. Visual estimation of jaundice can lead to errors, particularly in darkly pigmented infants. 5. Interpret bilirubin levels according to the infant’s age in hours. AAP Jaundice Guideline The 10 Key Elements (cont) 6. Infants <38 weeks, particularly if breastfed, are high risk 7. Perform risk assessment prior to discharge. 8. Give parents written and oral information . 9. Provide appropriate follow-up based on time of discharge and risk assessment. 10. Treat newborns, when indicated, with phototherapy or exchange transfusion. Risk assessment and follow up will prevent disasters We need to assess jaundice risks the way we assess other risks Risk Assessment Do this on every baby Risk factors and/or measure TcB or TSB Best to use both Risk Factors for Developing Hyperbilrubinemia TSB or TCB >75% Jaundice <24hr or before discharge ABO with +ve DAT or other hemolytic disease (G6PD) Gestation <39wk Previous sibling jaundiced Cephalhematoma or bruising (vacuum) Exclusive breastfeeding East Asian Male Discharge <72hr Predictive Ability of a Predischarge Hour-specific Serum Bilirubin for Subsequent Significant Hyperbilirubinemia in Healthy Term and Near-Term Newborns Bhutani VK, Johnson L, Sivieri EM. Pediatrics 1999;103:6-14 Newman Arch Ped Adolesc Med 2005;159:113 Predischarge Bilirubin Levels and Risk of Subsequent Hyperbilirubinemia TSB before discharge TSB after discharge Percentile > 95th percentile 95th 76th – 95th 40th – 75th < 40th TOTAL N 172 (6.1%) 356 (12.5%) 556 (19.6%) 1756 (61.8%)* 2840 68/172 (39.5%) 46/356 (12.9%) 12/556 (2.15%) 0/1756 126 (4.4%) * Newborn TSB were obtained between 18 and 72 hours and 61.8% of all values obtained were below the 40th percentile. Bhutani, et al. Pediatrics 1999;103:6-14. Give Physicians the Tools to Implement the Guidelines Risk assessment tool at bedside Predischarge Assessment for the Risk of Hyperbilirubinemia in Infants >35 wk Gestation (Pediatrics 2004;114:257-313) 25 Date Time Age (hrs) TcB TS B Initials Serum Bilirubin (mg/dl) 20 95 th%ile High Risk Zone 15 h Hig L ow 10 In te In rm e e te rm d iate dia te Ris R k e Zon 75 th%ile e 40 %ile Z on isk th Low Risk Zone 5 Bhutani, Pediatrics1999;103:6 0 TcB – Transcutaneous Bilirubin TSB – Total Serum Biilirubin/Direct 0 12 24 36 48 60 72 84 96 108 120 132 144 Postnatal Age (hours) Risk Factors for Development of Severe Hyperbilirubinemia Risk Factors Major Risk 3 Minor Risk Predischarge TSB or TcB (see nomogram above) Visible Jaundice In high zone (>95%) In high intermediate zone (>75%) First 24 hrs. Before discharge Gestational age 35-36 wks 37-38 wks. Previous sibling Received phototherapy Jaundiced, no phototherapy Blood Groups Hemolytic disease Blood grp. incompatibility with +DAT. Other known hemolytic Feeding Exclusive breast (↑risk if poor feeder or ↑ wt. loss ) East Asian 3 Decreased Risk Low risk zone (<40%) >41 wk disease (eg. G^PD deficiency) Race Breast fed, nursing well Hispanic (Mexican)? Exclusive formula feeding. African American *unless G^PD def.~12% are G6PD deficient Other factors Cephalhematoma or significant bruising *The more risk factors present, the greater the risk of developing severe hyperbilirubinemia Macrosomic infant of IDM,male gender, maternal age >25 yr. Discharged from hospital after 72 hrs. Follow-up should be provided as follows Any infant discharged before age 72 hours should be seen within 2 days of discharge. *If an infant is discharged before age 72 hours AND if you plan to follow up in more than 2 days, please document your reasons in the chart. **If considering phototherapy or exchange transfusion please refer to the back of this page for guidelines and information. 3 Implementation tools (low tech) Wallet-sized nomogram and guidelines Tony Burgos, MD, MPH Stanford University and Packard Children’s Hospital Chris Longhurst, MD, MS Stanford University and Packard Children’s Hospital Stuart Turner, DVM University of California Davis