Bilirubin Management in Newborns Guidelines

Bilirubin Management in Newborns

• Neonatal jaundice is common, with careful monitoring and treatment crucial to avoid complications like bilirubin encephalopathy and kernicterus.
• Kernicterus is a severe, permanent neurologic condition involving various symptoms: choreoathetoid cerebral palsy, upward gaze paresis, enamel dysplasia, sensorineural hearing loss, and specific brain MRI findings.
• The 2022 American Academy of Pediatrics (AAP) clinical practice guideline replaces the 2004 guideline, updating management and prevention of hyperbilirubinemia in newborns ≥35 weeks' gestation.

Clinical Practice Guideline Revision

• The guideline addresses issues of prevention, risk assessment, monitoring, and treatment of hyperbilirubinemia.
• A multidisciplinary committee of neonatologists, hospitalists, primary pediatricians, nurses, and breastfeeding experts reviewed evidence published since 2004 and parental experiences.
• The guideline acknowledges differences in resource availability between countries in infant management.

Prevention of Hyperbilirubinemia

• Screening and treating pregnant women at risk for Rh incompatibility is key to preventing hemolytic disease of the newborn.
• If a mother has a positive antibody screen or unknown screen due to lack of prenatal screening, immediate direct antiglobulin test (DAT) and blood typing of the infant are necessary.
• Exclusive breastfeeding and hyperbilirubinemia are strongly linked. Jaundice in breastfed infants is classified as either "suboptimal intake hyperbilirubinemia" (due to insufficient intake) or "breastmilk jaundice" (persistent with adequate intake).

Assessment and Monitoring

• Infants with risk factors for hyperbilirubinemia require more intensive monitoring. Risk factors include prematurity, jaundice present within 24 hours of birth, transcutaneous bilirubin (TcB) levels near phototherapy thresholds, hemolysis, previous phototherapy, family history of significant jaundice, significant bruising, exclusive breastfeeding with suboptimal intake, and Down syndrome.
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a crucial risk factor for severe hyperbilirubinemia. Genetic ancestry and ethnicity (e.g., African American males, African American females) play a role in assessing the risk.
• Serum total serum bilirubin (TSB) levels guide treatment decisions (phototherapy, exchange transfusions). Critical risk factors for bilirubin neurotoxicity include gestational age <38 weeks, albumin<3.0 g/dL, known or suspected hemolytic disease, sepsis, clinical instability.
• Visual estimation of jaundice is a useful screening method, with a correlation between visual estimations and TSB levels, although it's not precise.
• TcB measurements are valid tools for assessing bilirubin levels but TSB remains definitive.

Treatment of Hyperbilirubinemia

• Phototherapy is a primary treatment to lower bilirubin levels by using photochemical reactions to allow bilirubin excretion.
• Important considerations for phototherapy include intensity, surface area exposure, and the use of narrow-spectrum LED blue light (irradiance of at least 30 µW/cm² per nm).
• Home-based phototherapy is an option for infants who meet specific criteria (gestational age ≥38 weeks, ≥48 hours old, clinically well, no known risk factors for rebound hyperbilirubinemia, TSB close to but not above the phototherapy threshold).
• Intravenous immunoglobulin (IVIG) may be an option for managing isoimmune hemolytic disease in infants whose bilirubin levels exceed the escalation of care thresholds.
• Exchange transfusions should be considered for infants with signs of acute bilirubin encephalopathy (e.g., hypertonia, arching, retrocollis) or when TSB levels reach or exceed the exchange transfusion threshold.
• Critical factors when considering exchange transfusions are the TSB level in relation to gestational age and whether hyperbilirubinemia risk factors are present. The TSB to albumin ratio may be used to guide treatment decisions in some infants.

Post-Discharge Follow-Up

• The guideline provides a flow diagram (Figure 7) to guide post-discharge follow-up, based on the difference between the last bilirubin measurement and the hour-specific phototherapy threshold.
• Parents of all infants should receive written and verbal education about neonatal jaundice, including monitoring for jaundice, dehydration, illness, and proper feeding.
• Information about the infant should be shared with the primary care provider that will follow up after discharge.

This quiz covers the latest updates on bilirubin management in newborns, focusing on the revisions made in the 2022 AAP clinical practice guidelines. It highlights key aspects such as prevention, risk assessment, monitoring, and treatment of hyperbilirubinemia, crucial for avoiding complications like kernicterus. Understanding these guidelines is essential for healthcare professionals working with newborns.