American Academy of Pediatrics Updates Guidelines for the Management of Neonatal Hyperbilirubinemia

Nationwide Children’s physicians collaborate on updates to testing, treatment and follow-up recommendations for preventing hazardous hyperbilirubinemia and possible brain damage.

The American Academy of Pediatrics’ (AAP) recommendations for managing hyperbilirubinemia

in infants 35 gestational weeks and older are among its most accessed sets of clinical practice guidelines. A team led by Alex Kemper, MD, MPH, MS, division chief of Primary Care Pediatrics at Nationwide Children’s Hospital, has updated the 2004 guidelines in response to research developments.

Although nearly all newborns will have some degree of jaundice, relying on appearance is an unreliable way to determine which newborns are at risk for developing high concentrations of bilirubin. If not treated, elevated bilirubin levels could lead to kernicterus, a type of permanent brain damage associated with significant movement disorder, hearing loss and other problems. Measuring the bilirubin concentration of all newborns before discharge to guide follow-up and treatment, when necessary, is central to preventing the high levels of bilirubin that can lead to kernicterus.

“Recommending that all newborns be tested with a device that measures bilirubin levels through the skin or by a blood test is a major update of the previous guidelines. Because kernicterus is so serious and so often preventable, we wanted to make sure that management was guided by a specific measure. This is an important advance in care,” Dr. Kemper explains.

The new guidelines are accompanied by a technical report, which was led by Jonathan Slaughter, MD, MPH, neonatologist and principal investigator at the Center for Perinatal Research in the Abigail Wexner Research Institute at Nationwide Children’s. The technical report explains the risk of adverse outcomes from phototherapy, one of the main ways to lower bilirubin concentrations, is extremely low. Since the 2004 guidelines, evidence regarding the risk of kernicterus has also emerged allowing the guidelines to slightly increase the thresholds for a patient’s bilirubin levels before recommending phototherapy treatment.

“Data from the last 10-plus years show phototherapy is safe and effective when needed and used appropriately,” Dr. Slaughter says. “But, we also know phototherapy can be hard on families and can sometimes interfere with breastfeeding. Even moving the phototherapy thresholds a little bit substantially changes the number of babies who need to remain in the hospital.”

“The new guidelines better take into account factors like gestational age, risk of developing hyperbilirubinemia, and the risk of developing neurologic problems,” Dr. Slaughter adds.

This update also introduces the term “escalation of care,” formalizing procedures to lower a patient’s bilirubin levels once they reach 2 mg/dL below the threshold for an exchange transfusion, a risky treatment for rapidly lowering bilirubin concentrations by removing blood with elevated bilirubin and replacing it with fresh donor blood.

“Exchange transfusions are rare, and we want to prevent the need for such care when at all possible. Escalation of care is a medical emergency that requires aggressive care to prevent the need for an exchange transfusion. This includes the need to be in a neonatal intensive care unit, intensive phototherapy, and IV hydration,” Dr. Kemper says. “With escalation of care, you want to do everything you can to avoid an exchange transfusion.”

The guidelines emphasize the importance of educating parents on jaundice, hyperbilirubinemia, and kernicterus prevention.

“We want to empower families to understand what they can do to prevent hazardous levels of bilirubin. The new guideline emphasizes the importance of arranging follow-up care and making sure that parents understand these plans and what they should look for in the meantime,” Dr. Kemper says. “We are excited because the revised guideline helps pediatricians better target care based on risk and fully engages families in preventing a very serious health outcome.”

References:

1. Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs AM, Grout RW, Bundy DG, Stark AR, Bogen DL, Holmes AV, Feldman-Winter LB, Bhutani VK, Brown SR, Panayotti GMM, Okechukwu K, Rappo PD, Russel TL. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022 Aug 5; e2022058859.
2. Slaughter JL, Kemper AR, Newman TB. Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022 Aug 5; e2022058865.

Image credits: Adobe Stock (header); Nationwide Children’s (portraits)

This feature was included in the 2022 Fall/Winter print issue. Download the full issue.