This document does not represent a comprehensive review of relevant information or recommendations included in the Clinical Practice Guideline released by the AAP Subcommittee of Pediatrics. It is only meant to be a quick summary/reference of useful points coupled with our approach to bilirubin screening at LPCH. For the complete guideline visit the AAP link below.
The Pathophysiology of Hyperbilirubinemia
The LPCH Approach to Screening
AAP Clinical Practice Guideline
Bilirubin Basics:
- Bilirubin is derived from proteins that contain heme
- Biggest source is breakdown of from red blood cells
- Heme is broken down to biliverdin, which is reduced to bilirubin (in the process, CO is produced)
- Measurement of exhaled CO is an indication of ongoing hemolysis
Major Risk Factors for Developing Hyperbilirubinemia:
- Predischarge TSB in High Risk zone on Bhutani nomogram
- Jaundice observed in the first 24 hours
- ABO incompatibility with positive direct Coombs, other known helmolytic disease
- Gestational age 35-36 weeks
- Previous sibling received phototherapy
- Cephalohematoma or significant bruising
- Exclusive breastfeeding, especially if not nursing well and excessive weight loss
- East Asian race
Use of Nomograms and Guidelines:
- Nomograms help assess risk for developing hyperbilirubinemia and help arrange appropriate follow-up
- There is now good data and an accepted nomogram for assessing risk based on bilirubin level (Bhutani, 1999)
- Clinical Guidelines for screening and management are available from the AAP (July 2004)
- Early jaundice (age < 24h) still has a broad differential and requires workup, despite the ease of initiating management with phototherapy
Bilirubin Screening:
- Screening policies that are widely used do not have good evidence for predicting hyperbilirubinemia (eg. screening babies of all O+ moms)
- Total Serum Bilirubin is inexpensive (<$2) and thus has a good cost/benefit ratio
- Technology will ultimately allow us to determine ongoing hemolysis with exhaled CO
Guidelines for Initiating Phototherapy . . .
. . . IF INFANT IS "LOW RISK">38 WEEKS AND OTHERWISE WELL
Age |
24 hours |
48 hours |
72 hours |
96 hours |
TSB |
12 mg/dl |
15 mg/dl |
18 mg/dl |
20 mg/dl |
. . . IF INFANT IS "MEDIUM RISK"
>38 WEEKS WITH RISK FACTOR (see below) OR 35 - 37 WEEKS AND WELL
Age |
24 hours |
48 hours |
72 hours |
96 hours |
TSB |
10 mg/dl |
13 mg/dl |
15 mg/dl |
17 mg/dl |
. . . IF INFANT IS "HIGH RISK"
35-37 WEEKS WITH RISK FACTOR (see below)
Age |
24 hours |
48 hours |
72 hours |
96 hours |
TSB |
8 mg/dl |
11 mg/dl |
13 mg/dl |
15 mg/dl |
RISK FACTORS THAT IMPACT PHOTOTHERAPY RECOMENDATIONS ISOIMMUNE HEMOLYTIC DISEASE G6PD DEFICIENCY ASPHYXIA LETHARGY TEMPERATURE INSTABILITY SEPSIS ACIDOSIS ALBUMIN <3 g/dL |
BiliTool provides a free, user friendly, interactive way to match patient bili levels to the Bhutani nomogram and phototherapy guidelines.
the LPCH approach. . .
ABurgos, reviewed 5-06
