Hyperbilirubinemia is one the most common reasons for emergency department visits for the neonate. Most cases of unconjugated hyperbilirubinemia are benign. Although rare, unrecognized or untreated pathologic unconjugated hyperbilirubinemia can lead to the development of acute bilirubin encephalopathy and, ultimately, kernicterus. This issue reviews the emergency department evaluation and management of neonatal hyperbilirubinemia and discusses how to recognize acute bilirubin encephalopathy, with the goal of preventing kernicterus. Recommendations are provided for risk stratification and determining the need for phototherapy or exchange transfusion, using nomograms to plot total serum bilirubin levels and taking into consideration hyperbilirubinemia and neurotoxicity risk factors.
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Following are the most informative references cited in this paper, as determined by the authors.
17. * American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297-316. (Clinical practice guideline) DOI: 10.1542/peds.114.1.297
26. * Lauer BJ, Spector ND. Hyperbilirubinemia in the newborn. Pediatr Rev. 2011;32(8):341-349. (Review) DOI: 10.1542/pir.32-8-341
27. * Maisels MJ. Neonatal jaundice. Pediatr Rev. 2006;27(12):443-454. (Case reports) DOI: 10.1542/pir.27-12-443
54. * Maisels MJ, Bhutani VK, Bogen D, et al. Hyperbilirubinemia in the newborn infant > or =35 weeks’ gestation: an update with clarifications. Pediatrics. 20 09;124(4):1193-1198. (Commentary on clinical guideline) DOI: 10.1542/peds.2009-0329
91. * Bhutani VK, Committee on Fetus and Newborn American Academy of Pediatrics. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2011;128(4):e1046-e1052. (Technical report) DOI: 10.1542/peds.2011-1494
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Keywords: neonatal hyperbilirubinemia, neonatal jaundice, unconjugated hyperbilirubinemia, conjugated hyperbilirubinemia, acute bilirubin encephalopathy, ABE, bilirubin-induced neurologic dysfunction, BIND, kernicterus, nonpathologic hyperbilirubinemia, physiologic jaundice, breastfeeding jaundice, breast milk jaundice, pathologic hyperbilirubinemia, hour-specific nomogram, phototherapy nomogram, exchange nomogram, total serum bilirubin, TSB, transcutaneous bilirubinometers, TcB, hyperbilirubinemia risk factors, neurotoxicity risk factors, exchange transfusion, phototherapy
The American Academy of Pediatrics recommends risk assessment for the development of severe hyperbilirubinemia in every neonate. The Hour-specific Risk for Neonatal Hyperbilirubinemia tool predicts the risk of subsequent severe hyperbilirubinemia in neonates who are ≥35 weeks’ gestational age. This tool should not be used in neonates who have a positive direct Coombs test, or in neonates who require phototherapy at <60 hours of age. The tool is used at the time of discharge to help determine timing for follow-up visits, and should not be used to determine the need for exchange transfusion. Only a total serum bilirubin level should be used (ie, not direct or indirect bilirubin).
The hour-specific nomogram was created in 1999 following a study led by Dr. Vinod Bhutani. A percentile-based bilirubin nomogram was constructed from hour-specific predischarge and postdischarge total serum bilirubin values in newborns (n = 2840; median birth weight = 3230 g; median gestational age = 39 weeks) for the first week of life.
The study excluded newborns who had a positive direct Coombs test or who required phototherapy at <60 hours of age. The predischarge total serum bilirubin level in 61.8% of the newborns (1756/2840) was in the low-risk zone (<40th percentile), and there was no measurable risk for significant hyperbilirubinemia (likelihood ratio = 0; 100% sensitivity; 64.7% specificity; 0% probability).
Chionye Ossai, MD
The Hour-specific Risk for Neonatal Hyperbilirubinemia is for use at the time of discharge in otherwise healthy neonates who are ≥35 weeks’ gestational age. It should not be used in neonates with a positive direct Coombs test, or in neonates who require phototherapy at <60 hours of age. Do not use this tool to determine the need for exchange transfusion.
The recommendations listed here for starting phototherapy are based on American Academy of Pediatrics guidelines. Always use clinical judgment, in addition to considering evidence-based clinical guidelines, in making treatment decisions.
Vinod K. Bhutani, MD
Abdullah Khan, MD; Tommy Y. Kim, MD
Jennifer Bellis, MD, MPH; Mary Jane Piroutek, MD
January 2, 2022
January 31, 2025
Date of Original Release: January 1, 2022. Date of most recent review: December 15, 2021. Termination date: January 1, 2025.
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