BiliSummary - Newborn Nursery at LPCH - Stanford University School of Medicine

Bilirubin Screening and Management of

Hyperbilirubinemia
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

Guidelines for Phototherapy

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:

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BiliSummary - Newborn Nursery at LPCH - Stanford University School of Medicine

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

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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

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BiliSummary - Newborn Nursery at LPCH - Stanford University School of Medicine

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.

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the LPCH approach. . .

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BiliSummary - Newborn Nursery at LPCH - Stanford University School of Medicine

 ABurgos,  reviewed 5-06

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