Evaluation and Treatment of Neonatal Hyperbilirubinemia



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Although neonatal jaundice is common, acute bilirubin encephalopathy and kernicterus (i.e., chronic bilirubin encephalopathy) are rare. Universal screening for neonatal hyperbilirubinemia is controversial. The American Academy of Pediatrics recommends universal screening with bilirubin levels or targeted screening based on risk factors. However, the U.S. Preventive Services Task Force and the American Academy of Family Physicians found insufficient evidence that screening improves outcomes. Universal screening may also increase rates of phototherapy, sometimes inappropriately. Younger gestational age and exclusive breastfeeding are the strongest risk factors for the development of hyperbilirubinemia. Infants who appear jaundiced should be evaluated by a risk score or by measurement of total serum or transcutaneous bilirubin. Phototherapy is an effective treatment for hyperbilirubinemia, but the number needed to treat varies widely depending on sex, gestational age, and time since delivery. If indicated, phototherapy should be initiated based on gestational age and risk factors. Exchange transfusion leads to complications in about 5% of treated infants and has a mortality rate of three or four per 1,000 infants. Infants who breastfeed exclusively—particularly those who consume inadequate calories—are at increased risk of hyperbilirubinemia. However, interrupting breastfeeding for the treatment of jaundice increases the risk of early discontinuation of breastfeeding. Encouragement from health care professionals is important to promote breastfeeding in these situations.

Neonatal jaundice affects up to 84% of term newborns1 and is the most common cause of hospital readmission in the neonatal period.2 Severe hyperbilirubinemia (total serum bilirubin [TSB] level of more than 20 mg per dL [342.1 μmol per L]) occurs in less than 2% of term infants and can lead to kernicterus (i.e., chronic bilirubin encephalopathy) and permanent neurodevelopmental delay.2 Therefore, it is important to systematically evaluate all infants for hyperbilirubinemia.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Phototherapy decreases the incidence of severe hyperbilirubinemia in newborns.

C

5

Phototherapy decreases the need for exchange transfusion in newborns with severe hyperbilirubinemia.

B

3, 26

Interrupting breastfeeding in an infant with jaundice decreases the chances of successful breastfeeding.

B

28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Phototherapy decreases the incidence of severe hyperbilirubinemia in newborns.

C

5

Phototherapy decreases the need for exchange transfusion in newborns with severe hyperbilirubinemia.

B

3, 26

Interrupting breastfeeding in an infant with jaundice decreases the chances of successful breastfeeding.

B

28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Acute bilirubin encephalopathy develops in one in 10,000 infants and presents with hypertonia, arching, retrocollis, opisthotonos, fever, and high-pitched cry.2 Data on progression of acute bilirubin encephalopathy to kernicterus are limited, but one study found that 95% of infants with acute bilirubin encephalopathy had full resolution of symptoms, and 5% had evidence of kernicterus by the time of discharge.3 Kernicterus develops in one in 100,000 infants and manifests as athetoid cerebral palsy, auditory dysfunction, dental dysplasia, paralysis of upward gaze, and variable intellectual disability.

Risk factors for the development of severe hyperbilirubinemia include cephalhematoma or significant bruising, early gestational age, exclusive breastfeeding (especially unsuccessful breastfeeding and/or weight loss of 8% to 10%), isoimmune or other hemolytic anemia, and a sibling with a history of neonatal jaundice.4 In addition to hyperbilirubinemia, earlier gestational age, hemolysis, sepsis, and low birth weight are associated with the development of bilirubin encephalopathy. One study found that less than 5% of healthy term infants with a TSB level greater than 30 mg per dL (513.1 μmol per L) developed acute bilirubin encephalopathy or kernicterus.3

What Are the Current Recommendations on Screening for Hyperbilirubinemia?

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The Author

KAREN E. MUCHOWSKI, MD, FAAFP, is a faculty member in the Family Medicine Residency Program at Naval Hospital Camp Pendleton, Calif.

The author thanks Larry Moore, librarian at Naval Hospital Camp Pendleton, Calif., for his assistance with research.

Address correspondence to Karen E. Muchowski, MD, FAAFP, Naval Hospital Camp Pendleton, 200 Mercy Circle, Camp Pendleton, CA 92055 (e-mail: karen.muchowski@med.navy.mil). Reprints are not available from the author.

The views expressed in this article are those of the author and do not necessarily reflect the official policy of the Department of the Navy, Department of Defense, or the U.S. government.

REFERENCES

1. Bhutani VK, Stark AR, Lazzeroni LC, et al.; Initial Clinical Testing Evaluation and Risk Assessment for Universal Screening for Hyperbilirubinemia Screening Group. Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy. J Pediatr. 2013;162(3):477–482.

2. Sgro M, Campbell D, Shah V. Incidence and causes of severe neonatal hyperbilirubinemia in Canada. CMAJ. 2006;175(6):587–590.

3. Gamaleldin R, Iskander I, Seoud I, et al. Risk factors for neurotoxicity in newborns with severe neonatal hyperbilirubinemia. Pediatrics. 2011;128(4):e925–e931.

4. Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or = 35 weeks' gestation: an update with clarifications. Pediatrics. 2009;124(4):1193–1198.

5. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics. 2004;114(4):1138]. Pediatrics. 2004;114(1):297–316.

6. Ip S, Chung M, Kulig J, et al.; American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics. 2004;114(1):e130–e153.

7. Maisels MJ, Deridder JM, Kring EA, Balasubramaniam M. Routine transcutaneous bilirubin measurements combined with clinical risk factors improve the prediction of subsequent hyperbilirubinemia. J Perinatol. 2009;29(9):612–617.

8. Keren R, Luan X, Friedman S, Saddlemire S, Cnaan A, Bhutani VK. A comparison of alternative risk-assessment strategies for predicting significant neonatal hyperbilirubinemia in term and near-term infants. Pediatrics. 2008;121(1):e170–e179.

9. Keren R, Bhutani VK, Luan X, Nihtianova S, Cnaan A, Schwartz JS. Identifying newborns at risk of significant hyperbilirubinaemia: a comparison of two recommended approaches. Arch Dis Child. 2005;90(4):415–421.

10. U.S. Preventive Services Task Force. Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2009;124(4):1172–1177.

11. American Academy of Family Physicians. Clinical recommendations: hyperbilirubinemia, infants. http://www.aafp.org/patient-care/clinical-recommendations/all/hyperbilirubinemia.html. Accessed March 10, 2014.

12. Trikalinos TA, Chung M, Lau J, Ip S. Systematic review of screening for bilirubin encephalopathy in neonates. Pediatrics. 2009;124(4):1162–1171.

13. Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe hyperbilirubinemia and phototherapy use. Pediatrics. 2009;124(4):1031–1039.

14. Petersen JR, Okorodudu AO, Mohammad AA, Fernando A, Shattuck KE. Association of transcutaneous bilirubin testing in hospital with decreased readmission rate for hyperbilirubinemia. Clin Chem. 2005;51(3):540–544.

15. Suresh GK, Clark RE. Cost-effectiveness of strategies that are intended to prevent kernicterus in newborn infants. Pediatrics. 2004;114(4):917–924.

16. Barrington KJ, Sankaran K; Canadian Paediatric Society; Fetus and Newborn Committee. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants. http://www.cps.ca/en/documents/position/hyperbilirubinemia-newborn. Accessed January 20, 2014.

17. Varvarigou A, Fouzas S, Skylogianni E, Mantagou L, Bougioukou D, Mantagos S. Transcutaneous bilirubin nomogram for prediction of significant neonatal hyperbilirubinemia. Pediatrics. 2009;124(4):1052–1059.

18. Besser I, Perry ZH, Mesner O, Zmora E, Toker A. Yield of recommended blood tests for neonates requiring phototherapy for hyperbilirubinemia. Isr Med Assoc J. 2010;12(4):220–224.

19. Maisels MJ, Kring E. Rebound in serum bilirubin level following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156(7):669–672.

20. Al-Saedi SA. Rebound hyperbilirubinemia in term infants after phototherapy. Saudi Med J. 2002;23(11):1394–1397.

21. Kumar P, Chawla D, Deorari A. Light-emitting diode phototherapy for unconjugated hyperbilirubinaemia in neonates. Cochrane Database Syst Rev. 2011;(12):CD007969.

22. Akobeng AK. Neonatal jaundice. Clin Evid Concise. 2004;12:84–85.

23. Newman TB, Kuzniewicz MW, Liljestrand P, Wi S, McCulloch C, Escobar GJ. Numbers needed to treat with phototherapy according to American Academy of Pediatrics guidelines. Pediatrics. 2009;123(5):1352–1359.

24. Aspberg S, Dahlquist G, Kahan T, Källén B. Confirmed association between neonatal phototherapy or neonatal icterus and risk of childhood asthma. Pediatr Allergy Immunol. 2010;21(4 pt 2):e733–e739.

25. Dahlquist G, Kallen B. Indications that phototherapy is a risk factor for insulin-dependent diabetes. Diabetes Care. 2003;26(1):247–248.

26. Matichard E, Le Hénanff A, Sanders A, Leguyadec J, Crickx B, Descamps V. Effect of neonatal phototherapy on melanocytic nevus count in children. Arch Dermatol. 2006;142(12):1599–1604.

27. Bauer J, Büttner P, Luther H, Wircker TS, Möhrle M, Garbe C. Blue light phototherapy of neonatal jaundice does not increase the risk for melanocytic nevus development. Arch Dermatol. 2004;140(4):493–494.

28. Kemper K, Forsyth B, McCarthy P. Jaundice, terminating breast-feeding, and the vulnerable child. Pediatrics. 1989;84(5):773–778.

29. Brethauer M, Carey L. Maternal experience with neonatal jaundice. MCN Am J Matern Child Nurs. 2010;35(1):8–14.

30. Usatin D, Liljestrand P, Kuzniewicz MW, Escobar GJ, Newman TB. Effect of neonatal jaundice and phototherapy on the frequency of first-year outpatient visits. Pediatrics. 2010;125(4):729–734.

31. Gourley GR. Breast-feeding, neonatal jaundice and kernicterus. Semin Neonatol. 2002;7(2):135–141.

32. Bertini G, Dani C, Tronchin M, Rubaltelli FF. Is breastfeeding really favoring early neonatal jaundice? Pediatrics. 2001;107(3):E41.

33. Willis SK, Hannon PR, Scrimshaw SC. The impact of the maternal experience with a jaundiced newborn on the breastfeeding relationship. J Fam Pract. 2002;51(5):465.

34. Newman TB, Liljestrand P, Jeremy RJ, et al.; Jaundice and Infant Feeding Study Team. Outcomes among newborns with total serum bilirubin levels of 25 mg per deciliter or more. N Engl J Med. 2006;354(18):1889–1900.

35. Jangaard KA, Fell DB, Dodds L, Allen AC. Outcomes in a population of healthy term and near-term infants with serum bilirubin levels of > or = 325 micromol/L (> or = 19 mg/dL) who were born in Nova Scotia, Canada, between 1994 and 2000. Pediatrics. 2008;122(1):119–124.


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