Reducing Unnecessary Phototherapy for Jaundice in Newborns

Up to 4 in 5 newborns will develop jaundice from the accumulation of unconjugated bilirubin during the first week of life. Most of the time, neonatal hyperbilirubinemia is benign and does not require intervention. To prevent the rare outcomes of acute bilirubin encephalopathy (1 in 10,000 infants) and kernicterus (1 in 100,000 infants), the American Academy of Pediatrics (AAP) recommends universal screening of newborns 35 weeks' gestational age or greater using total serum bilirubin and transcutaneous bilirubin at 24 to 48 hours of life or before hospital discharge if occurring sooner.

Online tools such as the BiliTool allow clinicians to quickly compare measured bilirubin levels with the AAP’s hour- and gestational age-specific thresholds for phototherapy (these are slightly lower in infants with neurotoxicity risk factors). Phototherapy converts unconjugated bilirubin to lumirubin, a structural isomer that is directly excreted via urine or stool. In its 2022 guideline, the AAP increased previous phototherapy thresholds based on updated evidence regarding the risk of neurotoxicity. An FPIN (Family Practice Inquiries Network) Clinical Inquiry found that rebound elevation of bilirubin levels after phototherapy discontinuation is uncommon (less than 2% of infants with levels less than 14 mg per dL [239.46 μmol/L] at initial discontinuation). In infants without known hemolytic disease or other significant risk factors, repeating a bilirubin level after phototherapy discontinuation is not recommended.

Reducing unnecessary treatment of jaundiced neonates with safe bilirubin levels, or subthreshold phototherapy, was previously identified by pediatric hospitalists as a Choosing Wisely campaign goal. Subthreshold phototherapy is common and may have increased after the 2022 AAP guideline.

A recent report in Pediatrics described the Learning and Implementing Guidelines for Hyperbilirubinemia Treatment (LIGHT) Collaborative, a national quality improvement collaborative involving 146 hospitals that aimed to reduce subthreshold phototherapy use to 10% of all phototherapy encounters over a 12-month period. Baseline data was collected from February 2022 to January 2023. Hospitals implemented a combination of quality improvement coaching, educational webinars, electronic health record order sets and documentation templates, clinical algorithms, and communication aids from February 2023 to January 2024. Individual sites were encouraged to use Plan-Do-Study-Act (PDSA) cycles to identify and address barriers to reducing subthreshold phototherapy.

The final analysis included more than 33,000 patient encounters. Subthreshold phototherapy decreased from a median of 48.2% of encounters prior to August 2022 (when the updated AAP guideline was published) to 41.1% during the last 6 months of the intervention, well short of the goal of 10%. A secondary outcome, the median deviation from the phototherapy threshold in subthreshold phototherapy encounters, decreased from 1.57 mg/dL (26.85 μmol/L) to 1.13 mg/dL (19.33 μmol/L). (Of note, the guideline offers the option to consider phototherapy for selected patients when the total serum bilirubin level is within 1.9 mg/dL [32.50 μmol/L] below the phototherapy threshold.) There were no significant changes in hospital length of stay, phototherapy duration, or readmissions for rebound elevation of bilirubin levels.