2022 American Academy of Pediatrics Updated Guidelines on Hyperbilirubinemia
As a pediatrician, I see many jaundiced babies.
Jaundice is the clinical observation of the yellowing of the skin and the sclera (the white part of the eye). It is due to hyperbilirubinemia, defined as elevated circulating blood levels of bilirubin, a normal breakdown product of red blood cells. It is expected to have some degree of red blood cell breakdown in the baby after delivery. The liver is responsible for converting the bilirubin into a form that can easily be excreted through stooling. The expected elevation of serum bilirubin concentration seen in the first few days of life is due to the high rate of neonatal bilirubin synthesis combined with immature neonatal liver functionality. Levels typically peak on day 3 or 4 of life and then gradually decline in association with increased volume of feeds and stooling.
When assessing jaundiced babies, I take into account their hospital course, how many days old they are, the percentage of weight loss and how they are regaining weight, the method of feeding, how well feeding is going, the quantity and quality of urine and stool outputs, and the infant’s exam. For some, all that is needed is reassurance to the family that newborn jaundice is often a self-limited condition that resolves with normal feeding and stooling, Others infants require further intervention.
Bilirubin Levels
As an outpatient physician, the babies I see have had at least one bilirubin level measured in the hospital before they were discharged. Most of the jaundiced babies I see do not require further bilirubin level testing, just very good history taking regarding feeding and very good anticipatory guidance regarding infant feeding and anticipated outputs. I can always bring a baby back in for a repeat weight check and exam. For babies where they appear jaundiced and have any combination of excessive weight loss, poor feeding, or sleepiness, I would check a bilirubin level.
Interpreting that bilirubin number isn’t as simple as just looking at the number. Interpretation requires taking into account how many weeks gestation the baby was born at, and whether or not there are any risk factors present for the baby to develop kernicterus, a devastating neurologic injury.
To prevent the development of kernicterus, the AAP guidelines offer recommendations regarding which babies need routine care, which need closer monitoring, or which require further managements such as phototherapy, or even exchange transfusion if excessively high. The guidelines take into account the infant’s gestational age, hours of life, measured bilirubin level, and risk factors. Risk factors lower the threshold for more aggressive treatment management of hyperbilirubinemia.
Treatment and Intervention
Phototherapy intervention helps convert bilirubin into a form that is more easily excreted by the baby. Below are two nomograms from the guidelines— the first one demonstrates the phototherapy thresholds in infants with no hyperbilirubinemia risk factors, and the second demonstrates the phototherapy threshold in infants with risk factors. You will see that the threshold for starting phototherapy is lower for those babies who have risk factors, and also that the threshold is lower for babies born at younger gestational ages.
Phototherapy Thresholds in Infants with no Hyperbilirubinemia Risk Factors
Figure 2: doi:10.1542/peds.2022-058859
Phototherapy Threshold in Infants with Risk Factors
Figure 3: doi:10.1542/peds.2022-058859
A free user-friendly tool for interpreting bilirubin level is available at Peditools.
The updated guidelines slightly raised the threshold for initiation of phototherapy. This is significant in that by raising the threshold, it leads to less mother-baby separation (including less interruption to the breastfeeding relationship).That being said, these babies that are close to the phototherapy threshold need to have very close monitoring by their pediatrician.
Jaundice and Breastfeeding
How does this relate to breastfeeding?
Among the various risk factors for developing hyperbilirubinemia, exclusive breastfeeding with suboptimal intake is a modifiable risk factor. Early assessment and continued support of breastfeeding in those early days can make a notable difference. Identifying those dyads with difficulties, teaching hand expression, and appropriately supplementing those babies (ideally with their parent’s own expressed milk) will decrease the risk of hyperbilirubinemia in some infants.
The full 2022 AAP Clinical Practice Guideline can be found here.
For more information on jaundice in neonates, check out Chapter 12 in the 6th Edition of Breastfeeding and Human Lactation by Karen Wambach and Becky Spencer.
