Neonatal hyperbilirubinemia: An evidence-based approach
This review provides the latest advice on the screening and management of hyperbilirubinemia in term infants.
PRACTICE RECOMMENDATIONS
› Diagnose hyperbilirubinemia in infants with bilirubin measured at >95th percentile for age in hours. Do not use visual assessment of jaundice for diagnosis as it may lead to errors. C
› Determine the threshold for initiation of phototherapy by applying serum bilirubin and age in hours to the American Academy of Pediatrics phototherapy nomogram along a risk curve assigned based on gestational age and neurotoxicity risk factors (not major and minor risk factors for severe hyperbilirubinemia). C
› Make arrangements to ensure that all infants are seen by a health care provider within 2 days of discharge (within 1 day if significant risk factors for development of severe hyperbilirubinemia are present). C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Diagnosis relies on TSB and/or TcB
TSB measurement is the traditional and most widely used method for screening and diagnosing neonatal hyperbilirubinemia, but the blood draw is invasive and carries a risk (albeit low) of infection and anemia.17 Transcutaneous bilirubin (TcB) assessment is a noninvasive alternative that generally correlates well with TSB values ≤15 mg/dL,17-20 even in Hispanic, African, and multiethnic populations.18,21,22
Diagnosis of hyperbilirubinemia is made with TSB or TcB measured at >95th percentile for age in hours. TcB levels measured at >15 mg/dL should be confirmed with TSB measurement. Visual assessment of jaundice should not be used for diagnosis, as it may lead to errors.9-23
The total cost of testing is lower with TcB ($4-$15 per patient17) than with TSB when the cost of supplies and personnel are considered.24 Although more recent evidence suggests that TcB is an acceptable way to measure bilirubin in premature infants, no professional society currently recommends the use of TcB for the diagnosis of hyperbilirubinemia in infants25 <35 weeks’ gestation.
Screening recommendations lack consensus
There is a lack of consensus among professional societies on appropriate screening for neonatal hyperbilirubinemia, likely due to limited available data, necessitating expert-driven recommendations.
The AAP recommends universal screening of infants ≥35 weeks’ gestation prior to discharge with measurement of TSB/TcB and/or clinical assessment.9 The Canadian Pediatric Society recommends universal screening with TSB/TcB measurement in all infants in the first 72 hours of life.26
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