Hiperbilrubin Aap

7/27/2019 Hiperbilrubin Aap

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AMERICAN ACADEMY OFPEDIATRICS

Subcommittee on Hyperbilirubinemia

Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant >35 Weeks of Gestation

Pediatrics 2004 (July);114:297



AAP Jaundice Guideline

The 10 Key Elements

1. Promote and support successfulbreastfeeding.

2. Establish nursery protocols–includecircumstances in which nurses can order abilirubin.

3. Measure TSB or TcB if jaundiced in the first24 hours.

4. Visual estimation of jaundice can lead toerrors, particularly in darkly pigmentedinfants.

5. Interpret bilirubin levels according to theinfant’s age in hours.





AAP Jaundice Guideline

The 10 Key Elements (cont)

6. Infants <38 weeks, particularly if breastfed,

are high risk7. Perform risk assessment prior to discharge.

8. Give parents written and oral information .

9. Provide appropriate follow-up based on timeof discharge and risk assessment.

10. Treat newborns, when indicated, withphototherapy or exchange transfusion.



Risk assessment and

follow up will preventdisasters



We need to assess

jaundice risks the waywe assess other risks



Risk Assessment

Do this on every baby

Risk factors and/or measure TcB or TSB

Best to use both



Risk Factors for Developing

Hyperbilrubinemia

TSB or TCB >75%

Jaundice <24hr or before discharge ABO with +ve DAT or other hemolytic disease(G6PD)

Gestation <39wk

Previous sibling jaundiced

Cephalhematoma or bruising (vacuum)

Exclusive breastfeeding

East Asian

Male

Discharge <72hr



Predictive Ability of a

Predischarge Hour-specific SerumBilirubin for Subsequent

Significant Hyperbilirubinemia inHealthy Term and Near-Term

Newborns

Bhutani VK, Johnson L, Sivieri EM.

Pediatrics 1999;103:6-14



Newman Arch Ped Adolesc Med 2005;159:113





Predischarge Bilirubin Levels and

Risk of Subsequent Hyperbilirubinemia

TSB after dischargeTSB before discharge

126 (4.4%)2840TOTAL

68/172 (39.5%)

46/356 (12.9%)

12/556 (2.15%)

0/1756

172 (6.1%)

356 (12.5%)

556 (19.6%)

1756 (61.8%)*

95th

76th – 95th

40th – 75th

< 40th

> 95th percentileNPercentile

* Newborn TSB were obtained between 18 and 72 hours and 61.8%

of all values obtained were below the 40th percentile.

Bhutani, et al. Pediatrics 1999;103:6-14.

Gi Ph i i th T l t



Give Physicians the Tools to

Implement the Guidelines

Risk assessment tool at bedside



Predischarge Assessment for the Risk of Hyperbilirubinemia in

Infants >35 wk Gestation (Pediatrics 2004;114:257-313)

Postnatal Age (hours)

0 12 24 36 48 60 72 84 96 108 120 132 144

S e r u m B

i l i r u b i n ( m g / d l )

0

5

10

15

20

25

H i g h I n

t e r m e d i a

t e R i s k

Z o n e

L o w I n t

e r m e d i a

t e R i s k

Z o n e

95 th%ile

75th

%ile

40th

%ile

High Risk Zone

Low Risk Zone

*The more risk factors present, the greater the risk of developing severe hyperbilirubinemia

Follow-up should be provided as follows

Any infant discharged before age 72 hours should be seen

within 2 days of discharge.

* If an infant is discharged before age 72 hours AND if you plan to follow up in more than 2 days, please document your reasons in the chart .

**If considering phototherapy or exchange transfusion please refer to the back of this page for guidelines and information.

Date Time Age

(hrs)

TcB TS

B

Initials

TcB – Transcutaneous Bilirubin

TSB – Total Serum Biilirubin/Direct

Risk Factors for Development of Severe Hyperbilirubinemia

Risk Factors Major Risk 3 Minor Risk3

Decreased Risk3

Predischarge TSB or

TcB

(see nomogram above)

In high zone (>95%) In high intermediate zone

(>75%)

Low risk zone (<40%)

Visible Jaundice First 24 hrs. Before dischargeGestational age 35-36 wks 37-38 wks. >41 wk

Previous sibling Received phototherapy Jaundiced, no phototherapy

Blood Groups

Hemolytic disease

Blood grp. incompatibility with

+DAT. Other known hemolytic

disease (eg. G^PD deficiency)

Feeding Exclusive breast (↑risk if poor

feeder or ↑

wt. loss )

Breast fed, nursing well Exclusive formula

feeding.

Race East Asian Hispanic (Mexican)? African American*unless G^PD def.~12% are

G6PD deficient

Other factors Cephalhematoma or significant

bruising

Macrosomic infant of

IDM,male gender, maternal

age >25 yr.

Discharged from

hospital after 72 hrs.

Bhutani, Pediatrics1999;103:6



Implementation tools (low tech)

Wallet-sized nomogram and guidelines





Tony Burgos, MD, MPH Chris Longhurst , MD, MS Stuart Turner, DVM

Stanford University and Stanford University and University of California Davis

Packard Children’s Hospital Packard Children’s Hospital

Documents

Hiperbilrubin Aap