AAP updates guidance on hyperbilirubinemia in infants

The AAP updated its guidance on treating hyperbilirubinemia in infants.

Alex R. Kemper, MD, MPH, MS, FAAP, a practitioner in the division of primary care pediatrics at Nationwide Children’s Hospital, noted that “hyperbilirubinemia is very common.”

“Nearly all babies develop jaundice at some point early in life,” Kemper, who co-authored the new guidance and a technical report, told Healio. “Most babies do well, but some babies get very high levels of bilirubin, and that can lead to kernicterus, which is a permanent, seriously disabling neurologic outcome. The issue is figuring out which babies need careful monitoring, and which babies need treatment to prevent kernicterus.”

The AAP developed guidance for the management of hyperbilirubinemia in 2004, but aside from a 2009 commentary, had not updated them.

“It was time to take a look and see what could be clarified, and where the options were to strengthen the guideline to help pediatricians and other child health care providers, as well as to improve the safety and effectiveness of the care that we provide to these newborns,” Kemper said.

One new recommendation suggests bilirubin screening for all babies prior to discharge, either through a blood test or a through a transcutaneous device.

“If you have that information, it can really help guide the kind of follow-up care that you provide to that baby,” Kemper said.

The revised guidance also introduces a slightly increased threshold for when phototherapy, a common treatment for hyperbilirubinemia, or an exchange transfusion is needed.

The guidance examined other interventions that can be used for babies with very high bilirubin levels, including phototherapy, or the application of a light with a special frequency and intensity to the skin, or an exchange transfusion, which replaces a baby’s blood to lower the bilirubin level. Because research published in the years since the original guidance suggests bilirubin does not cause toxicity unless it reaches levels higher than previously thought, the revised clinical guideline raises phototherapy and exchange transfusion thresholds by a narrow range.

“What we've learned over the years since the 2004 guidelines is that it's safe to have the levels of bilirubin go up a little bit higher than then was in the previous guidelines,” Kemper said. “So it decreases the number of babies that need to be treated.”

Another change in the guidance, Kemper added, involves properly educating parents and families on the importance of bilirubin levels.

“When babies are discharged from the hospital, there [has to be] a clear plan to have a follow-up and retesting if it's warranted, based on the bilirubin level at the time of discharge,” Kemper said.

“The key thing, I think, for people to understand is that jaundice is common,” Kemper continued. “Most babies won't get the kind of high levels that could lead to chronic issues. But because kernicterus is really such a such a bad outcome, we need to remain vigilant and we can't let our guard down. The goal of the new guidelines [was] to help target care to really help those babies at high risk.”

References:

Slaughter J, et al. Pediatrics. 2022;doi:10.1542/peds.2022-058865.