Management of Hyperbilirubinemia in the Newborn Infant 3. More Weeks of Gestation . Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment. Although kernicterus should almost always be preventable, cases continue to occur. These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 3. In every infant, we recommend that clinicians 1) promote and support successful breastfeeding; 2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia; 3) provide early and focused follow- up based on the risk assessment; and 4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus). BACKGROUNDIn October 1.
Background We conducted a randomized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal. We handle a wide range of commodities and package designs. Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia of the American Academy of Pediatrics (AAP) produced a practice parameter dealing with the management of hyperbilirubinemia in the healthy term newborn. The current guideline represents a consensus of the committee charged by the AAP with reviewing and updating the existing guideline and is based on a careful review of the evidence, including a comprehensive literature review by the New England Medical Center Evidence- Based Practice Center. See “An Evidence- Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia”3 for a description of the methodology, questions addressed, and conclusions of this report.) This guideline is intended for use by hospitals and pediatricians, neonatologists, family physicians, physician assistants, and advanced practice nurses who treat newborn infants in the hospital and as outpatients. A list of frequently asked questions and answers for parents is available in English and Spanish at www. DEFINITION OF RECOMMENDATIONSThe evidence- based approach to guideline development requires that the evidence in support of a policy be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. Evidence- based recommendations are based on the quality of evidence and the balance of benefits and harms that is anticipated when the recommendation is followed. This guideline uses the definitions for quality of evidence and balance of benefits and harms established by the AAP Steering Committee on Quality Improvement Management. See Appendix 1 for these definitions. The draft practice guideline underwent extensive peer review by committees and sections within the AAP, outside organizations, and other individuals identified by the subcommittee as experts in the field. Liaison representatives to the subcommittee were invited to distribute the draft to other representatives and committees within their specialty organizations. The resulting comments were reviewed by the subcommittee and, when appropriate, incorporated into the guideline. BILIRUBIN ENCEPHALOPATHY AND KERNICTERUSAlthough originally a pathologic diagnosis characterized by bilirubin staining of the brainstem nuclei and cerebellum, the term “kernicterus” has come to be used interchangeably with both the acute and chronic findings of bilirubin encephalopathy. Bilirubin encephalopathy describes the clinical central nervous system findings caused by bilirubin toxicity to the basal ganglia and various brainstem nuclei. To avoid confusion and encourage greater consistency in the literature, the committee recommends that in infants the term “acute bilirubin encephalopathy” be used to describe the acute manifestations of bilirubin toxicity seen in the first weeks after birth and that the term “kernicterus” be reserved for the chronic and permanent clinical sequelae of bilirubin toxicity. See Appendix 1 for the clinical manifestations of acute bilirubin encephalopathy and kernicterus. FOCUS OF GUIDELINEThe overall aim of this guideline is to promote an approach that will reduce the frequency of severe neonatal hyperbilirubinemia and bilirubin encephalopathy and minimize the risk of unintended harm such as increased anxiety, decreased breastfeeding, or unnecessary treatment for the general population and excessive cost and waste. Recent reports of kernicterus indicate that this condition, although rare, is still occurring. Analysis of these reported cases of kernicterus suggests that if health care personnel follow the recommendations listed in this guideline, kernicterus would be largely preventable. These guidelines emphasize the importance of universal systematic assessment for the risk of severe hyperbilirubinemia, close follow- up, and prompt intervention when indicated. The recommendations apply to the care of infants at 3. These recommendations seek to further the aims defined by the Institute of Medicine as appropriate for health care: 1. They specifically emphasize the principles of patient safety and the key role of timeliness of interventions to prevent adverse outcomes resulting from neonatal hyperbilirubinemia. The following are the key elements of the recommendations provided by this guideline. Clinicians should: Promote and support successful breastfeeding. Establish nursery protocols for the identification and evaluation of hyperbilirubinemia. Measure the total serum bilirubin (TSB) or transcutaneous bilirubin (Tc. B) level on infants jaundiced in the first 2. Recognize that visual estimation of the degree of jaundice can lead to errors, particularly in darkly pigmented infants. Interpret all bilirubin levels according to the infant’s age in hours. Recognize that infants at less than 3. Perform a systematic assessment on all infants before discharge for the risk of severe hyperbilirubinemia. Provide parents with written and verbal information about newborn jaundice. Provide appropriate follow- up based on the time of discharge and the risk assessment. Treat newborns, when indicated, with phototherapy or exchange transfusion. PRIMARY PREVENTIONIn numerous policy statements, the AAP recommends breastfeeding for all healthy term and near- term newborns. This guideline strongly supports this general recommendation. RECOMMENDATION 1. Clinicians should advise mothers to nurse their infants at least 8 to 1. C: benefits exceed harms). Poor caloric intake and/or dehydration associated with inadequate breastfeeding may contribute to the development of hyperbilirubinemia. Increasing the frequency of nursing decreases the likelihood of subsequent significant hyperbilirubinemia in breastfed infants. Providing appropriate support and advice to breastfeeding mothers increases the likelihood that breastfeeding will be successful. Additional information on how to assess the adequacy of intake in a breastfed newborn is provided in Appendix 1. RECOMMENDATION 1. The AAP recommends against routine supplementation of nondehydrated breastfed infants with water or dextrose water (evidence quality B and C: harms exceed benefits). Supplementation with water or dextrose water will not prevent hyperbilirubinemia or decrease TSB levels. SECONDARY PREVENTIONRECOMMENDATION 2. Clinicians should perform ongoing systematic assessments during the neonatal period for the risk of an infant developing severe hyperbilirubinemia. Blood Typing. RECOMMENDATION 2. All pregnant women should be tested for ABO and Rh (D) blood types and have a serum screen for unusual isoimmune antibodies (evidence quality B: benefits exceed harms). RECOMMENDATION 2. If a mother has not had prenatal blood grouping or is Rh- negative, a direct antibody test (or Coombs’ test), blood type, and an Rh (D) type on the infant’s (cord) blood are strongly recommended (evidence quality B: benefits exceed harms). RECOMMENDATION 2. If the maternal blood is group O, Rh- positive, it is an option to test the cord blood for the infant’s blood type and direct antibody test, but it is not required provided that there is appropriate surveillance, risk assessment before discharge, and follow- up. C: benefits exceed harms). Clinical Assessment. RECOMMENDATION 2. Clinicians should ensure that all infants are routinely monitored for the development of jaundice, and nurseries should have established protocols for the assessment of jaundice. Jaundice should be assessed whenever the infant’s vital signs are measured but no less than every 8 to 1. D: benefits versus harms exceptional). In newborn infants, jaundice can be detected by blanching the skin with digital pressure, revealing the underlying color of the skin and subcutaneous tissue. The assessment of jaundice must be performed in a well- lit room or, preferably, in daylight at a window. Jaundice is usually seen first in the face and progresses caudally to the trunk and extremities,2. In most infants with TSB levels of less than 1. L (2. 57 . The need for and timing of a repeat Tc. B or TSB measurement will depend on the zone in which the TSB falls (Fig 2),2. Recommendations for TSB measurements after the age of 2. Fig 1 and Table 1. Fig 1. Algorithm for the management of jaundice in the newborn nursery. Fig 2. Nomogram for designation of risk in 2. The serum bilirubin level was obtained before discharge, and the zone in which the value fell predicted the likelihood of a subsequent bilirubin level exceeding the 9. Appendix 1, Table 4. Used with permission from Bhutani et al. See Appendix 1 for additional information about this nomogram, which should not be used to represent the natural history of neonatal hyperbilirubinemia. Infant Discharged. Should Be Seen by Age. Before age 2. 4 h. Between 2. 4 and 4. Between 4. 8 and 7.
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