Connections: Being more judicious with newborn jaundice | Winter 2020

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From the OHSU Doernbecher Children's Hospital

Eliza Hayes Bakken headshot

Eliza Hayes Bakken, M.D.

Dr Bakken is medical director of the OHSU Doernbecher General Pediatric Clinic and a board-certified lactation consultant. Her focus is newborn medicine, clinical quality improvement and systems change.

Less light is often right when it comes to neonatal hyperbilirubinemia. Studies show that kernicterus and other complications from hyperbilirubinemia are very rare, yet current national guidelines have led to larger numbers of babies getting phototherapy.

At OHSU Doernbecher, we have recently adopted the evidence-based Northern California Neonatal Consortium phototherapy guidelines, which recommend treatment thresholds for hyperbilirubinemia at higher levels than the current American Academy of Pediatrics guidelines.

The AAP last issued phototherapy guidelines for neonatal hyperbilirubinemia in 2004, recommending all infants receive systematic assessment for hyperbilirubinemia before discharge from the hospital.

Since then, studies show that these guidelines and recommendations have successfully reduced bilirubin levels in general and resulted in fewer babies needing exchange transfusion. However, studies show that implementation of these guidelines has also led to larger numbers of infants receiving phototherapy even if they hadn’t crossed the AAP thresholds.

At OHSU Doernbecher, we believe the evidence supports us in safely doing less phototherapy intervention and balancing the benefits and potential harms for lower-risk babies.

Research is underway to determine what the potential harms of phototherapy may include, but we know that hospital readmission is very stressful and takes a toll on families. Two studies have shown an increased risk of developing a seizure disorder in male babies exposed to phototherapy. Researchers are also looking to see if there are links to DNA damage and increased risk of cancer from neonatal exposure to phototherapy.

The AAP will likely update the guidelines in the near future, and it appears conclusive that the recommended bilirubin thresholds for phototherapy will go up. We believe that we do not need to wait for these new guidelines, and we can safely intervene less often right now. The NCNC guidelines can be found here.

Doernbecher teams are happy to consult for any infant with hyperbilirubinemia and discuss options for treatment. Admission may be warranted below NCNC thresholds if other concerns exist, such as poor feeding or concern for infection. In general, our teams will not use phototherapy until or unless serum bilirubin approaches NCNC guideline thresholds.

When to refer

  • Babies with hyperbilirubinemia.
  • Babies with excessive weight loss, feeding concerns or concerns for infection.
  • Babies with risk factors for kernicterus, including hemolysis or sepsis.

Phototherapy thresholds: basic recommendations

Identify neurotoxicity risk factors

  • Isoimmune hemolytic disease, G6PD deficiency or other hemolytic disease
  • Sepsis or suspected sepsis (sufficient to be currently on antibiotics)
  • Acidosis (BE −8 meq/L or pCO2 >50 mmHg within the last 24 hours)
  • Albumin <3.0 mg/dL
  • Any clinical instability

TsB within 1-2 mg/dL below NCNC phototherapy threshold = CONSIDER PHOTOTHERAPY

  • Optimize feeding (breastfeeding support, supplement, formula, etc.)
  • Repeat TsB @ 4-24 hours (before discharge if during birth admission)
  • Consider phototherapy (including home phototherapy if available)

NOTE: NCNC threshold to initiate phototherapy is lower for younger gestational ages, rapid rate of rise, or neurotoxicity risk factors (i.e., “medium risk” or “higher risk” infants)

TsB ≥ NCNC threshold = PERFORM PHOTOTHERAPY

  • Start phototherapy
  • Optimize feeding (as above)

If there is suspicion for hemolysis or other underlying causes of hyperbilirubinemia (G6PD, sepsis, etc), it is appropriate to start phototherapy at the threshold for newborns with neurotoxicity risk factors and proceed with an appropriate work up for those causes.

Contact us

OHSU Doernbecher Children’s Hospital specialists are always happy to speak with you.

Please call the OHSU Physician Advice and Referral Service at 888-346-0644 with questions.

To refer a patient, please fax to 503-346-6854.