Subject: Management of Hyperbilirubinemia in Healthy Term Newborns

POLICY:         All infants who present to the center with hyperbilirubinemia will be properly assessed to rule out the need for follow up and or referral to pediatric care.

DEFINITION: Hyperbilirubinemia is one of the most common problems encountered in term newborns that are otherwise healthy. Neonatal hyperbilirubinemia is defined as a total serum bilirubin level above 5 mg per dL.  Up to 60% of term newborns will present with clinincal jaundice, few have underlying disease.  However, few babies with jaundice in the newborn period can have severe illnesses such as hemolytic disease, metabolic and/or endocrine disorders, liver disorders, and infections.

                     Most commonly, neonatal jaundice is considered to be physiologic. Physiologic jaundice in healthy term newborns follows a typical pattern.  The total serum bilirubin level usually peaks at 5-6 mg per dL on the third or fourth day of life, then declines over the first week after birth. Higher levels of total unconjugated bilirubin may occur and are defined as early-onset exaggerated physiologic jaundice, and the level may be as high as 12 mg per dL to 17mg per dL.

                     Breast milk jaundice may occur as well, although not as commonly.  Breast-fed infants may be at increased risk for early onset jaundice because of caloric deprivation in the first few days of life before maternal milk comes in.  Due to decreased volume of milk and frequency of feeds may result in mild dehydration and slow passage of meconium.  Compared with formula fed babies, breast-fed babies are 3-6 times more likely to develop moderate jaundice (total bilirubin level above 12 mg per dL), or severe jaundice (total serum bilirubin level above 15 mg per dL).

                     Jaundice is considered pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by more than 5mg per dL per day or is higher than 17 mg per dL, or an infant has signs or symptoms suggestive of illness.

Risk Factors for Jaundice in Newborns:

        Maternal Factors                              

·         Blood type ABO or Rh                         

incompatibility

·         Breastfeeding

·         Drugs (oxytocin)

·         Ethnicity (Asian, Native American)

·         Maternal illness

·         Gestational diabetes

Neonatal Factors

·          Birth Trauma, bruising

·         Excessive weight loss after birth

·         Infections (TORCH)

·         Infrequent feedings, trouble breastfeeding

·         Male gender

·         Polycythemia

·         Prematurity

·         Previous sibling with jaundice

PROCEDURE: 1.  Physical Examination

1.   Examine infant in well lit area ie: infant warmer under light source. Infants will be examined for jaundice immediately following birth and at the 48 hour visit.

2.   Blanch skin with digital pressure to reveal color of skin and subcutaneous tissue (jaundice is not noticeable at a total serum bilirubin level below 4 mg per dL)

3.   Increasing serum bilirubin levels are accompanied by the progression of jaundice from the face to the trunk and extremities, and finally to soles of feet.

4.   Total serum bilirubin levels can be estimated reliably if the jaundice is above the nipple line only.  It can be estimated by the degree of caudal extension. As jaundice extends below the middle of the chest, correlation between physical signs and measured bilirubin levels becomes unreliable.

5.   Total serum bilirubin levels can be estimated clinically by the degree of caudal extension, although that may be unreliable. Face, 5mg per dL; upper chest, 10 mg per dL; abdomen, 12 mg per dL; palms and soles, greater than 15 mg per dL.  

6.   Infant should be assessed for: pallor, petechiae, bleeding, bruising, abdominal swelling, weight loss, and evidence of dehydration.

7.   Consider possible risk factors for pathologic jaundice.

2. Laboratory Evaluation

1.   Any infant with jaundice that extends beyond the upper chest/ nipple line may have a pediatric bilirubin panel drawn and submitted to lab, with a STAT request.

2.   The nomogram for hyperbilirubinemia in neonates will be used to classify the total serum bilirubin result as: low, intermediate, or high.  (Bhutani VK, et al, 1999)

3.    Any infant with a total serum bilirubin level that falls in the High-Intermediate Risk Zone at any point, they will be referred to their pediatrician for evaluation and follow-up care.

·         At 48 hour visit, the total serum bilirubin should be below 11 mg per dL.

·         If a higher result is noted, the infant will be referred to the pediatrician immediately.