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American Academy of Pediatrics guideline: increase thresholds for light therapy
Clinical Question
What are the recommendations from the American Academy of Pediatrics regarding the management of newborns with hyperbilirubinemia?
Bottom line
With 80% of infants exhibiting some jaundice at birth, your hospital should change their thresholds for measuring and treating it based on these guidelines. The American Academy of Pediatrics has raised the thresholds for treating elevated bilirubin in newborns born at 35 weeks' or later. The determination should be based on gestational age, hours since birth, and total serum bilirubin. The group points out that there is no evidence that light therapy affects subtle adverse neurodevelopmental findings and there is a small increased risk of epilepsy associated with light therapy. Oddly, the group never considered whether treatment of hyperbilirubinemia prevents the development of kernicterus. 5
Reference
Study design: Practice guideline
Funding: Foundation
Setting: Various (guideline)
Synopsis
This guideline revises the guidelines from the group last published in 2004, citing new evidence that the risk of kernicterus (bilirubin toxicity) occurs at much higher thresholds than previous thought. The guideline focused on patient-oriented outcomes — the development of kernicterus and the risk of side effects with phototherapy — and provides clear guidance. The guidelines are based on expert consensus following interpretation of a technical report. The guideline development committee comprised a number of stakeholders, including patients, or, rather, their parents. There were minimal conflicts of interest among committee members. The group continues to recommend prevention of hemolytic disease by screening for Rh incompatibility. Even though exclusive breastfeeding is associated with hyperbilirubinemia, the group recommends against supplementing feeding with water to prevent or treat elevated levels (strong recommendation). The guideline suggests visual assessment for jaundice and using total serum bilirubin testing in infants noted to be jaundiced in the first 24 hours (strong recommendation). After the first 24 hours, either serum or transcutaneous bilirubin determinations can be used for evaluation, though treatment decisions should be based only on serum levels. Phototherapy treatment decisions should be based on total serum bilirubin, gestational age, and hours since birth, and the thresholds are quite a bit higher than in previous guidelines. For example, in 40-week gestational age infants at 24 hours, the threshold for treatment is 13.5 mg/dL as compared with 11.5 mg/dL in previous guidance (expert opinion). Thresholds get dramatically higher quickly in the first few days after birth. Home light therapy is an option, with daily serum bilirubin monitoring (option).
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
incr light therapy thresholds for hyperbili at birth
no indication of any longterm complications