Visual Estimation of TSB ConcentrationsĪ joint recommendation from the North American and European Societies for Pediatric Gastroenterology, Hepatology, and Nutrition defines a direct serum bilirubin concentration >1.0 mg/dL as abnormal, 78 whereas a cutoff of ≥0.3 mg/dL has been used for conjugated bilirubin. Although there were insufficient data for the committee to recommend measuring the albumin concentration of all newborn infants, measuring albumin is recommended as part of escalation of care. To address those gaps, these guidelines consider an albumin concentration <3.0 g/dL to be a hyperbilirubinemia neurotoxicity risk factor ( Table 2). 44, 45 Most clinical laboratories cannot directly measure unbound bilirubin concentrations, and even if this information were available, there are insufficient data to guide clinical care using specific unbound bilirubin concentrations. Low serum albumin can increase the risk of neurotoxicity because of the greater availability of unbound bilirubin (ie, bilirubin not bound to albumin). Other important neurotoxicity risk factors are related to serious illness in the newborn infant (eg, sepsis). Although it is not clear if hemolysis attributable to causes other than isoimmunization also increases the risk of bilirubin neurotoxicity, it is prudent to assume that it does. Lower gestational age and isoimmune hemolytic disease are risk factors both for developing significant hyperbilirubinemia and for bilirubin neurotoxicity. 13 One study found that 28 days after birth, 34% of predominantly breastfed infants had TcB concentrations ≥5 mg/dL, 9% had concentrations ≥10 mg/dL, and 1% had concentrations ≥12.9 mg/dL. 13 In contrast to suboptimal intake, hyperbilirubinemia that persists with adequate human milk intake and weight gain is referred to as “breast milk jaundice” or the “breast milk jaundice syndrome.” This cause of prolonged unconjugated hyperbilirubinemia, which can last up to 3 months, is almost always nonpathologic and not associated with direct or conjugated hyperbilirubinemia. ![]() 17 Low milk and low caloric intake contribute to decreased stool frequency and increased enterohepatic circulation of bilirubin. Because this type of jaundice, especially when excessive, is almost always associated with inadequate milk intake rather than breastfeeding per se, it is more correctly described as “suboptimal intake hyperbilirubinemia.” 13 Breastfeeding fewer than 8 times per day has been associated with higher TSB concentrations. Suboptimal intake can lead to hyperbilirubinemia, the so-called “breastfeeding jaundice,” which typically peaks on days 3 to 5 after birth and is frequently associated with excess weight loss. These types of jaundice must be differentiated to guide appropriate management. 13 Jaundice in breastfed infants falls into 2 main categories, depending on its timing of onset. Prevention of HyperbilirubinemiaĮxclusive breastfeeding and hyperbilirubinemia are strongly associated. The committee also used new research findings to revise the risk-assessment approach based on the hour-specific bilirubin concentration and the approach to rapidly address elevated bilirubin concentrations, defined as “escalation of care.” I. On the basis of an evaluation of evidence published since 2004, the committee raised the phototherapy thresholds by a narrow range that the committee considered to be safe. 13 Because the new evidence is insufficient to derive specific treatment thresholds by quantitatively estimating the risks and benefits of different approaches to care, the committee began with the previous AAP guidelines. 11 In addition, the committee reviewed guidelines from the Northern California Neonatal Consortium 12 and the Academy of Breastfeeding Medicine. ![]() Key new research findings appear in the evidence tables included in Appendix B and in the accompanying technical report. Since the publication of the previous guideline, the evidence base regarding the monitoring and treatment of hyperbilirubinemia has expanded.
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