According to recommendation 2.2 of the AAP Clinical Practice Guideline (76), “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 12 hours.” Recommendation 2.2.1 states that “protocols for the assessment of jaundice should include the circumstances in which nursing staff can obtain a TcB or order a TSB measurement.” Nursing staff have always assumed the responsibility for monitoring infants for jaundice but, for the first time, hospitals are now asked to develop protocols under which nurses can obtain a TcB or TSB without a physician order. Thus a nurse who notices jaundice in an infant who is younger than 24 hours old, will obtain a TcB or TSB and notify the physician of the result. If a TcB measurement is used as a screening tool, TSB measurements can be obtained by nurses whenever the TcB measurement is above a certain bilirubin percentile (see Fig. 35-20 and Noninvasive Measurements of Bilirubin above).

Recommendation 5.1 of the AAP Clinical Practice Guideline (76) states: “Before discharge, every newborn should be assessed for the risk of developing severe hyperbilirubinemia, and all nurseries should establish protocols for assessing this risk. Such assessment is particularly important in infants who are discharged before age 72 hours.” The guideline continues, “The AAP recommends 2 clinical options used individually or in combination for the systematic assessment of risk: predischarge measurement of the bilirubin level using TSB or TcB and/or assessment of clinical risk factors” (76). This must be followed by appropriate evaluation, monitoring, surveillance, and followup to ensure that severe hyperbilirubinemia is identified early and treated appropriately.

Table 35-26 lists the risk factors for the development of hyperbilirubinemia. Almost all of these factors can be identified readily without recourse to the laboratory but, because these risk factors are common and the risk of severe hyperbilirubinemia is small, individually, these factors are of limited use as predictors of severe hyperbilirubinemia. Nevertheless, if no risk factors are present, the risk of severe hyperbilirubinemia is extremely low, and the more risk factors that are present, the greater the risk of severe hyperbilirubinemia (206). Some factors, such as breast-feeding, gestation age below 38 weeks, and significant jaundice (need for phototherapy) in a previous sibling, seem to be particularly important. It is remarkable that almost every recently described case of kernicterus occurred in a breast-fed infant, even when the infant had underlying G6PD deficiency (124,133,328,390).