Prevention, Identification, and Management of Neonatal Hyperbilirubinemia
The Approach to a Jaundiced Infant
The Institute of Medicine (IOM) issued a report in 2001 that describes a “chasm in health care quality” which needs to be crossed for patients to receive better care (414). The report calls for a “systems approach” drawing on the rapid evolution of knowledge about complex adaptive systems. The IOM report offers 10 “simple rules” to “redesign and improve care” (414) Palmer and associates (415) studied the care of newborns with hyperbilirubinemia in two large managed care organizations and describe how this care might be improved by using practical applications of the ideas about complex adaptive systems.
The recently published guideline of the AAP provides an approach to the evaluation and treatment of hyperbilirubinemia in the term and near-term newborn ≥35 weeks of gestation (76). Although bilirubin encephalopathy or kernicterus should almost always be preventable, it is still occurring in this group of infants. Table 35-24 lists the key elements of the recommendations provided in the AAP guideline. The discussion that follows deals primarily with infants ≥35 weeks of gestation, although the basic principles apply to the evaluation and management of hyperbilirubinemia in all infants.
Primary Prevention
Prenatal Testing
Screening for Isoimmunization
All pregnant women should be tested for ABO and Rh (D) typing and undergo a serum screen for unusual isoimmune antibodies (76). If such prenatal testing has not been performed, then a direct Coombs test, a blood type, and an Rh (D) type on the infant’s cord blood should be done; this should always be done if the mother is Rh-negative. In addition to identification of potentially Rh-sensitized infants, this testing is obligatory because it identifies Rh-negative mothers who require anti-D gammaglobulin to prevent Rh (D) sensitization.
In infants of group O, Rh-positive mothers, the AAP recommends that routine testing for blood type and Coombs test is optional “provided there is appropriate surveillance
and risk assessment before discharge and followup (76) so that significantly jaundiced infants are not missed.” (See ABO Hemolytic Disease above.)
and risk assessment before discharge and followup (76) so that significantly jaundiced infants are not missed.” (See ABO Hemolytic Disease above.)
TABLE 35-24 KEY ELEMENTS OF THE AMERICAN ACADEMY OF PEDIATRICS GUIDELINE ON MANAGEMENT OF HYPERBILIRUBINEMIA IN THE NEWBORN INFANT ≥35 WEEKS OF GESTATION | ||
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Preventing Hyperbilirubinemia
To prevent severe hyperbilirubinemia, we need to (a) identify infants who are at risk for developing hyperbilirubinemia, (b) follow them closely, and (c) treat them with phototherapy when indicated.
Ensuring Successful Breast-feeding.
Because exclusively breast-feeding an infant is strongly associated with an increased risk of hyperbilirubinemia (see Breast-Feeding and Jaundice above), the only primary preventive intervention available to us is to ensure the adequacy and success of breast-feeding. In many, but not all, cases of severe hyperbilirubinemia in breast-fed infants, poor caloric intake associated with inadequate breast-feeding (and manifested by increased weight loss) appears to play an important role (218,246,254,390). Exclusively breast-feeding an infant is also a well documented risk factor for dehydration (416), considered by some to be a cause of hyperbilirubinemia, although there is no plausible mechanism for this. It is much more likely that in breast-fed, dehydrated infants, it is the caloric deprivation and its effect on the enterohepatic circulation of bilirubin (see Table 35-14) that is primarily responsible for the severe hyperbilirubinemia (244).
Thus, the clinician’s primary role in preventing hyperbilirubinemia is to help ensure that breast-feeding will be successful. The first step is to ask mothers to nurse their infants at least 8 to 12 times per day for the first several days (417), because increasing the frequency of nursing significantly decreases the likelihood of subsequent hyperbilirubinemia (251,252,409). Evidence of adequate intake in breast-fed infants also includes 4 to 6 thoroughly wet diapers within 24 hours and the passage of 3 to 4 stools per day by the fourth day. By the third to fourth day, the stools in adequately breast-fed infants should have changed from meconium to a mustard yellow, mushy stool (418). Weight loss must also be monitored. Unsupplemented breast-fed infants experience their maximum weight loss by day 3 and, on average, lose 6.1 ±2.5% (SD) of their birth weight (243,246,251,261,419,420,421 and 422). Thus, approximately 5% to 10% of exclusively breast-fed infants lose 10% or more of their birth weight by day 3, suggesting that adequacy of intake should be evaluated and the infant monitored if weight loss is greater than 10% (423). These assessments will also help to identify breast-fed infants who, because of inadequate intake, are at risk for dehydration.
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