The American Academy of Pediatrics Subcommittee on Hyperbilirubinemia acknowledged the fact that there is no standard for discontinuing phototherapy.1 For infants who are readmitted after birth, it recommends that phototherapy may be discontinued when the total serum bilirubin level (TSB) falls to <13 to 14 mg/dL (239–239 μmol/L).1
On the basis of a huge cohort of newborns treated for hyperbilirubinemia, Chang et al2 thankfully provided an evidence-based prediction tool (score) to help clinicians decide when to stop phototherapy in birth-hospitalized infants with rebound hyperbilirubinemia to avoid readmission and retreatment.
However, applying this prediction score (Score = 15 [if gestational age <38 weeks] − 7 × [age in days at phototherapy initiation] − 4 × [AAP phototherapy threshold (TSBth)] – total serum bilirubin at phototherapy termination [TSBtm] + 50) is only sensible in newborns that need phototherapy within the first 4 to 5 days of life.
This is because when applying the score for a mature infant on its sixth day of life with an initial TSB of 20 mg/dL, the rebound likelihood according to the Chang score would be 0 when the TSB came only down to 18 mg/dL (50 – [7 × 6] − 4 × [20 mg/dL – 18 mg/dL] = 50 −  − 8 = 0). From the seventh day onward, virtually no more phototherapy would be necessary at all, irrespective of the bilirubin levels.
In the case of the recent 100 mature newborns referred to our communal children’s hospital in Cologne, Germany, for treatment of hyperbilirubinemia, 35.2% of infants were ≥6 days of age.
Most of these ≥6 days of age infants were breastfed, with huge problems in the initiation of the nursing management in combination with weakness of drinking, which was documented in the weight loss (up to 15% of the birth weight) in these infants.
In our experience, a sufficient milk supply is essential in an effective therapy of hyperbilirubinemia, and it is necessary to apply the Chang rule even in the first days of life.
In summary, I want to emphasize that Chang’s score is only helpful to decide when to terminate a first phototherapy within the first 4 to 5 days of life and, importantly, only if a safe milk supply is established.
CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
- ↵American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297–316
- Chang PW,
- Kuzniewicz MW,
- McCulloch CE,
- Newman TB
- Copyright © 2017 by the American Academy of Pediatrics