Sixteen Clinical Questions Were Generated by the Committee

Clinical QuestionCSW Recommendation(s) and Evidence Rating
1What are admission criteria for the inpatient unit and ICU?There is no evidence to guide a recommendation. Established AAP thresholds should continue to be used to determine the need for floor admission for phototherapy or ICU admission for exchange transfusion.
Criteria for automatic admission to the ICU:
 1. signs of acute bilirubin encephalopathy;
 2. bilirubin >5 mg/dL above the exchange level (AAP definition);
 3. sepsis or ill-appearing (E).
2What are consultation criteria for ICU?Consult neonatology to discuss any patient with 1 or more of the following:
 1. a bilirubin level above exchange level (to discuss the need to order appropriate blood products for possible exchange transfusion);
 2. a bilirubin level remaining above the exchange level after 4 h of intensive phototherapy;
 3. gestational age at birth of <35 wk;
 4. an infant <24 h of age;
 5. patients with immune-mediated hemolysis for consideration of IV immunoglobulin use; and
 6. the presence of questions regarding management of hyperbilirubinemia (E).
3What are high-risk criteria for developing kernicterus?Identify infants with hyperbilirubinemia as being at increased risk of developing kernicterus if they have any of the following:
 1. a serum bilirubin level >20 mg/dL in infants with a gestational age of 35 wk or more;
 2. a rapidly rising bilirubin level of >0.5 mg/dL per h;
 3. clinical features of acute bilirubin encephalopathy (neurologic symptoms); or
 4. jaundice within the first 24 h of life.
Consider other risks for developing bilirubin encephalopathy, including
 1. isoimmune hemolytic disease;
 2. G6PD deficiency;
 3. asphyxia;
 4. lethargy;
 5. sepsis;
 6. acidosis; or
 7. albumin <3.0 g/dL (E).
4What are indications for IV hydration?Supplemental IVFs may be beneficial for some infants with hyperbilirubinemia and should be given to infants who are clinically dehydrated or who have a total serum bilirubin approaching the exchange transfusion level (exchange level: −2 mg/dL) or with a rapidly rising bilirubin level (>0.5 mg/dL per h).a
5What is the best nutritional management?Infants undergoing conventional phototherapy (ie, infants not near the exchange level) should not routinely be supplemented with IVF or formula.b
Interruption of phototherapy for breastfeeding up to 30 min should be encouraged. For infants undergoing intensive phototherapy (ie, near the exchange level or rapidly rising bilirubin), IVF and/or enteral feeds should be given such that phototherapy is not interrupted.c
Maternal expressed breast milk is the additional feed of choice, when available.b
For infants with bilirubin near the exchange transfusion levels, use IVFs and do not interrupt phototherapy.c
Lactation consultation support for every inpatient admission (E).
6What is the best fluid management?Offer feeds every 2 h (breast milk preferred; formula is an option if there is inadequate breast milk production) (E).
7What is the optimal rehydration strategy?Mothers should be assessed for adequate milk supply (E).
For high-risk patients, maximize the time under phototherapy (no more than 20 min out per 3 h) (E).
8What initial laboratories (diagnostic tests) are indicated?Test the following for all patients (E):
 1. total serum bilirubin and
 2. blood glucose
Additional laboratories for concern for hemolysisa:
 1. hematocrit;
 2. blood group;
 3. DAT;
 4. reticulocyte count; and
 5. G6PD (for unexplained hemolysis).
9What daily laboratories (diagnostic tests) are indicated?There are no good studies in which laboratory timing is examined. Frequencies recommended in various guidelines span a wide range. Recommendations are aimed at detecting rapidly rising bilirubin, identifying phototherapy failure, and avoiding unnecessary testing in select infants (E).
10What follow-up laboratories are indicated and with what timing?Check serum bilirubin ∼12 h after starting phototherapy or with morning laboratories.a
Check serum bilirubin at 4–6 h after starting phototherapy for the following criteria: near exchange transfusion, age <72 h, or hemolysis.a
Subsequent checks every 6–24 h as clinically indicated.a
11What intensity of phototherapy is indicated?Use LED therapy covering maximal body surface area (excluding eyes, genitalia). The adequacy of phototherapy can be documented with a bili-meter measurement ≥30 µW/cm2 per nm over multiple locations (abdomen, head, knees, etc). Fiberoptic therapy alone is not recommended.b
12What are indications for home phototherapy?Current evidence does not support the use of home phototherapy.
13When is an isolette indicated?Maintain a thermo-neutral environment.a
14What are the discharge criteria?Phototherapy may be discontinued when the bilirubin level is 50 μmol/L (3 mg/dL) below the phototherapy threshold, and the following discharge criteria are recommended:
 1. discharge once off phototherapy and otherwise well;
 2. discharge when there is no concern for ongoing hemolysis; and
 3. follow-up on day after discharge is secured.a
15What is the timing of PCP follow-up?Arrange follow-up appointment for the day after discharge (E).
16What follow-up laboratories (diagnostic tests) are indicated for rebound?Do not routinely check a rebound TSB (ie, TSB after some interval of time after phototherapy cessation) before discharge.a
  • Each question resulted in a specific recommendation that was assigned a GRADE rating. All recommendations were then translated into algorithmic format. CSW, clinical standard work; DAT, direct antiglobulin test; E, expert opinion; G6PD, glucose-6-phosphate dehydrogenase; IVF, intravenous fluid; LED, light-emitting diode; PCP, primary care physician; TSB, total serum bilirubin.

  • a Very low quality.

  • b High quality.

  • c Moderate quality.