1. Beal, Judy A. DNSc, RN, FAAN

Article Content

In August of 2022, the American Academy of Pediatrics (AAP) released updated guidance for managing neonatal hyperbilirubinemia for infants born at 35 weeks or more of gestation (Kemper et al., 2022). This new set of clinical guidelines, developed by a team of neonatologists, hospitalists, pediatricians, breastfeeding experts, and a nurse, updates and replaces the AAP (2004) clinical practice guidelines and evidence published in the 2009 follow-up commentary (Maisels et al., 2009). They are accompanied by a technical report that presents new research published from 2009 through March of 2022 that address prevention, risk assessment, monitoring, and treatment (Slaughter et al., 2022).


More than 80% of newborns experience some degree of jaundice that can cause acute bilirubin encephalopathy and kernicterus (Kemper et al., 2022). Although rare, kernicterus is a permanent disabling neurologic condition that leads to lifelong developmental impairment. It is, therefore, essential that all newborns are carefully monitored and treated and that pregnant women be screened for antierythrocyte antibodies to determine risk for hemolytic disease of their unborn and newborn infants (Bhutani et al., 2013; Kemper et al., 2022).


The technical report covers new evidence that substantiates the need for clinical guidance change. The research committee conducted two systematic reviews of randomized clinical trials and observational studies published since 2009 focused on topics not previously addressed in (Slaughter et al., 2022). The research questions were: "What are the adverse clinically detectable effects of phototherapy in newborns?" and "How effective is intravenous immune globulin (IVIG) for preventing exchange transfusion in infants with indirect hyperbilirubinemia?" (Slaughter et al., 2022, p. 40). Based on findings, the team concluded that there is limited and inconsistent evidence of risk for adverse effects of phototherapy and that IVIG may not be effective in preventing exchange transfusion. Specifically, the new evidence suggests that neurotoxicity does not occur until bilirubin concentrations are significantly above the thresholds recommended in the 2004 guidelines (Slaughter et al., 2022).


The committee recommended the phototherapy thresholds be raised by a narrow range. They made several recommendations to the risk assessment approach based on hour-by-hour bilirubin concentrations. They also covered prevention of hyperbilirubinemia that begins during pregnancy; a specific management strategy for early identification and treatment of infants with maternal antierythrocyte antibodies; promotion of breastfeeding support; closer monitoring of infants with risk factors; visual assessment of jaundice at least every 12 hours for all infants following birth up to hospital discharge; and guidelines for treatment of hyperbilirubinemia and follow-up post discharge (Kemper et al., 2022).


The guidelines stress the importance of prevention and need for clearly established policies and procedures in all hospital and birthing centers. The role of nurses was emphasized as essential in the monitoring and treatment of neonatal jaundice and the prevention of kernicterus.




American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316.


Bhutani V. K., Stark A. R., Lazzeroni L. C., Poland R., Gourley G. R., Kazmierczak S., Meloy L., Burgos A. E., Hall J. Y., Stevenson D. K.for the Initial clinical testing evaluation and risk assessment for universal screening for hyperbilirubinemia study group. (2013). Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy. The Journal of Pediatrics, 162(3), 477.e1-482.e1.[Context Link]


Kemper A. R., Newman T. B., Slaughter J. L., Maisels M. J., Watchko J. F., Downs S. M., Grout R. W., Bundy D. G., Stark A. R., Bogen D. L., Holmes A. V., Feldman-Winter L. B., Bhutani V. K., Brown S. R., Panayotti G. M. M., Okechukwu K., Rappo P. D., Russell T. L. (2022). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation (Clinical Practice Guideline Revision). Pediatrics, 150(3), e2022058859.[Context Link]


Maisels M. J., Bhutani V. K., Bogen D., Newman T. B., Stark A. R., Watchko J. F. (2009). Hyperbilirubinemia in the newborn infant >35 weeks' gestation: An update with clarifications. Pediatrics, 124(4), 1193-1198.[Context Link]


Slaughter J. L., Kemper A. R., Newman T. B. (2022). Diagnosis and management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation (Technical Report). Pediatrics, 150(3), e2022058865.[Context Link]