Skylife Webinar

2022 AAP Guidance for Managing Neonatal Hyperbilirubinemia a Review

Dr. Jessica Madden delivers a comprehensive review of the 2022 AAP Guidance for Managing Neonatal Hyperbilirubinemia. Jessica Madden, MD completed her pediatric residency at the University of Massachusetts and her neonatology fellowship at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. She is a longstanding member of both the American Academy of Pediatrics and the Academy of Breastfeeding Medicine and is a former Clinical Instructor of Pediatrics at Harvard Medical School. At the time of this webinar, she was an Assistant Professor of Pediatrics at Case Western Reserve University’s School of Medicine.

Webinar Transcript


00:00:01 Kim Vittorio

It is with immense pleasure and my privilege to welcome the presenter of our webinar today, Doctor Jessica Madden.

00:00:08 Kim Vittorio

Doctor Madden is a board-certified neonatologist, pediatrician and lactation consultant who is passionate about breastfeeding, medicine, perinatal mental disorders, 4th trimester mother, baby care and the neurodevelopmental follow-up of premature babies.

00:00:26 Kim Vittorio

She founded Primrose Newborn care, a newborn medicine, and lactation home visiting service in Cleveland, OH, in 2018.

00:00:36 Kim Vittorio

Her services include newborn and infant well baby visits in the home setting, telemedicine, lactation, and breastfeeding consultations.

00:00:45 Kim Vittorio

Jaundice checks.

00:00:47 Kim Vittorio

Holistic infant feeding consultations.

00:00:50 Kim Vittorio

Nick, your second opinions in home.

00:00:52 Kim Vittorio

Nick, you follow up visit’s postpartum mental health support and house calls for minor pediatric illnesses.

00:00:59 Kim Vittorio

Doctor Madden is an assistant professor of Pediatrics at the Case Western Reserve University School of Medicine in the Division of Neonatology at Rainbow Babies and Children's Hospital, and is currently the executive Excuse Me, and is currently on the Executive Board of the Center for fourth trimester Care serving.

00:01:19 Kim Vittorio

As the advocacy Co chair.

00:01:21 Kim Vittorio

She is passionate about discussing neonatology, breastfeeding, medicine and the 4th trimester care via writing, public speaking, and acting as a consultant for patients, families, nonprofit organizations, industry, and other practitioners.

00:01:37 Kim Vittorio

So, with no further ado, I would like to hand over to Doctor Madden for today's presentation.

00:01:43 Kim Vittorio

Thanks, Doctor Maddie.

00:01:44 Dr. Jessica Madden


00:01:45 Dr. Jessica Madden


00:01:45 Dr. Jessica Madden

Thank you so much, Kim.

00:01:47 Dr. Jessica Madden

It is an honor to be here today and as Kim mentioned, I will be walking all of us through highlights of the brand-new American Academy of Pediatrics guidelines for the treatment of neonatal jaundice.

00:02:03 Dr. Jessica Madden

It is important always to just remember what hyperbilirubinemia is and why newborns are more predisposed to this.

00:02:14 Dr. Jessica Madden

So bilirubin is formed in all of our bodies from the normal breakdown of our red blood cells, they're continually recycling.

00:02:23 Dr. Jessica Madden

And we make new blood cells in our bone marrow, but our bodies must be able to excrete and get rid of our old red blood cells from our body.

00:02:32 Dr. Jessica Madden

And so essentially, jaundice is when there is a buildup of these red blood cell breakdown products in the.

00:02:39 Dr. Jessica Madden

Body or bilirubin?

00:02:41 Dr. Jessica Madden

It's very common in newborns, depends on what statistics you use, but overall about 80% of newborns will develop some degree of jaundice, which is a Billy ribbon level greater than or equal to 5 milligrams per deciliter, and phototherapy is the mainstay of jaundice.

00:03:03 Dr. Jessica Madden

There are three main reasons why newborns develop jaundice.

00:03:08 Dr. Jessica Madden

The first is that they are born with an excessive number of red blood cells from placental blood flow in utero.

00:03:15 Dr. Jessica Madden

This second is that the liver is the organ of the body that really helps to metabolize and get rid of bilirubin and newborns.

00:03:25 Dr. Jessica Madden

Livers are not fully developed or functioning until.

00:03:29 Dr. Jessica Madden

They are a couple of weeks old.

00:03:31 Dr. Jessica Madden

And the third is that another way that babies bodies get rid of bilirubin?

00:03:38 Dr. Jessica Madden

Is through the gastrointestinal tract, and specifically through stooling.

00:03:42 Dr. Jessica Madden

So the more that they stool, the more they're able to get rid of their bilirubin load.

00:03:46 Dr. Jessica Madden

However, in the early days of life, many newborns are not eating very much yet.

00:03:51 Dr. Jessica Madden

So because of that, there's a delay in their ability to get rid of bilirubin through the intestinal tract.

00:04:00 Dr. Jessica Madden

And this this is an overview, it is a schematic of the chemical structure of bilirubin, and again walking through here just the pathway is that when red blood cells are broken down by our body, there is a series of chemical reactions that leads to unconjugated bilirubin.

00:04:21 Dr. Jessica Madden

This is the type of Billy ribbon that we are discussing in newborn hyperbilirubinemia.

00:04:27 Dr. Jessica Madden

This unconjugated bilirubin is then, as we discussed, is metabolized in the liver, and is excreted from our body as conjugated bilirubin.

00:04:39 Dr. Jessica Madden

Conjugated bilirubin is water soluble because the liver and there is an addition through this pathway of extra hydrogen bonds.

00:04:48 Dr. Jessica Madden

In the bilirubin molecule.

00:04:52 Dr. Jessica Madden

So why do we care about jaundice? Mainly because we know that extremely elevated levels of bilirubin in a newborn's body can cause harm.

00:05:03 Dr. Jessica Madden

Kernicterus is brain damage that is caused by high levels of bilirubin.

00:05:09 Dr. Jessica Madden

They can cross the blood, blood, blood, brain barrier and lead to staining and damage in a specific area of the brain called the basal ganglia.

00:05:19 Dr. Jessica Madden

This problem is associated with multiple lifelong morbidities, including cerebral palsy, deafness, hypotonia, problems with vision, dental, enamel defects and intellectual disability.

00:05:36 Dr. Jessica Madden

We do know from decades of research.

00:05:39 Dr. Jessica Madden

At the risk of connector risk is highest if the newborns serum bilirubin levels are greater than 25.

00:05:48 Dr. Jessica Madden

There are two ways that we are able to measure Billy Ribbon.

00:05:52 Dr. Jessica Madden

One is the traditional method, which is through a blood draw.

00:05:57 Dr. Jessica Madden

So we take serum, total bilirubin measurements, the 2nd is transcutaneous.

00:06:03 Dr. Jessica Madden

This is the ability using specific devices to be able to measure newborns.

00:06:08 Dr. Jessica Madden

Ribbon levels through the skin. The two main bilirubin Meter is currently used for transcutaneous measurements in the United States. Are the dragger JM 105 and the Phillips Philly chef?

00:06:21 Dr. Jessica Madden

We know that if the transcutaneous, bilirubin or skin measurement is less than 15 milligrams per deciliter, there is a good correlation with the serum or blood level. However, and these new 2022.

00:06:42 Dr. Jessica Madden

AP guidelines emphasize this next statement.

00:06:45 Dr. Jessica Madden

We know that if the transcutaneous or skin bilirubin level is within three of the phototherapy thresh.

00:06:57 Dr. Jessica Madden

Or if it is greater than fifteen, it is essential that a baby get a sarin bilirubin level, so the transcutaneous is a good screen, but the decision to start phototherapy and to continue to monitor phototherapy.

00:07:13 Dr. Jessica Madden

We need blood serum levels to be able to.

00:07:15 Dr. Jessica Madden

Do so.

00:07:19 Dr. Jessica Madden

So back in 2004 is when the American Academy of Pediatrics published incredibly detailed guidelines for pediatricians and other practitioners in terms of how to manage newborn jaundice. These guidelines and subsequent, as we will see, they are geared.

00:07:38 Dr. Jessica Madden

For infants who are born at 35 weeks gestation or older, that is because the vast majority of babies who were born 35 weeks and up are cared for in newborn nurseries, at least here in the United States.

00:07:52 Dr. Jessica Madden

All newborns who are born earlier or more premature than 35 weeks are admitted to neonatal intensive care units, and different niches have quite different guidelines and algorithms that they will follow that can be make you dependent, but for the purposes of the AAP guidelines in this talk we are talking about.

00:08:13 Dr. Jessica Madden

User recommended for usage across the board.

00:08:17 Dr. Jessica Madden

In 2009, they did start to really parse out and differentiate. There was an update to the 2004 guidelines where there was a differentiation of newborns who are at risk for high for high jaundice levels versus those that are risk for both high jaundice levels and neurotoxicity or connectorized.

00:08:39 Dr. Jessica Madden

At this point, they recommended that all newborns be screened for jaundice before he discharged home from the newborn nurseries.

00:08:49 Dr. Jessica Madden

And then in 2022, just this past August, there was a total overhaul of these two thousand 04 guidelines and that is what I will be discussing from here on out.

00:09:01 Dr. Jessica Madden

Just to go back to 2004, this table two listed out all the risk factors, the reason that I am sharing this is that they had differentiated major risk factors for severe hyperbilirubinemia versus minor risk factors versus.

00:09:20 Dr. Jessica Madden

Decreased risk factors.

00:09:23 Dr. Jessica Madden

They have since taken out.

00:09:25 Dr. Jessica Madden

No longer are we looking at that.

00:09:27 Dr. Jessica Madden

We are basically putting all babies on equal footing at birth in terms of their risk of jaundice.

00:09:35 Dr. Jessica Madden

We are not considering any specific populations anymore to be lower risk, they are either kind of at equal risk or they're going to be at higher risk.

00:09:43 Dr. Jessica Madden

As we will go into and specifically, I circled black race because that has been totally eliminated from the new guidelines.

00:09:50 Dr. Jessica Madden

We are not looking at race, we are not looking at gender, we are not looking at those types of demographics any longer.

00:09:59 Dr. Jessica Madden

This is from the old 2004 guidelines too. I am just putting this up here as a reminder.

00:10:05 Dr. Jessica Madden

It was confusing at times in terms of stratifying patients, in terms of where they low risk, low intermediate or high risk.

00:10:14 Dr. Jessica Madden

Essentially I used to look at.

00:10:19 Dr. Jessica Madden

These next curves, which were called the Bhutani.

00:10:24 Dr. Jessica Madden

And what you would do on these and these are again updated, which I'll mention in a few minutes is you.

00:10:30 Dr. Jessica Madden

Would take. How?

00:10:31 Dr. Jessica Madden

Old your newborn patient was in terms of hours to days and you would take what their current total serum bilirubin level was, and you'd make a you'd make a decision based on if they were high risk, medium risk or low risk.

00:10:47 Dr. Jessica Madden

In terms of whether they qualified for phototherapy to be initiated.

00:10:54 Dr. Jessica Madden

We also have had a specific guideline for when newborns would need to have a double volume exchange transfusion.

00:11:04 Dr. Jessica Madden

This is I'll talk about this a little bit later on.

00:11:07 Dr. Jessica Madden

This is a procedure that we do in the most severe cases of jaundice to help to prevent babies from connectors.

00:11:16 Dr. Jessica Madden

So what is here? We really did. It was we kept hearing for quite a while. There is going to be new guidelines coming and it was very, very exciting when these were published in August of 2022 to update the old guidelines.

00:11:33 Dr. Jessica Madden

So, per the new 2022 guidelines, again they have taken out any concept of a newborn being at lower or decreased risk. And so, some of these are like the old ones, but they have also added some and.

00:11:47 Dr. Jessica Madden

We know that babies who are lower gestational age, specifically less than 38 weeks, are at risk.

00:11:54 Dr. Jessica Madden

Babies who develop high bilirubin levels in their first twenty.

00:11:57 Dr. Jessica Madden

4 hours of life.

00:11:59 Dr. Jessica Madden

Babies who, as they are approaching discharge, have ability.

00:12:03 Dr. Jessica Madden

Ruben level.

00:12:03 Dr. Jessica Madden

That is kind of just under where we would start phototherapy.

00:12:07 Dr. Jessica Madden

Alice's red blood cell breakdown and that can be from multiple causes.

00:12:11 Dr. Jessica Madden

That is a definite risk factor for jaundice.

00:12:14 Dr. Jessica Madden

Median phototherapy before going home.

00:12:17 Dr. Jessica Madden

Having a parent or sibling who needed phototherapy as a newborn, family history of certain inherited red blood cell disorders, exclusive breastfeeding with suboptimal intake.

00:12:29 Dr. Jessica Madden

This is breastfeeding and jaundice.

00:12:32 Dr. Jessica Madden

Having scalp hematoma, which is a collection of blood that is in the head that is related to the trauma of childbirth.

00:12:41 Dr. Jessica Madden

Down syndrome in babies who are large for gestational age whose moms had diabetes, they are also at risk.

00:12:48 Dr. Jessica Madden

That is typically because they are born with higher-than-average red blood cell counts or hematocrits.

00:12:55 Dr. Jessica Madden

So, because they have a higher hematocrit than a normal newborn, they have more of a red blood cell.

00:13:01 Dr. Jessica Madden

Breakdown and they are at a higher risk of jaundice.

00:13:04 Dr. Jessica Madden

So, there's also in the new guidelines.

00:13:07 Dr. Jessica Madden

So we look at the last slide we talked about newborns who are at risk for developing higher bilirubin levels and needing phototherapy.

00:13:16 Dr. Jessica Madden

This specific group of babies with neurotoxicity risk factors are the ones that the most.

00:13:24 Dr. Jessica Madden

Highest risk of developing severe jaundice. Those levels above 25 at which we start to worry about the brain damage.

00:13:32 Dr. Jessica Madden

And so the narrow toxicity risk factors as you can see are gestational age less than 38 weeks having a low serum albumin level.

00:13:42 Dr. Jessica Madden

Any type of isoimmunization hemolytic disease. This is when babies have excessive red blood cell breakdown due to an antibody mediated process and I will talk about this in a little more detail in a few minutes. Sepsis, which is an infection and or any significant clinical instability in the previous 24 hours.

00:14:02 Dr. Jessica Madden

So if the baby is admitted to the NICU with some respiratory distress.

00:14:07 Dr. Jessica Madden

Any issues with blood pressure on babies being born who had some hypoxia at the time of birth that would all lump them into this category of being higher risk?

00:14:22 Dr. Jessica Madden

I want to emphasize G6PD deficiency because, as you can see, they specifically designate this as a neurotoxicity risk factor.

00:14:33 Dr. Jessica Madden

G6 PD is one of the leading causes of dangerously high bilirubin levels in newborns. We know it is an excellent recessive disorder.

00:14:43 Dr. Jessica Madden

And there are certain populations in which there are higher percentage of newborns with G6PD deficiency, including sub-Saharan Africa, Middle East, Mediterranean, Arabian Peninsula and Southeast Asia. So overall, this condition affects a significant percentage of African American males.

00:15:04 Dr. Jessica Madden

However, females who are carriers for this can also have manifestations of G6PD deficiency.

00:15:13 Dr. Jessica Madden

And so these are babies where we often times we'll even admit them to the NICU from home when they come in several days or week, week and a half of life with it's just sky High Billy Ribbon level where there's no clear cut explanation. Oftentimes we find out that they do have G6 PD depression study.

00:15:33 Dr. Jessica Madden

And then I just wanted to add that my current institution at Rainbow Babies, I one of my colleagues is one of the world's experts in G6PD deficiency. Dr. Nah.

00:15:47 Dr. Jessica Madden

And we have universal screening of all male infants and we are finding G6PD deficiency in much higher numbers of infants who do not belong into these specific ethnic groups than you would think.

00:16:03 Dr. Jessica Madden

I assume the.

00:16:03 Dr. Jessica Madden

Hemolysis, as I discussed, is an antibody mediated red blood cell breakdown.

00:16:10 Dr. Jessica Madden

That is a huge risk factor for significant jaundice and newborn.

00:16:15 Dr. Jessica Madden

The most common one that we see clinically in the NICU.

00:16:19 Dr. Jessica Madden

Is due to.

00:16:20 Dr. Jessica Madden

ABO incompatibility.

00:16:23 Dr. Jessica Madden

This is if mothers are blood type O and their fetus or baby has blood type, either A or B moms.

00:16:31 Dr. Jessica Madden

When the fetus is in utero, they can make start to make.

00:16:35 Dr. Jessica Madden

Antibodies that attack the babies if the baby is blood type A or B.

00:16:41 Dr. Jessica Madden

These antibodies cross the placenta into the baby's blood and they will continue to cause red blood cells to basically burst open, and the DAT, which I'm just seeing here, this is a really important lab marker that we basically test on all newborns.

00:16:58 Dr. Jessica Madden

It is the direct antiglobulin test.

00:17:01 Dr. Jessica Madden

It is also called the coup.

00:17:03 Dr. Jessica Madden

Test this is how we know whether this antibody mediated destruction of red blood cells is occurring.

00:17:11 Dr. Jessica Madden

So we have a baby who's born DAT positive.

00:17:14 Dr. Jessica Madden

That is very, very helpful information.

00:17:17 Dr. Jessica Madden

We know that this baby is at higher risk of needing phototherapy for jaundice, and also these are babies that we need to check the bilirubin more frequently.

00:17:27 Dr. Jessica Madden

I am going to just change gears to go into jaundice treatment since so overall the main crux of these guidelines is how do we manage newborn hyperbilirubinemia.

00:17:38 Dr. Jessica Madden

The main treatment for jaundice is phototherapy.

00:17:43 Dr. Jessica Madden

Why does it work?

00:17:44 Dr. Jessica Madden

How does it work?

00:17:45 Dr. Jessica Madden

It is the light therapy.

00:17:47 Dr. Jessica Madden

There's photochemical reactions that allow bilirubin to be excreted more easily in both the urine and the.

00:17:55 Dr. Jessica Madden

We know now that the ideal wavelength of light therapy is between 470 to 475 nanometers.

00:18:04 Dr. Jessica Madden

Your radiance is especially important.

00:18:06 Dr. Jessica Madden

We now for the most part use what we typically what we used to call intensive phototherapy.

00:18:12 Dr. Jessica Madden

Now is the standard of care and the normal phototherapy that we use in the hospital setting and intensive phototherapy has an irradiance of at least thirty microwatts per centimeter.

00:18:25 Dr. Jessica Madden

Squared, per nanometer.

00:18:27 Dr. Jessica Madden

We also know that the surface area of an infant that is exposed to the phototherapy lights is especially important, so it is optimal to have babies who are under phototherapy.

00:18:39 Dr. Jessica Madden

Typically we have them in a diaper.

00:18:42 Dr. Jessica Madden

Their skin is otherwise exposed, and then we also have eye covering just to protect their eyes so they are naked.

00:18:47 Dr. Jessica Madden

Outside of his diaper and the eye covers.

00:18:51 Dr. Jessica Madden

I added this in because although we no longer recommend that newborns get treated for jaundice with sunlight, I can anecdote anecdotally tell you during a lot of my newborn visits, this is still being recommended.

00:19:09 Dr. Jessica Madden

So I'll come in for a visit.

00:19:11 Dr. Jessica Madden

And find that the parents have put.

00:19:13 Dr. Jessica Madden

The baby right into a window.

00:19:15 Dr. Jessica Madden

And that's if babies are going home with some borderline jaundice levels.

00:19:19 Dr. Jessica Madden

The entrance.

00:19:19 Dr. Jessica Madden

Same thing I have noticed.

00:19:20 Dr. Jessica Madden

Also, is parents doing this?

00:19:22 Dr. Jessica Madden

They do not have the baby exposed, so they have this, like swaddled wrapped baby with a hat on.

00:19:26 Dr. Jessica Madden

And the only.

00:19:26 Dr. Jessica Madden

Part of the body.

00:19:28 Dr. Jessica Madden

Is the face it is being exposed.

00:19:30 Dr. Jessica Madden

To sunlight.

00:19:31 Dr. Jessica Madden

And so this quotation in terms of why it's not recommended.

00:19:34 Dr. Jessica Madden

Used directly from these 2022 new guidelines.

00:19:39 Dr. Jessica Madden

Overall, the major changes in terms of the recommendations for phototherapy from 2004 to now include the following the thresholds for when to start phototherapy for infants who are 40 weeks and older, who do not have risk factors for connectorized.

00:20:01 Dr. Jessica Madden

Is higher than it used to be.

00:20:03 Dr. Jessica Madden

So on average, it's about 2 milligrams per deciliter higher.

00:20:08 Dr. Jessica Madden

We will tolerate higher bilirubin levels without treatment if babies do not have any risk factor.

00:20:15 Dr. Jessica Madden

For infants who are 35 weeks to 40 weeks, if they do not have neurotoxicity, neurotoxicity, risk factors, the threshold has also increased. It is by about 1 milligram per deciliter.

00:20:30 Dr. Jessica Madden

And then the.

00:20:31 Dr. Jessica Madden

Third thing that's important is that they've made they've included recommendations for what to do in terms of chronologic age.

00:20:41 Dr. Jessica Madden

To determine when to start phototherapy, and this is where it did used to get confusing. If you have a baby who's born at 37 weeks in zero days to station but they developed jaundice when they're a week and a half old, they're actually correct or chronologic to 38 weeks.

00:21:00 Dr. Jessica Madden

So it used to be very confusing. Do you measure them based on when you would start photos? You would be on a thirty-seven meter because they were born at.

00:21:06 Dr. Jessica Madden

37 weeks.

00:21:08 Dr. Jessica Madden

Or would you start?

00:21:09 Dr. Jessica Madden

Phototherapy, based on them being now 38 weeks and it is very clear now we use 38 weeks to use the chronology chronologic age.

00:21:19 Dr. Jessica Madden

And so yes, another example would be, especially that is really important also with babies who are right at that cusp of really going up on the curves in terms of when you start phototherapy.

00:21:31 Dr. Jessica Madden

And I will.

00:21:32 Dr. Jessica Madden

Show you that in a minute.

00:21:36 Dr. Jessica Madden

So the new phototherapy curves, unlike the previous guidelines, there are very, very specific ways that we plot and determine when to treat babies that have no hyperbilirubinemia neurotoxicity risk factor.

00:21:53 Dr. Jessica Madden

Others versus those that do so babies that have one or more risk factors.

00:22:00 Dr. Jessica Madden

And umm, an example would be you know, I just wanted to use an example comparing the difference between then and now.

00:22:08 Dr. Jessica Madden

So I just for I plot it out.

00:22:11 Dr. Jessica Madden

If I took.

00:22:11 Dr. Jessica Madden

A 37 week baby who is 96 hours old.

00:22:18 Dr. Jessica Madden

On the old guidelines, if that baby's Sarah and Bilirubin were seventeen milligrams per deciliter, they would meet criteria for phototherapy.

00:22:27 Dr. Jessica Madden

If you look.

00:22:28 Dr. Jessica Madden

At our new guidelines and go up, so we have a.

00:22:31 Dr. Jessica Madden

96 hour old.

00:22:33 Dr. Jessica Madden

And you hit this turquoise line of 37 weeks, you can see that you would not in this case, you actually wouldn't start until about 20 or so.

00:22:46 Dr. Jessica Madden

And then the same.

00:22:48 Dr. Jessica Madden

So when we're looking at babies that do have the risk factors for very, very severe jaundice.

00:22:53 Dr. Jessica Madden

Again, just an example would be on the old guidelines. So you had a 38 week.

00:22:58 Dr. Jessica Madden

Infant who was 72 hours old.

00:23:03 Dr. Jessica Madden

It is very same in terms of that there is a higher threshold and I also do want to point out the difference too between the two curves and the new guidelines.

00:23:14 Dr. Jessica Madden

So the difference in terms of when to start phototherapy if there are no risk factors versus risk factor.

00:23:20 Dr. Jessica Madden

There's if you look here, if you have a 72 hour old 38 week.



00:23:28 Dr. Jessica Madden

Who has risk factors you would?

00:23:33 Dr. Jessica Madden

Be starting your phototherapy here at around seventeen or so.

00:23:41 Dr. Jessica Madden


00:23:43 Dr. Jessica Madden

And on this curve, without you are closer to like 18 or 18.7 or 19.

00:23:54 Dr. Jessica Madden

They are also in the new guidelines. There are many different tables, so you, if you do not want to do the curve and the graphene it parses is down every single baby gestational age category from 35 to 40 weeks.

00:24:09 Dr. Jessica Madden

You can just look so for 40 week infants.

00:24:11 Dr. Jessica Madden

Again, you look at how.

00:24:12 Dr. Jessica Madden

Many days old they are.

00:24:14 Dr. Jessica Madden

How many hours on that day?

00:24:16 Dr. Jessica Madden

We are and what was really fascinating to me because we didn't have this type of information in the old guidelines is, for example, if you look at say you had a baby who is, this is a 50 hour old newborn, if they're 40 weeks gestation, you start phototherapy.

00:24:36 Dr. Jessica Madden

At 17.3.

00:24:38 Dr. Jessica Madden

But if they are 39 weeks gestation so born just one week earlier, you would start phototherapy at 16.7.

00:24:46 Dr. Jessica Madden

This does not sound like that big of a difference, but clinically this is an excessively significant difference because this can really impact, you know, not only when you start phototherapy, but really the length of stay for a baby.

00:25:00 Dr. Jessica Madden

Also in the hospital before going home.

00:25:04 Dr. Jessica Madden

What I use is It is a lovely online application. It is a website actually. You just put in you plug and check everything.

00:25:15 Dr. Jessica Madden

And instead of even having to plot on the curve or look at that incredibly detailed graph of numbers, it just spits out for you whether to start phototherapy.

00:25:24 Dr. Jessica Madden

And so this is something most of my colleagues and I use on a regular basis.

00:25:30 Dr. Jessica Madden

We do discuss. I am in the new guidelines very, very specific criteria for home studio phototherapy and I think this is very important because there are so many emerging technologies to be able to really provide high quality phototherapy in the home setting. And so babies who are greater than 38 weeks.

00:25:52 Dr. Jessica Madden

If they are at least 48 hours old, if they are clinically well, adequately feeding, being that they do not have the breastfeeding or suboptimal intake jaundice if they do not have any risk factors for connectorized, they did not need phototherapy when they were in the newborn nursery.

00:26:08 Dr. Jessica Madden

They are not super high above their threshold for starting phototherapy, they have to be like at their line or within one or so that there's ability to be able to get the phototherapy to the home in a very timely manner.

00:26:22 Dr. Jessica Madden

And also this is very important that there is a way to be able to have these babies.

00:26:28 Dr. Jessica Madden

You are getting treated at home.

00:26:31 Dr. Jessica Madden

Have stern Billy ribbon levels monitored every day.

00:26:41 Dr. Jessica Madden

Another important part of the new guidelines is they give a really, really nice flow chart and how we specifically should be managing babies who have jaundiced due to hemolysis.

00:26:55 Dr. Jessica Madden

I am not going to go through the whole thing.

00:26:57 Dr. Jessica Madden

I just want to let you know that it is.

00:26:59 Dr. Jessica Madden

That it is in here and is.

00:27:01 Dr. Jessica Madden

Very easy to.

00:27:02 Dr. Jessica Madden

Follow if you have a baby with.

00:27:08 Dr. Jessica Madden

Isoimmunization Moyses, or antibody mediated hemolysis in you are in a newborn nursery.

00:27:13 Dr. Jessica Madden

I would be very, very recommend right away that you do consult with a local nick, your neonatologist and the AAP guidelines do.

00:27:23 Dr. Jessica Madden

Reflect this.

00:27:27 Dr. Jessica Madden

Intravenous immunoglobulin is used for treatment of hyperbilirubinemia and these babies with severe the ISO immune antibody mediated breakdown of red blood cells.

00:27:38 Dr. Jessica Madden

So ones that have that positive DAT or Coombs test, whose bilirubin levels are really rising.

00:27:43 Dr. Jessica Madden

And the dose that we use and this is spelled out by the AP is .5 to 1 grams per kilo over 2 hours. And you can repeat the dose 12 hours later.

00:27:54 Dr. Jessica Madden

We do.

00:27:55 Dr. Jessica Madden

We typically used to view it, I say we places where I where I've practiced.

00:28:01 Dr. Jessica Madden

I have looked at it.

00:28:03 Dr. Jessica Madden

As a treatment without any real risk of any serious side effects.

00:28:08 Dr. Jessica Madden

So you would give it to babies only who are at high risk for connect risk trying to avoid an exchange transfusion.

00:28:15 Dr. Jessica Madden

However, they did bring up and include some research studies showing that there might be a link between IVIG administration.

00:28:24 Dr. Jessica Madden

And the development of necrotizing enterocolitis.

00:28:28 Dr. Jessica Madden

This is a this happens only in newborns, mostly preemies.

00:28:34 Dr. Jessica Madden

It is an infection of the bowels due to a decrease in blood flow and it can cause death.

00:28:40 Dr. Jessica Madden

The reason I mention this is this helps to show us that when we have these.

00:28:45 Dr. Jessica Madden

Elevated risk babies.

00:28:46 Dr. Jessica Madden

Their bodies are breaking down tons of red blood cells.

00:28:49 Dr. Jessica Madden

If we start phototherapy right away, good solid phototherapy with an irradiance with the body surface area that that they have recommended.

00:29:00 Dr. Jessica Madden

We will have we will not have to use this as often and the less that we use the IVIG, the lower risk we are going to have for potentially causing neck, which can lead to death.

00:29:12 Dr. Jessica Madden

And then a double volume transfer exchange transfusion. We fortunately do not have to do this procedure very often. These are the infants that come into our into their incus who have levels of bilirubin levels way above 25.

00:29:28 Dr. Jessica Madden

Closer to thirty or are?

00:29:29 Dr. Jessica Madden

Already showing abnormal neurologic signs.

00:29:32 Dr. Jessica Madden

Of passable connectors where they have increased muscle tone.

00:29:36 Dr. Jessica Madden

A lot of them are arching.

00:29:38 Dr. Jessica Madden

They'll have a high pitched cry.

00:29:40 Dr. Jessica Madden

So what is done in this procedure is there are central lines, there's access in a newborn to one of the major arteries.

00:29:50 Dr. Jessica Madden

And then there is also access to one of their major veins.

00:29:56 Dr. Jessica Madden

It is a blood transfusion where twice of the baby's total blood volume is replaced by donor blood.

00:30:04 Dr. Jessica Madden

It is done over hours and hours.

00:30:07 Dr. Jessica Madden

This I could not find an actual photo on the Internet.

00:30:11 Dr. Jessica Madden

An actual real baby. This baby is not going to. Obviously, this fake baby is going to tolerate its exchange transfusion. Fine. It is associated with about a 3% mortality.

00:30:22 Dr. Jessica Madden

Body and so it is something that we again if we are able to treat babies with the phototherapy that they need when they need it adequately, we do fortunately do not have to do this procedure very often.

00:30:38 Dr. Jessica Madden

There are very, very.

00:30:40 Dr. Jessica Madden

Nice exchange transfusion thresholds spelled out in the new AP guidelines as.

00:30:46 Dr. Jessica Madden

Well, and so there are different thresholds for babies without risk factors at baseline for connectors and then babies who are at risk for connector.

00:30:57 Dr. Jessica Madden

They also, which is really nice, is there is guidance in terms of when should babies who are discharged home from the newborn nursery, who need follow up, when should they be followed up.

00:31:11 Dr. Jessica Madden

So when do they need a home, bilirubin check or when should they go back into their pediatricians?

00:31:16 Dr. Jessica Madden

Office after hospital discharged to get a Billy ribbon check.

00:31:20 Dr. Jessica Madden

Overall, it really takes it takes OK what is that baby, the day they go home from the nursery?

00:31:27 Dr. Jessica Madden

What is their Billy ribbon level and then how much the distance is there between their current bilirubin level and the threshold for phototherapy? And so as you can see, if it's within .1.

00:31:40 Dr. Jessica Madden

To 1.9, you need to follow up much quicker than if you have a baby.

00:31:45 Dr. Jessica Madden

Who has saved their bilirubin level is five, but their threshold for phototherapy is not, you know, until I do not know, 18, there would be a much more room to be able to go home and not have to worry.

00:31:58 Dr. Jessica Madden

Or monitor that baby.

00:32:00 Dr. Jessica Madden

As much so overall, they are at the end of the.

00:32:05 Dr. Jessica Madden

With the paper and guidelines, they have twenty-five key action statements and I am just going to highlight a few of the ones that I believe are the most important for us to be aware of right now.

00:32:19 Dr. Jessica Madden

#5 and again we have talked about, I have talked about some of this already in the body of this presentation actually statement 5A, Sarum or transcutaneous bilirubin should be measured in all babies between 24 to 48.

00:32:34 Dr. Jessica Madden

Hours after birth.

00:32:36 Dr. Jessica Madden

The statement 6, the Sarah and Billy Ribbon should be measured.

00:32:41 Dr. Jessica Madden

If that skin or transcutaneous level is within 3 milligrams per deciliter of the phototherapy threshold, or if that skin level is greater than or equal to 15.

00:32:53 Dr. Jessica Madden

#8 is, if appropriate, follow up cannot be arranged for an infant who needs outpatient bilirubin follow-ups. You may need to delay hospital discharge.

00:33:04 Dr. Jessica Madden

#10 is a reminder that intensive phototherapy that is greater than thirty microwatts per centimeter squared, per nanometer, should be used in all babies who need phototherapy.

00:33:16 Dr. Jessica Madden

#11 newborn infants who have hyperbilirubinemia who meet criteria for phototherapy, can be treated with home phototherapy if they meet their criteria that I had discussed earlier, like being exceptionally minimal risk, more severe for neurotoxicity.

00:33:35 Dr. Jessica Madden

#15 is helpful in term will when do you?

00:33:38 Dr. Jessica Madden

Stop phototherapy so phototherapy can be discontinued when the serum level has decreased to 2 milligrams per deciliter below that threshold when they started it.

00:33:52 Dr. Jessica Madden

#24 for infants being discharged home, the timing of that post discharge. Billy, Check is again determined by how close they are to their phototherapy threshold at the.

00:34:05 Dr. Jessica Madden

Time of discharge.

00:34:06 Dr. Jessica Madden

And then #25 is all families should receive written and verbal information.

00:34:12 Dr. Jessica Madden

About jaundice and I just have the AP that just put out a brand new nice patient information sheet.

00:34:21 Dr. Jessica Madden

I am not going to go through it, but explains what jaundice is, why newborns get it.

00:34:25 Dr. Jessica Madden

Emphasizes her families on how important this is.

00:34:29 Dr. Jessica Madden

In terms of monitoring and follow up for it, that is it.

00:34:35 Dr. Jessica Madden

Thank you so much.