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.
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
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
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
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
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
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
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
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
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 billytool.org. 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
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
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.