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The Risk Nomogram
|Hours of Age|
The "risk zone" above refers to the risk of a subsequent bilirubin result in that infant at >95%ile for age.
If the "risk zone" is "High" or "High Int", consider a DAT.
Note that the "risk zone" above is not the same as the "risk category" below.
The Phototherapy Nomogram
|Hours of Age|
If requiring phototherapy, also assess for exchange transfusion.
Data and guidelines based on the Hour-Specific Nomogram for Risk Stratification and the Guidelines for Phototherapy published in "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation" (2004) by the AAP journal.
Additional Information Print with Charts
NOTE: This page is intended for information and visualization. The information above should not be considered a recommendation regarding management. Clinical judgement based on a complete history should be used for all decisions about patient management.
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Data extracted using Web Plot Digitizer.
Recommended Follow Up
(as published in "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation").
Recommendations are not a substitute for clinical decisions. An algorithm has been suggested for management (see below), but this should only be used with an understanding of the principles outlined in the excerpts below and in the original guideline documents. Those who use this tool but do not have this background should consult an appropriate clinician regarding management decisions.
Recommendation Excerpts (see original Guidelines for complete recommendations)
Clinical judgment should be used in determining follow-up. Earlier or more frequent follow-up should be provided for those who have risk factors for hyperbilirubinemia, whereas those discharged with few or no risk factors can be seen after longer intervals.
The follow-up assessment should include the infant’s weight and percent change from birth weight, adequacy of intake, the pattern of voiding and stooling, and the presence or absence of jaundice. Clinical judgment should be used to determine the need for a bilirubin measurement. If there is any doubt about the degree of jaundice, the TSB or TcB level should be measured.
In the High Risk Zone, evaluate for phototherapy and causes of jaundice. Check TSB in 4-48 hrs. If in phototherapy range, also assess for exchange transfusion.
If the TSB is increasing across percentile lines, it should be reassessed.
(Consider an algorithm for the first bilirubin. Clinical judgement should be used for subsequent bilirubins. - B.Poulin)
Consider the following statistics.
|Risk Zone||Newborns||Subsequent Hyperbilirubinemia|
From Appendix 1 of "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation" (2004).
DAT or Direct Antiglobulin (or Coombs) Test
The DAT result is an important major indicator of risk for severe hyperbilirbinemia.
When should we do a DAT?
"The need for phototherapy is increased in ABO-incompatible infants who are direct antiglobulin test (DAT [direct Coombs test])-positive compared with those who are DAT-negative. Universal testing for incompatibility with blood grouping, and for isoimmunization using the DAT, on cord blood does not improve clinical outcomes compared with testing only infants whose mothers are group O (evidence level 2b). Testing all babies whose mothers are group O does not improve outcomes compared with testing only those with clinical jaundice (evidence level 2b). Therefore, it is reasonable to perform a DAT in clinically jaundiced infants of mothers who are group O and in infants with an elevated risk of needing therapy (ie, in the high-intermediate zone). The results will determine whether they are low risk or high risk, and may therefore affect the threshold at which therapy would be indicated." - from the Canadian Pediatric Society POSITION STATEMENT: Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants
Risk Factors for Development of Severe Hyperbilirubinemia
Major risk factors
Jaundice observed in the first 24 h
Blood group incompatibility with positive direct antiglobulin test, other known hemolytic disease (eg, G6PD deficiency), elevated ETCOc
Gestational age 35–36 wk
Previous sibling received phototherapy
Cephalohematoma or significant bruising
Exclusive breastfeeding, particularly if nursing is not going well and weight loss is excessive
East Asian race
Minor risk factors
Gestational age 37–38 wk
Jaundice observed before discharge
Previous sibling with jaundice
Macrosomic infant of a diabetic mother
Maternal age ≥25 y
Decreased risk (these factors are associated with decreased risk of significant jaundice, listed in order of decreasing importance)
Gestational age ≥41 wk
Exclusive bottle feeding
Black race (as defined by mother’s description.)
Discharge from hospital after 72 h
AlgorithmFor those looking for an algorithm after the first bilirubin, please see this figure from CMAJ. 2015 Mar 17; 187(5): 335–343. The algorithm has also been published in Maisels et al.,5 Pediatrics 2009;124:1193–8.
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