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The Risk Nomogram
Serum
Bilirubin
in
µmol/L
(mg/dL)

  Hours of Age


High Risk High Int Risk Low Int Risk ] Low Risk

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
Serum
Bilirubin
in
µmol/L
(mg/dL)

  Hours of Age


Phototherapy Threshold For Low Risk Infants (>= 38 wks and well) Phototherapy Threshold For Med Risk Infants (>= 38 wks and risk factors or 35-37 6/7 wks and well) Phototherapy Threshold For High Risk Infants (35-37 6/7 wks and risk factors)
If requiring phototherapy, also assess for exchange transfusion.

Designed and maintained by Brett Poulin, MD at Coldstream Informatics.

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.
Given the possibility of error, the User should confirm the information on this page through independent sources.
This information is provided without warranties of any kind, express or implied, and the author disclaims any liability, loss, or damage caused by it or its content.
By continuing to use this page, you have indicated your acceptance of these terms.

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)

The best documented method for assessing the risk of subsequent hyperbilirubinemia is to measure the TSB or TcB level and plot the results on a nomogram.

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 ZoneNewbornsSubsequent Hyperbilirubinemia
High6%39.5%
High Int12.5%12.9%
Low Int19.6%2.26%
Low61.8%0%

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

(as published in "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation")

Major risk factors

 Predischarge TSB or TcB level in the high-risk zone
 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

 Predischarge TSB or TcB level in the high intermediate-risk zone
 Gestational age 37–38 wk
 Jaundice observed before discharge
 Previous sibling with jaundice
 Macrosomic infant of a diabetic mother
 Maternal age ≥25 y
 Male gender

Decreased risk (these factors are associated with decreased risk of significant jaundice, listed in order of decreasing importance)

 TSB or TcB level in the low-risk zone
 Gestational age ≥41 wk
 Exclusive bottle feeding
 Black race (as defined by mother’s description.)
 Discharge from hospital after 72 h

Algorithm

 For 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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Disclaimer

The user of this web site acknowledges and agrees that this site will be used only as a visualization aid, and that no medical advice of any kind is provided. The information above should not be considered a recommendation regarding management. Any information given should be confirmed through independent sources, including the referenced original sources. The information contained in the site is not a substitute for professional judgement. Clinical judgement based on a complete history should be used for all decisions about patient management. This site is provided without warranties of any kind, express or implied, and the author disclaims any liability, loss, or damage caused by it or its content. By continuing to use this site, you have indicated your acceptance of these terms.