Recent advances in the management of neonatal jaundice

Figures & data

Figure 1 Gestational age impacts risk for severe hyperbilirubinemia.

Notes: Risk of developing a total serum bilirubin (TSB) level of 20 mg/dL (342 μmol/L) or higher as a function of gestational age and percentile of the first TSB measured at less than 48 hours on the Bhutani nomogram.²² Copyright © 2005 American Medical Association. All rights reserved. Reproduced from Newman TB, Liljestrand P, Escobar GJ. Combining clinical risk factors with serum bilirubin levels to predict hyperbilirubinemia in newborns. Arch Pediatr Adolesc Med. 2005;159(2):113–119.²²
Abbreviation: wk, weeks.

Figure 2 American academy of pediatrics phototherapy guidelines.

Notes: Guidelines for phototherapy in hospitalized infants ≥35 weeks’ gestation. Risk factors are isoimmune hemolytic disease, glucose-6-phosphate dehydrogenase deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or an albumin level of less than 3.0 g/dL (if measured). Use total bilirubin. Do not subtract direct-reacting or conjugated bilirubin. Reproduced with permission from Pediatrics, 124, 1193–1198, Copyright © 2009 by the AAP.¹⁶
Abbreviation: wk, weeks.

Figure 3 Bf/TBC ratio improves prediction of bilirubin-induced brainstem response abnormalities.

Notes: Receiver-operating characteristics of the total bilirubin concentration (TBC), plasma-unbound or “free” bilirubin concentration (Bf), and the Bf/TBC ratio as predictors of an abnormal automated auditory brainstem response are shown. The straight line is the expected curve (unity) if the variable has no predictive value (are under the curve, 0.5). The areas under the curve are Bf/TBC ratio, 0.83; Bf, 0.69; and TBC, 0.50. The areas under the Bf/TBC and Bf are significantly greater than that under the TBC curve. Reprinted by permission from Macmillan Publishers Ltd: J Perinatol. Ahlfors CE, Amin SB, Parker AE. Unbound bilirubin predicts abnormal automated auditory brainstem response in a diverse newborn population. 2009;29:305–309. Copyright © 2009.⁴³

Table 1 Clinical bilirubin-induced neurological dysfunction (BIND) score of onset, severity, and progression of acute bilirubin encephalopathy, as elicited by history and physical examination

Clinical signs	Bilirubin-induced neurological dysfunction score	Acute bilirubin encephalopathy
Mental status
Normal	0	None
Sleepy but able to be aroused; decreased feeding	1	Subtle
Lethargy, poor suck, and/or irritable/jittery with strong suck	2	Moderate
Semicoma, apnea, unable to feed, seizures, coma	3	Advanced
Muscle tone
Normal	0	None
Persistent mild to moderate hypotonia	1	Subtle
Mild to moderate hypertonia alternating with hypotonia, beginning arching of neck and trunk on stimulation	2	Moderate
Persistent retrocollis and opisthotonos, bicycling or twitching of hands and feet	3	Advanced
Cry pattern
Normal	0	None
High-pitched when aroused	1	Subtle
Shrill, difficult to console	2	Moderate
Inconsolable crying or weak or absent cry	3	Advanced
Total BIND (acute bilirubin encephalopathy score)

Notes: Scores of 1–3 are consistent with subtle signs of acute bilirubin encephalopathy in infants with hyperbilirubinemia. Scores of 4–6 represent moderate acute bilirubin encephalopathy and are likely reversible with urgent and prompt bilirubin reduction strategies. Scores of 7–9 represent advanced acute bilirubin encephalopathy; urgent, prompt, and individualized intervention are recommended to prevent further brain damage, minimize severity of sequelae, and possibly reverse acute damage. Reprinted by permission from Macmillan Publishers Ltd: J Perinatol. Johnson L, Bhutani VK, Karp K, Sivieri EM, Shapiro SM. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). 2009;29(Suppl 1):S25–S45. Copyright © 2009.³⁶

Newman TB, Liljestrand P, Escobar GJ. Combining clinical risk factors with serum bilirubin levels to predict hyperbilirubinemia in newborns. Arch Pediatr Adolesc Med. 2005;159(2):113–119.

 Google Scholar

Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant ≥35 weeks’ gestation: an update with clarifications. Pediatrics. 2009;124(4):1193–1198.

 PubMed Web of Science ®Google Scholar

Ahlfors CE, Amin SB, Parker AE. Unbound bilirubin predicts abnormal automated auditory brainstem response in a diverse newborn population. J Perinatol. 2009;29(4):305–309.

 PubMed Web of Science ®Google Scholar

Johnson L, Bhutani VK, Karp K, Sivieri EM, Shapiro SM. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). J Perinatol. 2009;29(Suppl 1):S25–S45.

 PubMedGoogle Scholar