Neonatal Jaundice: What Changed in the AAP 2022 Guideline

AAP 2022 guidelineNeonatal jaundice35 weeks and over

Phototherapy thresholds are higher, risk is judged by how far the bilirubin sits from the threshold, and there is now a defined “escalation of care” stage. Here is what changed in the American Academy of Pediatrics guideline, and what to do at each step.

The bottom line

Every baby needs at least one bilirubin measurement between 24 and 48 hours. Read it against the threshold for their gestational age and neurotoxicity risk factors, and treat any rise to within 2 mg/dL of the exchange threshold as an emergency.¹

>80%of newborn infants will have some degree of jaundice¹

24–48 hwindow for the universal TcB or TSB check, or before discharge if that is earlier¹

2 mg/dLbelow the exchange threshold is where escalation of care begins¹

The guideline gives bilirubin in mg/dL (1 mg/dL ≈ 17.1 μmol/L) and albumin in g/dL.

Prevention starts before birth

If the mother’s antibody screen is positive, or unknown because there was no antenatal screening, check the baby’s direct antiglobulin test (DAT) and blood group as soon as possible, using cord or peripheral blood.¹ A DAT that is positive to anti-D alone, after the mother received anti-D immunoglobulin (RhIG) and had no prior antibodies, can be managed as DAT negative.¹

Do

Support breastfeeding from the first hour, with feeds on demand at least 8 times in 24 hours¹
Check that feeding is going well: urine output, stooling, weight loss and audible swallowing¹
Agree any temporary top-up of donor milk or formula with the parents¹

Don’t

Give oral water or dextrose water to prevent or lower bilirubin (strong recommendation)¹
Routinely give formula to adequately hydrated breastfed babies¹
Use sunlight as a treatment¹

Two different sets of risk factors

This is the distinction people most often get wrong. One set predicts who will develop significant hyperbilirubinaemia. The other set lowers the treatment thresholds.¹

Risk of developing hyperbilirubinaemia

Lower gestational age
Jaundice in the first 24 hours
Pre-discharge TcB or TSB close to the threshold
Haemolysis, including a rapid rate of rise
Phototherapy before discharge
Parent or sibling who needed phototherapy or an exchange
Family history or ancestry suggesting a red cell disorder, such as G6PD deficiency
Exclusive breastfeeding with suboptimal intake
Scalp haematoma or significant bruising
Down syndrome; macrosomic infant of a diabetic mother

These mean closer monitoring.¹

Neurotoxicity risk factors

Gestational age under 38 weeks
Albumin below 3.0 g/dL
Isoimmune haemolytic disease, G6PD deficiency or other haemolytic conditions
Sepsis
Significant clinical instability in the previous 24 hours

These mean lower phototherapy and exchange thresholds

G6PD deficiency

This is now recognised as one of the most important causes of hazardous hyperbilirubinaemia leading to kernicterus. Most affected babies have no family history. Ancestry from sub-Saharan Africa, the Middle East, the Mediterranean, the Arabian Peninsula or Southeast Asia is a useful pointer. Suspect it if TSB is raised in a formula-fed baby or jaundice starts late. G6PD activity can read falsely normal during or soon after haemolysis or an exchange transfusion, so if suspicion remains, repeat the test at least 3 months later.¹

01Screen and measure

Assessment during the birth hospitalisation

Visual checkAt least every 12 hours until discharge. A baby jaundiced before 24 hours needs TcB or TSB as soon as possible.¹

Universal checkTcB or TSB between 24 and 48 hours, or before discharge if earlier. This includes babies born at home.¹

Move from TcB to TSBWhen TcB is within 3 mg/dL of the phototherapy threshold, above it, or 15 mg/dL or more.¹

Rapid rise≥0.3 mg/dL per hour in the first 24 hours, or ≥0.2 mg/dL per hour after that, suggests haemolysis. Check a DAT if not already done.¹

Deciding on treatmentTSB is the definitive test. Do not subtract the direct or conjugated fraction.¹

Reassurance pointIf TcB or TSB has fallen by itself over at least 6 hours, further measurements are not needed unless there are new concerns.¹

TcB accuracy can vary with skin melanin and the device used. The TSB is generally within 3 mg/dL of the TcB when TSB is below 15 mg/dL.¹

02Plan follow-up by distance from the threshold

The old risk-zone nomogram has been replaced. Take the phototherapy threshold at the time of the last pre-discharge measurement and subtract the bilirubin. This applies to babies at least 12 hours old who have not had phototherapy.¹

Threshold minus TcB or TSB → next step

0.1–1.9 mg/dL, under 24 hDelay discharge, consider phototherapy, and measure TSB in 4–8 hours

0.1–1.9 mg/dL, 24 h or olderTSB in 4–24 hours. Options: delay discharge and consider phototherapy, home phototherapy, or discharge with close follow-up

2.0–3.4 mg/dLTSB or TcB in 4–24 hours

3.5–5.4 mg/dLTSB or TcB in 1–2 days

5.5–6.9 mg/dLDischarged before 72 h: follow up within 2 days. At 72 h or later: clinical judgement

7.0 mg/dL or moreDischarged before 72 h: follow up within 3 days. At 72 h or later: clinical judgement¹

Any baby discharged before 12 hours needs a bilirubin check between 24 and 48 hours of age.¹

03Phototherapy

Thresholds were raised by a narrow margin, because newer evidence shows neurotoxicity does not occur until levels well above the 2004 exchange thresholds.^1,2 They remain based on expert opinion, and families and clinicians may choose to treat at lower levels.¹

Intensive phototherapy

LightNarrow-spectrum LED blue light, at least 30 μW/cm² per nm at around 475 nm (range 460–490 nm), covering as much skin as possible¹

InvestigationsHaemoglobin, haematocrit or full blood count for all babies. DAT if the mother’s antibody screen was positive, or she is group O or RhD negative¹

G6PD activityIf jaundice has no known cause and TSB rises despite intensive phototherapy, rises suddenly, rises again after falling, or needs escalation of care¹

First repeat TSBWithin 12 hours of starting treatment in hospital. TcB underestimates TSB on skin exposed to phototherapy¹

FeedingContinue feeding. Breaks for breastfeeding do not reduce effectiveness, but keep them short near escalation levels. IV fluids only for dehydration that cannot be corrected by feeding, or at escalation of care¹

StoppingStopping is an option once TSB is at least 2 mg/dL below the hour-specific threshold at which treatment started. Consider continuing longer if under 38 weeks, started before 48 hours, or haemolytic disease¹

Rebound checkIf phototherapy started before 48 h, the DAT was positive or haemolysis is known: TSB 6–12 h after stopping and again the next day. Other birth-hospital cases: the next day. Readmissions not treated at birth, or home phototherapy: 1–2 days after stopping¹

Phototherapy is not given to prevent subtle neurodevelopmental effects. There is some evidence of a small increase in later epilepsy risk. The committee judged that the benefit outweighs this risk at or above the threshold.^1,2

Home phototherapy: all of these must apply

Eligible

Already discharged; gestational age 38 weeks or more
48 hours old or older; well and feeding well
No neurotoxicity risk factors; no previous phototherapy
TSB no more than 1 mg/dL above the threshold
LED device available at home without delay; daily TSB possible¹

Admit instead if

Any doubt about the device, delivery, the family’s ability to use it, or daily testing
TSB rises and gets closer to the threshold
TSB is 1 mg/dL or more above the threshold¹

04Escalation of care

Medical emergency

Escalation of care begins when TSB reaches 2 mg/dL below the exchange transfusion threshold. If there are signs of intermediate or advanced acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, high-pitched cry or recurrent apnoea), carry out an urgent exchange transfusion, whatever the bilirubin level.¹

Escalation-of-care bundle

WhereNICU, ideally admitted directly rather than through the emergency department. If exchange transfusion is not available on site, contact a neonatologist about urgent transfer, and continue phototherapy and IV fluids on the way¹

Urgent bloodsTotal and direct bilirubin, full blood count, albumin, serum chemistries, group and crossmatch¹

TreatmentIV hydration and emergency intensive phototherapy¹

MonitoringTSB at least every 2 hours until it falls below the escalation threshold¹

IVIG (option)0.5–1 g/kg over 2 hours for DAT-positive isoimmune disease at escalation level, repeatable at 12 hours. Benefit is unclear, and it may be linked to NEC^1,2

Exchange transfusionUrgent if TSB is at or above the exchange threshold. It can be deferred if a repeat TSB falls below the threshold and there are no signs of encephalopathy. Use washed red cells with fresh frozen plasma to a haematocrit of about 40%¹

Bilirubin-to-albumin ratioConsider exchange at ≥8.0 (38 weeks or more, no risk factors), ≥7.2 (38 weeks or more with a risk factor, or 35–37 weeks without), or ≥6.8 (35–37 weeks with a risk factor)¹

Prolonged jaundice

Look for cholestasis

Measure total and direct (or conjugated) bilirubin if a breastfed baby is still jaundiced at 3–4 weeks, or a formula-fed baby at 2 weeks. Check the newborn screening results too, for conditions such as galactosaemia, hypothyroidism and tyrosinaemia.¹

Prolonged indirect hyperbilirubinaemia

At 7 days or older, a TSB persistently within 2 mg/dL of the threshold is usually due to breast milk jaundice. Other causes include haemolysis, hypothyroidism and Crigler–Najjar syndrome. Home phototherapy is an option.¹

Context matters

These thresholds were developed for high-resource settings. The committee advises caution and local expertise when adapting them, and says they were not designed for low- and middle-income countries.¹

References

Kemper AR, Newman TB, Slaughter JL, et al. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859
Slaughter JL, Kemper AR, Newman TB. Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3). doi:10.1542/peds.2022-058865

Tiny Taught · Neonatal & Paediatric EducationFor education only. The AAP thresholds are expert opinion rather than trial-derived. Doses and thresholds are for orientation only; use the full guideline charts and follow your local guidelines.