that in 19% of the sudden, unexpected infant death cases, knowledge about the history was essential for

the final diagnosis.

Siri Hauge Opdal, PhD

Torleiv Ole Rognum, MD
Institute of Forensic Medicine
Rikshospitalet
0027 Oslo, Norway
REFERENCES
1. Gregersen MRJ, Laursen H, Baandrup U, et al. Pathologic criteria for the
Nordic Study of SIDS. In: Rognum TO, ed. Sudden Infant Death Syndrome, New Trends in the Nineties. Oslo, Norway: Scandinavian University Press; 1995:50 58
2. Vege A, Rognum TO. Use of new Nordic criteria for classification of
SIDS to re-evaluate diagnoses of sudden unexpected infant death in the
Nordic countries. Acta Paediatr. 1997;86:391396
3. Opdal SH, Rognum TO. The sudden infant death syndrome gene: does
it exist? Pediatrics. 2004;114(4). Available at: www.pediatrics.org/cgi/
content/full/114/4/e506
4. Rognum TO, Arnestad M, Bajanowski T, et al. Consensus on diagnostic
criteria for the exclusion of SIDS. Nord Rettsmedisin. 2003;9:6273
5. Krous HF, Beckwith JB, Byard RW, et al. Sudden infant death syndrome
and unclassified sudden infant deaths: a definitional and diagnostic
approach. Pediatrics. 2004;114:234 238
6. Stray-Pedersen A, Arnestad M, Opdal SH, Vege A, Rognum TO, Byard
RW. Globally accepted definition and diagnostic criteria crucial for
solving the SIDS enigma. Scand J Forensic Sci. 2004;10:70 71
7. Fleming PJ, Blair PS, Sidebotham PD, Hayler T. Investigating sudden
unexpected deaths in infancy and childhood and caring for bereaved
families: an integrated multiagency approach. BMJ. 2004;328:331334
8. Krous HF. The international standardized autopsy protocol for sudden
unexpected infant death. In: Rognum TO, ed. Sudden Infant Death Syndrome, New Trends in the Nineties. Oslo, Norway: Scandinavian University Press; 1995:8195
9. Hunt CE. Genes and sudden infant death syndrome. Pediatr Res. 2004;
56:321322
10. Arnestad M, Vege A, Rognum TO. Evaluation of diagnostic tools applied in the examination of sudden unexpected deaths in infancy and
early childhood. Forensic Sci Int. 2002;125:262268

doi:10.1542/peds.2004-2743

Hyperbilirubinemia Guidelines in Newborn

Infants
To the Editor.
We read with interest the recent hyperbilirubinemia guidelines
by the American Academy of Pediatrics1 (AAP). We found them
to be very informative, but we believe these guidelines can be
adapted further to become more user friendly. To follow the
guidelines, the practicing pediatrician needs to use information
from 1 algorithm, 3 nomograms, and 4 tables that are spread over
several pages. In our experience, using a 1-page practice guideline
is a feasible solution to this problem (see Fig 1).
The AAP allows 2 options for predischarge assessment of newborns: (1) predischarge bilirubin measurement, which is a universal screening, and/or (2) assessment of clinical risk factors without
a universal screening. Either of these 2 options can be used with
appropriate postdischarge follow-up. The AAP also states, however, that [t]he best documented method for assessing the risk of

TABLE 1.

subsequent hyperbilirubinemia is to measure the TSB [total serum

bilirubin] or TcB [transcutaneous bilirubin] level and plot the
results on a nomogram [by Bhutani et al2].
Between 1992 and 2002, bilirubin encephalopathy was voluntarily reported in 125 healthy term and near-term infants to the
Kernicterus Pilot Registry.3 Kernicterus and severe hyperbilirubinemia are not reportable conditions. These cases probably underestimate the true incidence of kernicterus in the United States
because of the lack of a universal registry, missed diagnosis, and
underreporting. In addition, there is an inability to assess adequately neonatal jaundice by clinical judgment alone.4 For these 2
reasons, the AAP identified universal screening of all term or
near-term infants before their discharge as the best documented
method for hyperbilirubinemia screening.
In July 2003, we were able to create and implement 1-page
hyperbilirubinemia prevention and management guidelines for
term and near-term infants in the Cedars-Sinai Medical center
Well Infant Nursery (Fig 1). These guidelines were based on the
previous AAP guidelines,5 the Bhutani et al nomogram,2 and the
neonatal jaundice task force of NICU-Cedars-Sinai Medical Center. It is notable that our guidelines are similar to the current AAP
guidelines.2
One-year experience showed that since the implementation of
our guidelines in July 2003, the hyperbilirubinemia readmission
rate to the pediatric ward and NICU combined decreased by 38%
(P .001). Between July 2002 and June 2003, we had a total of 66
hyperbilirubinemia readmissions versus 41 between July 2003 and
June 2004. The ratio of readmitted newborns to the pediatric ward
versus the NICU went up from 1.2 to 4.85. Of note, the number of
newborns born in academic years 2002 and 2003 were similar
(Table 1). Per our policy, newborns admitted to the pediatric ward
have lower serum bilirubin levels on admission in comparison to
those admitted to the NICU (20 vs 20 mg/dL, respectively).
Thus, a reduction in hyperbilirubinemia frequency and severity
was observed.
In the future, a prospective, large, multicenter, long-term follow-up study is necessary to evaluate the impact of these guidelines on readmission rate, severity of hyperbilirubinemia at the
time of admission, and the rate of kernicterus. Such a study will
become increasingly challenging in our profession equipoise on
this key aspect of neonatal clinical management.

Arie L. Alkalay, MD
Charles F. Simmons, MD
Department of Pediatrics, Division of Neonatology
Ahmanson Pediatric Center
Cedars-Sinai Medical Center
David Geffen School of Medicine
University of California Los Angeles
Los Angeles, CA 90048
REFERENCES
1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia.
Management of hyperbilirubinemia in the newborn infant 35 or more
weeks of gestation. Pediatrics. 2004;114:297316
2. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge
hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103:
6 14
3. Bhutani VK, Johnson LH, Maisles MJ, et al. Kernicterus: epidemiological
strategies for its prevention through systems-based approaches. J Perinatol. 2004;24:650 662

Readmissions Due to Neonatal Hyperbilirubinemia

Academic
Year

Ward Readmissions
(n Newborns)

NICU Readmissions
(n Newborns)

Ward NICU
Readmissions Total
(per 1000 Deliveries)

Ward NICU
Readmission Ratio

Annual Deliveries
(n Newborns)

2002*
2003

36
34

30
7

66 (9.4)
41 (5.9)

1.20
4.85

6981
6890

P .001 (2).
* Before implementation of hyperbilirubinemia guidelines.
After implementation of hyperbilirubinemia guidelines.

824

LETTERS TO THE EDITOR

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Hyperbilirubinemia Guidelines for Infants 34 Weeks of Gestation

Newborn infant in the WBN

Pre-discharge Bilia+EM
Nomogram*
428

25

342
95th % ile

High Risk Zone

15
In
High
Lo

10

ter

te
w In

iat
med

rme

diat

eR

eR

isk Z

one

75th % ile

40th % ile

on
isk Z

257

mol/L

Serum Bilirubin (mg/dl)

20

171

Low Risk Zone

85

0
0

12

24

36

48

60

72

84

96

108

120

132

144

Postnatal Age (hours)

*PEDIATRICS, 1999; 103:6-14 (modified)

Risk factors

no

yes

Low Zone: Regular follow-up by PMD*

Low-inter Zone: Bili in 48 4hrs
High-inter Zone: Bili in 24 4hrs
High Zone: Bili in 12 4hrs, consider Photox
*If discharge at <24, 24-47, 48-72hrs, to be
seen by PMD at 72, 96, and 144hrs of age,
respectively.

Table* Hyperbilirubinemia Management Guidelines

Photox
Exchange

Risk Factors
1. Family history of jaundice or hemolysis
2. Near term infants (34-38 wks)
3. Polycythemia
4. Internal or external bleeding
5. Postnatal hemolysis
6. Increase Bili rise (>0.5mg/dl/hr)
7. Increased Bili production (high ETCOc)
8. Hypoxemia, acidosis, sepsis, hypoalbuminemia
Abbreviations
Bili=Total bilirubin
EM=Educational material
ETCOc=End tidal volume corrected CO
Photox=Phototherapy
PMD=Attending pediatrician
WBN=Well Baby Nursery

Low Zone: Follow-up by PMD in 48 4hrs

Low-inter Zone: Bili in 36 4hrs
High-inter Zone: Bili in 18 4hrs
High Zone: Bili in 6 2hrs, Photox

24hrs
10-12 (7-10)
20 (18)
25-48hrs 12-15 (10-12)
20-25 (20)
49-72hrs 15-18 (12-15)
25-30 (>20)
>72hrs
18-20 (12-15)
25-30 (>20)
Bilirubin levels expressed in mg/dl
In brackets are Bili levels for infants with risk factors
*PEDIATRICS, 1994; 94:558-565 (modified)

a). Bilirubin can be obtained either by blood sample or by transcutaneous measurement

This algorithm is a suggested practice guidelines
and do not intend to replace clinical judgement.
Neonatology Division, Ahmanson Pediatric Center,
Cedars--Sinai Medical Center, Los Angeles, California; July, 2003
Arie L. Alkalay, MD; Charles F. Simmons, MD

Fig 1. Hyperbilirubinemia guidelines for infants 34 weeks gestation.

4. Moyer VA, Ahn C, Sneed S. Accuracy of clinical judgement in neonatal

jaundice. Arch Pediatr Adolesc Med. 200;154:391394
5. American Academy of Pediatrics, Provisional Committee for Quality
Improvement and Subcommittee on Hyperbilirubinemia. Practice

parameter: management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994;94:558 562
doi:10.1542/peds.2004-2442

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LETTERS TO THE EDITOR

825

Hyperbilirubinemia Guidelines in Newborn Infants

Arie L. Alkalay and Charles F. Simmons
Pediatrics 2005;115;824
DOI: 10.1542/peds.2004-2442
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2005 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Hyperbilirubinemia Guidelines in Newborn Infants

Arie L. Alkalay and Charles F. Simmons
Pediatrics 2005;115;824
DOI: 10.1542/peds.2004-2442

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/115/3/824.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2005 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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