Treating Hyperbilirubinemia in Newborns: AAP Updates Clinical Guidelines

Updated clinical guidelines on phototherapy and intravenous immune globulin (IVIG) treatment for hyperbilirubinemia in newborns were published in the journal Pediatrics.

Hyperbilirubinemia can cause kernicterus, which may be life-threatening or lead to severe, lifelong neurodevelopmental impairment. In 2004, the American Academy of Pediatrics (AAP) published guidelines about the management of hyperbilirubinemia in newborn infants born at 35 or more weeks’ gestation.

This second guideline revision incorporated new evidence from large cohort investigations published through April 2022. The AAP guideline committee focused on two topics: the adverse effects of phototherapy for newborns and the efficacy of IVIG to prevent exchange transfusion in infants.

Based on evidence from 38 published manuscripts, the committee found significant, but low, overall risk for potential harm from phototherapy. The most serious associated risk with phototherapy during infancy was childhood seizures with an adjusted ten-year excess risk of 2.4 per 1000 phototherapy-treated infants.

In addition, there was some evidence to suggest that phototherapy may interrupt familial boding with the infant. The guideline authors stated that phototherapy treatment thresholds should balance the risk for adverse effects with potential benefits of reducing total serum bilirubin concentrations.

For IVIG, 11 published manuscripts were considered. The consensus of evidence suggested that IVIG may not be effective at preventing exchange transfusion among infants with severe Rhesus (Rh) disease, however, larger, randomized trials are needed to validate this finding. In addition, IVIG in non-Rh-mediated hemolysis and ABO incompatibility remains understudied.

No randomized trials reported safety concerns for IVIG. Some observational studies have found an association between IVIG and necrotizing enterocolitis (odds ratio [OR], 31.66; 95% CI, 3.25-308.57) without an increase in mortality.

The guideline authors stated that IVIG may be considered for infants with isoimmune hemolytic disease who were unresponsive to phototherapy.

The guideline authors stated that “A systematic approach combining the best available evidence and expert opinion, when necessary, was used to generate an updated guideline for the diagnosis and management of hyperbilirubinemia in neonates ≥ 35 weeks’ gestation.”

They added that “The committee has developed new phototherapy and exchange transfusion treatment recommendations that should reduce the numbers of infants unnecessarily treated with phototherapy while at the same time ensuring that infants at higher risk for bilirubin-associated neurotoxicity, on the basis of serum bilirubin concentrations, gestational age, and neurotoxicity risk factors, will receive proper treatment to prevent hyperbilirubinemia-associated harm.”