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Lisa Black

A committee of neonatologists, hospitalists, general pediatricians, a nurse, and breastfeeding experts worked from 2014 through 2022 to evaluate new evidence to inform the revised guidelines

The American Academy of Pediatrics has revised clinical guidelines on treating infants born at least 35 weeks into pregnancy for hyperbilirubinemia. For most babies, hyperbilirubinemia leads only to jaundice, a yellow appearance to the skin and whites of the eyes. However, very rarely, it can lead to severe complications affecting the brain.

The “Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation,” published in the September 2022 Pediatrics (published online Aug. 5) incorporates new research findings on risk-assessment and treatment. The guideline updates and replaces the 2004 AAP clinical practice guideline for the management and prevention of hyperbilirubinemia. A technical report, “Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation,” also will be published.

“It’s important for hospitals and clinicians caring for newborns to have plans in place to prevent the serious complications of hyperbilirubinemia, including measuring bilirubin on all newborns prior to discharge,” said Alex R. Kemper, MD, MPH, MS, FAAP, chair of the guideline authoring committee.

“There are ways we can help prevent hyperbilirubinemia, starting with good prenatal care and breastfeeding support,” Dr. Kemper said. “However, measuring bilirubin levels on all babies is a critical step in knowing which babies need phototherapy, or light treatment, to bring down the bilirubin level, or how soon a baby needs follow-up after discharge.”

The committee considered the effectiveness of therapy and the potential harm of phototherapy in developing these guidelines.

If a high bilirubin level goes untreated, it can cause kernicterus, a type of permanent brain damage that is associated with cerebral palsy and serious movement problems. “This is why we need to make sure clinicians understand why it is important to test bilirubin levels and for families to understand their babies’ risk and recommended follow-up,” added Dr. Kemper.

Another treatment called exchange transfusion can be used in severe cases of hyperbilirubinemia. It is an approach to rapidly replace the baby’s blood to lower the bilirubin level. Because research published since 2004 suggests bilirubin does not cause toxicity unless it reaches levels higher than previously thought, the revised clinical guideline raises phototherapy and exchange transfusion thresholds by a narrow range.

The AAP also used new research findings to revise the risk-assessment approach based on the difference between the phototherapy threshold and the infant’s current bilirubin level to guide when bilirubin should be measured again. This approach will help clinicians make sure there is timely follow-up.

“Fortunately, kernicterus is rare, but the impact on children and their families can be devastating,” Dr. Kemper said. “The guideline provides clinicians, birthing centers and hospitals with strategies to prevent the worst-case scenarios and to help educate families so they recognize the signs of jaundice and know when to follow-up with their pediatrician.”

To request a copy of the clinical guideline or request an interview with an author, contact AAP Public Affairs. A article for parents is here.

Editor’s note: A solicited commentary, “Applying an Equity Lens to Clinical Practice Guidelines: Getting Out of the Gate,” will be published in the same issue of Pediatrics.


The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.

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