美国儿科学会：≥35周胎龄新生儿高胆红素血症处理：临床实践指南的修订（第六部分）

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V. Hospital Policies and Procedures

Hospitals and other types of birthing centers should have clearly established policies and procedures to help all infants receive optimal care to prevent kernicterus. Clinicians should document activities specifically related to this clinical practice guideline in the medical record.

Nursing protocols with standing orders should be established for the physical assessment of neonatal jaundice and the circumstances in which the nursing staff can obtain a TcB or TSB measurement. This should include obtaining a TcB or TSB if jaundice is noted within the first 24 hours after birth.

All facilities treating infants should have the necessary equipment to provide intensive phototherapy. Hospitals should have systems to verify that appropriate irradiance is delivered and should follow the recommendations of the phototherapy system manufacturer. Hospitals are encouraged to have a family-centered approach to phototherapy that includes providing phototherapy in the mother’s room, when possible, to allow for bonding and breastfeeding.

All facilities treating infants without the equipment or personnel to escalate care should have written plans for rapid and safe transfer of infants who might require exchange transfusion. These plans should include the ability to provide phototherapy during transfer.

Facilities that provide care for newborn infants should have a mechanism, when needed, for infants to have a follow-up TcB or TSB measured that includes weekends and holidays. A key step to achieving this is to maintain a list of key contacts to support the seamless provision of care. A system should be in place to provide care whenever there is uncertainty regarding the provision of appropriate follow-up. This care includes a mechanism for providing the results of any testing to families and providing care according to these guidelines.

KAS 25: Before discharge, all families should receive written and verbal education about neonatal jaundice. Parents should be provided written information to facilitate postdischarge care, including the date, time, and place of the follow-up appointment and, when necessary, a prescription and appointment for a follow-up TcB or TSB. Birth hospitalization information, including the last TcB or TSB and the age at which it was measured, and DAT results (if any) should be transmitted to the primary care provider who will see the infant at follow-up. If there is uncertainty about who will provide the follow-up care, this information should also be provided to families. (Aggregate Evidence Quality Grade X, Strong Recommendation)

Education should include an explanation of jaundice; the need to monitor infants for jaundice, dehydration, and lethargy; signs of ineffective feeding, fussiness, and illness; and an assessment of understanding of these issues and the recommended follow-up. The AAP has a parent handout addressing these issues.

Summary

Although kernicterus is rare, the impact on affected individuals and their families can be devastating. Clinicians who provide care for newborn infants should understand the importance of the strategies to prevent kernicterus outlined in this guideline. Implementation of systems to provide consistent application of these recommendations for all infants 35 or more weeks of gestation within mother-baby units, hospitals, and primary care clinics is critical to the success of these recommendations.

This clinical practice guideline emphasizes the opportunities for primary prevention (eg, treatment to prevent isoimmune hemolytic disease, adequate breastfeeding support), the need to obtain an accurate history and physical examination to determine the presence of hyperbilirubinemia and hyperbilirubinemia neurotoxicity risk factors, the importance of predicting the risk of future hyperbilirubinemia including a predischarge measurement of TSB or TcB, and the importance of postdischarge follow-up. This clinical practice guideline provides indications and approaches for phototherapy and escalation of care and when treatment and monitoring can be safely discontinued. For all recommendations, the committee recognizes that clinicians should understand the rationale for what is recommended, use their clinical judgment, and, when appropriate, engage in shared decision making.

Subcommittee Authors

Alex R. Kemper, MD, MPH, MS, FAAP, Chairperson

Thomas B. Newman, MD, MPH, FAAP, Vice-chairperson

Jonathan L. Slaughter, MD, MPH, FAAP, Epidemiologist

M. Jeffrey Maisels, MB BCh, DSc, FAAP

Jon F. Watchko, MD, FAAP

Stephen M. Downs, MD, MS, AAP Partnership for Policy Implementation

Randall W. Grout, MD, MS, FAAP, AAP Partnership for Policy Implementation

David G. Bundy, MD, MPH, FAAP

Ann R. Stark, MD, FAAP, AAP Section on Neonatal-Perinatal Medicine

Debra L. Bogen, MD, FAAP

Alison Volpe Holmes, MD, MPH, FAAP

Lori B. Feldman-Winter, MD, MPH, FAAP

Vinod K. Bhutani, MD, FAAP

Steven Brown, MD, FAAFP, American Academy of Family Physicians Representative

Gabriela M. Maradiaga Panayotti, MD, FAAP

Kymika Okechukwu, MPA, Senior Manager, Evidence-Based Medicine Initiatives

Peter D. Rappo, MD, FAAP

Terri L. Russell, DNP, APN, NNP-BC, National Association of Neonatal Nurses Liaison

Staff

Kymika Okechukwu, MPA, Senior Manager, Evidence-Based Medicine Initiatives.

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