Neonatal Bilirubin

AAP 2022 Clinical Practice Guideline. Determines phototherapy threshold based on gestational age and risk factors.

Neurotoxicity Risk Factors for Phototherapy Threshold (AAP 2022)

Higher Risk (use lower threshold):

Gestational age 35-37 weeks (with other risk factors)
Albumin < 3.0 g/dL
Isoimmune hemolytic disease (ABO, Rh incompatibility)
G6PD deficiency
Asphyxia / significant lethargy
Sepsis
Acidosis (pH < 7.15)
Temperature instability / hypothermia

Lower Risk (use higher threshold):

Gestational age ≥ 38 weeks
No hemolysis
Well-appearing infant
No risk factors above

Source: AAP 2022 Clinical Practice Guideline

Risk Factors for Severe Neonatal Hyperbilirubinemia (Nelson Table 137.1)

Genetic Factors

Gilbert syndrome
Crigler-Najjar syndrome
Alagille syndrome
β-thalassemia
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Bilirubin glucuronosyltransferase polymorphism
Pyruvate kinase deficiency
Erythrocyte structural defects (hereditary spherocytosis, elliptocytosis)
Galactosemia

Maternal Factors

Family history of severe jaundice, splenectomy, or cholecystectomy
Primiparity
Teenage pregnancy
Diabetes
Rhesus incompatibility
ABO incompatibility
Other blood group isoimmunization
Use of drugs during labor (oxytocin, promethazine, bupivacaine)
Exclusive breastfeeding

Perinatal Factors

Mode of delivery (breech vs vertex, instrumentation)
Birth trauma (cephalohematoma, substantial bruising, extravasation)
Birth asphyxia
Congenital infections (CMV, syphilis)
Sepsis

Neonatal Factors

Male sex
Prematurity or low birthweight and small-for-gestational age
Hypothyroidism
Polycythemia
Hypoglycemia
Low intake of breast milk, dehydration, or weight loss
Breast milk jaundice
Jaundice in the first day of life
Trisomy 21
Infant of diabetic mother
Cephalohematoma, other bruising

Other Risk Factors and Markers

Previous sibling received phototherapy or exchange transfusion
Predischarge TSB or TcB in the high zone
Use of hemolytic agents (naphthalene, menthol-based products) in G6PD-deficient populations
Folate deficiency
Aflatoxins
Hypothermia
Birth outside of a healthcare facility

Modified from Olusanya BO, Kaplan M, Hansen TWR. Neonatal hyperbilirubinaemia: a global perspective. Lancet Child Adolesc Health. 2018;2:610-618. Nelson Textbook of Pediatrics, Table 137.1.

Gestational Age (weeks)

Age of Infant (hours)

Total Serum Bilirubin (mg/dL)

Risk Factors

Normal Vital Signs by Age

Harriet Lane Handbook

Reference ranges for heart rate, respiratory rate, and blood pressure by age. Source: Harriet Lane Handbook.

Age	Heart Rate (bpm)	Respiratory Rate	Systolic BP (mmHg)	Diastolic BP (mmHg)	Weight (kg)
Preterm	120-170	40-70	55-75	35-45	1-2.5
Newborn (0-1mo)	100-160	30-60	60-80	35-55	2.5-4.5
1-6 months	100-150	30-50	70-90	40-60	4-8
6-12 months	90-140	25-40	75-95	45-65	8-10
1-3 years	80-130	20-30	80-100	50-70	10-15
4-5 years	80-120	20-25	85-105	50-70	15-20
6-8 years	70-115	18-25	90-110	55-75	20-27
9-11 years	70-110	16-22	95-115	58-78	27-40
12-15 years	60-100	14-20	100-125	60-80	40-60
16-18 years	55-95	12-18	110-130	65-85	55-75

Quick Reference Formulas

Estimated Weight:
1-12mo: (age in mo + 9) / 2
1-5yr: 2 x (age in yr) + 8
6-12yr: 3 x (age in yr) + 7

Min Systolic BP:
1-10yr: 70 + (2 x age in yr)
Hypotension: SBP < 5th %ile

ETT Size:
Uncuffed: (age/4) + 4
Cuffed: (age/4) + 3.5
Depth: ETT size x 3

Maintenance Fluids (4-2-1):
First 10kg: 4 mL/kg/hr
Next 10kg: +2 mL/kg/hr
Each kg above 20: +1 mL/kg/hr

Pediatric Calculators

Blood Pressure Percentile

BMI Percentile

Body Surface Area

Weight-Based Dosing

Growth Percentiles

Neonatal Bilirubin

Normal Vital Signs by Age

Quick Reference Formulas