Pediatric Hospital Medicine – SHM, AAP, APA

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January 11, 2021

Do not initiate phototherapy in term or late preterm well-appearing infants with neonatal hyperbilirubinemia if their bilirubin is below levels at which the AAP guidelines recommend treatment

The risk of poor neurologic outcomes, such as cerebral palsy due to kernicterus, is extremely low for term and late preterm newborns with modestly elevated bilirubin levels. Confirmed cases of kernicterus have average bilirubin levels near 40 mg/dL, and are typically associated with hemolysis. While phototherapy for bilirubin values above published thresholds may be useful to prevent severe hyperbilirubinemia and exchange transfusions, its use for bilirubin values below published thresholds is unnecessary and is associated with additional costs and unnecessary hospitalization.

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How The List Was Created

A diverse committee with representatives from the Society of Hospital Medicine’s Pediatrics Special Interest Group, the American Academy of Pediatrics’ Section on Hospital Medicine and the Academic Pediatric Association’s Hospital Medicine Special Interest Group solicited a list of recommendations with specified criteria from colleagues and the various society listservs. Through an iterative process, recommendations were formatted, merged, and presented with an evidence review of publications from the past 10 years supporting each recommendation. From over 100 initial recommendations and through 2 rounds of a modified Delphi process, the highest scoring recommendations were chosen to represent the Pediatric Hospital Medicine Choosing Wisely list. The list was endorsed by the Boards of the Society of Hospital Medicine and the Academic Pediatric Association and peer reviewed by various AAP specialty groups and endorsed by the American Academy of Pediatrics’ Executive Committee.


American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics. 2004 Oct;114(4):1138]. Pediatrics. 2004;114(1):297-316. doi:10.1542/peds.114.1.297
Wu YW, Kuzniewicz MW, Wickremasinghe AC, et al. Risk for cerebral palsy in infants with total serum bilirubin levels at or above the exchange transfusion threshold: a population-based study. JAMA Pediatr. 2015;169(3):239-46. doi: 10.1001/jamapediatrics.2014.303
Newman TB, Liljestrand P, Jeremy RJ, et al. Outcomes among Newborns with Total Serum Bilirubin Levels of 25 mg per Deciliter or More. NEJM. 2006;354(18)1889-1900.
Newman TB, Kuzniewicz MW, Liljestrand P, et al. Numbers Needed to Treat With Phototherapy According to American Academy of Pediatrics Guidelines. Pediatrics 2009;123:1352–1359
Kuzniewicz MW, Wickremasinghe AC , Wu YW, et al. Incidence, Etiology, and Outcomes of Hazardous Hyperbilirubinemia in Newborns. Pediatrics 2014;134;504.
Kuzniewicz MW, Escobar G, Newman TB. Impact of Universal Bilirubin Screening on Severe Hyperbilirubinemia and Phototherapy Use. Pediatrics 2009;124:1031–1039. DOI:
Wickremasinghe AC, Kuzniewicz MW, Grimes BA, McCulloch CE, Newman TB. Neonatal Phototherapy and Infantile Cancer. Pediatrics. 2016;137(6):e20151353. doi:10.1542/peds.2015-1353