Figure 1. Newborn Jaundice Record and Age Specific Nomogram
NEWBORN JAUNDICE RECORD
(Complete prior to discharge)
NAME
MR#
DATE OF BIRTH:
TIME OF BIRTH
____/____/_______
____/____ am pm
AGE SPECIFIC BILIRUBIN NOMOGRAM
Bhutani VK et al. Pediatrics 1999;103:6-14 (with permission)
Plot total bilirubin at age drawn
Repeat bilirubin in 6-8 hours if value in High or High Intermediate zone
Risk Factors (check all that apply)
Maternal Blood Type: ____/_____
Infant Blood Type: ____/____ DAT: ____
Serum or Transcutaneous Bilirubin Record
Date Time Age (hrs)
Total Bilirubin
of Gilbert's Syndrome
f birth weight
____
_____ _________
_____________
____
_____ _________
_____________
____
_____ _________
_____________
____
_____ _________
_____________
____
_____ _________
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Figure 2. Guidelines for Phototherapy
With permission from American Academy of Pediatrics. Clinical Practice Guideline. Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2004;114:297-315
Figure 3. Guidelines for Exchange Transfusion
May also be used as guideline for initiation of formula supplementation of
breastfed infant and temporary interruption of breastfeeding.
With permission from American Academy of Pediatrics. Clinical Practice Guideline. Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2004;114:297-315