Experimental evidence shows that lack of sedation

during HT may abolish the neuroprotective effect (17).

10. Monitor urine output. Catheterization may be necessary to maintain accurate fluid balance in sedated

cooled infants.

11. Monitor core, surface, and scalp temperature (if on

head cooling) every 15 minutes during induction and

maintenance phases of HT, and during rewarming in

manual modes. In servo modes, core, surface, and scalp

temperatures can be monitored every 30 minutes during maintenance phase of HT.

12. Monitor skin for changes, and change the position of

the infant every 8 hours to avoid pressure sores.

G. Selective Head Cooling (SHC)

SHC with mild systemic hypothermia (rectal temperature

34°C to 35°C) was the first method in clinical use and aims

to selectively reduce the temperature of the brain more

than the rest of the body, thus minimizing the systemic

adverse effects of HT (18). It is currently not feasible to

accurately measure temperature in different parts of the

brain, and the large size of the infant’s head can preclude

achieving significant cooling in the deep brain without

reducing core temperature (19). There is no evidence to

suggest that either of the cooling methods (SHC or WBC)

is superior to the other. SHC with mild HT has been

reported to significantly reduce death and disability after

perinatal asphyxia (1,20).

Equipment

1. Olympic Cool-Cap system (Figs. 45.3 and 45.4) (Natus

Medical Incorporated, San Carlos, California)

a. Olympic Cool-Cap system (control unit and cooling

unit) (Fig. 45.3)

b. Radiant warmer with skin/servo temperature sensor

(Fig. 45.4)

c. Bag of sterile water, 1 L (Fig. 45.3)

d. Cool-Cap: Soft cap with water circulating channels

(Fig. 45.5A, B)

e. Water cap retainer: Ensures maximum surface area

contact between the water cap and the infant’s scalp

(Fig. 45.5C)

f. Outer insulator cap: Reflects external heat from the

radiant warmer (Fig. 45.6A)

g. Heat shield: Reflective shield to place over head and

neck to block heat from the radiant warmer (Fig.

45.6B)

h. Connecting tubes: Main hose pumps water in

and out of the cooling unit (Fig. 45.3); cap connector tubes connect the cap to the main hose and

feed water in and out of the water cap (Fig. 45.5A,

B).

 

Chapter 45 ■ Brain and Whole Body Cooling 325

E. Securing Rectal Temperature

Sensor

1. Measure and mark the rectal temperature sensor (tape

bridge) (Fig. 45.2A).

2. Insert to 6 cm into the infant’s rectum, after lubricating

the tip of the sensor (Fig. 45.2B).

3. Secure the bridge to the infant’s buttocks with tape

(Fig. 45.2C).

4. Secure a DuoDERM/Tegaderm dressing (4 × 4 cm) on

the infant’s thigh and fix the sensor over the DuoDERM/

Tegaderm with tape (Fig. 45.2E).

5. Insert a second rectal probe to 6 cm (Fig. 45.2 F), to be

connected to the patient monitor to double check the

A, B C

D, E F

Fig. 45.2. Insertion and fixation of rectal temperature sensors. A: Measuring the rectal temperature

sensor probe to 6 cm and marking with tape. B: The 6-cm mark on the rectal temperature sensor is identified by a bridge of tape. C, D: Securing the bridge on the rectal temperature sensor onto the buttock of the

infant. E: Securing the rectal temperature sensor to the thigh. F: Insertion of the second rectal probe.

Fig. 45.1. Amplitude integrated

electroencephalogram trace showing both voltage and pattern classification. Both infants with moderately

and severely abnormal tracings

will be eligible for cooling (from

ref 13).

326 Section IX ■ Miscellaneous Procedures

readings from the rectal probe connected to the cooling

machine.

F. Supportive Intensive

Care with HT

1. Provide airway support and monitoring: Appropriate

respiratory support with ventilator or continuous positive airway pressure, and monitoring of transcutaneous

oxygen saturation, pulmonary function, end-tidal CO2,

and arterial blood gases.

2. Maintain PCO2 corrected for temperature >35 mm Hg

(11) (PCO2 at 33.5°C is approximately PCO2 at 37°C ×

0.83). The reduction in metabolism induced by HT

can result in hypocapnia if ventilation is not closely

monitored.

3. Provide cardiac monitoring and support: Arterial blood

pressure, cardiac output, systemic vascular resistance

monitoring, and adequate support of cardiac function

and perfusion with inotropes, if necessary. Heart rate is

reduced by approximately 10 beats/1°C during HT.

Expected heart rate for cooled infants will be 80 to

100 beats per minute; however, inotropic support will

increase the heart rate (12).

4. Provide aEEG and EEG monitoring: Use single- or twochannel aEEG recording to assess the background

activity and monitor the time to normalization of background activity (13), identify seizures, and monitor the

effect of anticonvulsants.

5. Actively monitor and treat clinical and electrical seizures, because seizures worsen neurodevelopmental

outcome independent of the severity of hypoxicischemic brain injury (14). The serum drug levels of

anticonvulsants should be monitored closely because

HT reduces metabolism of drugs by the liver.

6. Monitor blood glucose and treat hypoglycemia.

Hypoglycemia is common in severely asphyxiated

infants, particularly within the first 24 hours (15).

7. Monitor serum electrolytes and maintain serum magnesium ≥1 mmol/L, as this may improve the neuroprotection (16).

8. Treat coagulopathy.

9. Sedate the cooled infants with appropriate sedatives to

avoid cold stress.

 

23. Carson TH, ed. Standards for Blood Banks and Transfusion services. 27th ed. Bethesda, MD: American Association of Blood

Banks; 2011.

24. Win N, Amess P, Needs M, et al. Use of red cells preserved in

extended storage media for exchange transfusion in anti-k haemolytic disease of the newborn. Transfus Med. 2005;15:157.

25. Samanta S, Kumar P, Kishore SS, et al. Donor blood glucose

6-phosphate dehydrogenase deficiency reduces the efficacy of

exchange transfusion in neonatal hyperbilirubinemia. Pediatrics.

2009;123:e96.

26. De Waal KA, Baerts W, Offringa M. Systematic review of the optimal fluid for dilutional exchange transfusion in neonatal polycythemia. Arch Dis Child Fetal Neonatal Ed. 2006;91:F7.

27. Mitra S, Samantha M, Sarkar M, et al. Pre- exchange 5% albumin

infusion in low birth weight neonates with intensive phototherapy

failure—a randomized controlled trial. J Trop Pediatr. 2011;

57:217.

28. Murakami Y, Yamashita Y, Nishimi T, et al. Changes in cerebral

hemodynamics and oxygenation in unstable septic newborns during exchange transfusion. Kurume Med J. 1998;45:321.

29. Weng YH, Chiu YW. Comparison of efficacy and safety of

exchange transfusion through different catheterizations: femoral

vein versus umbilical vein versus umbilical artery/vein. Pediatr

Crit Care Med. 2011;12:61.

30. Chen HN, Lee ML, Tsao LY. Exchange transfusion using peripheral vessels is safe and effective in newborn infants. Pediatrics.

2008;122:e905.

31. Patra K, Storfer- Isser A, Siner B, et al. Adverse events associated

with neonatal exchange transfusion in the 1990s. J Pediatr. 2004;

144:626.

 

323

45 Brain and Whole Body Cooling

46 Removal of Extra Digits and Skin Tags

47 Circumcision

48 Drainage of Superficial Abscesses

49 Phototherapy

50 Intraosseous Infusions

51 Tapping a Ventricular Reservoir

52 Treatment of Retinopathy of Prematurity

53 Peritoneal Dialysis

54 Neonatal Hearing Screening

55 Management of Natal and Neonatal Teeth

56 Relocation of a Dislocated Nasal Septum

57 Lingual Frenotomy

Miscellaneous

Procedures

IX

324

Ela Chakkarapani

Marianne Thoresen

45 Brain and Whole Body Cooling

Moderate therapeutic hypothermia (HT; rectal or esophageal temperature 33.5°C) initiated within 6 hours and continued for 72 hours reduces death or disability (NNT 6,

95% CI 5 to 9) and increases the number of survivors with

normal neurology after perinatal asphyxia (NNT 8, 95%

CI 5 to 17) (1–6). HT is delivered in newborn infants

as whole body cooling (WBC) using different types of

mattresses or wraps around the body, or as selective head

cooling (SHC) using a “coolcap” around the head (1–3).

A. Indications

To decrease death or disability in the following group of

infants (1–3)

a. ≥36 weeks’ gestation newborn infants <6 hours of age

b. Evidence of asphyxia (at least one of the four criteria

below must be met)

(1)Apgar score at 10 minutes of age ≤5

(2)Worst arterial or capillary or venous pH within 60

minutes of life <7

(3)Arterial or capillary or venous base deficit within 60

minutes of life ≥12 or 16

(4)Ventilated or resuscitated for at least the first

10 minutes after birth

and c or d

c. Moderate or severe encephalopathy characterized by

(1)Abnormal consciousness—lethargy or stupor or

coma and

(2)Hypotonia or abnormal reflexes (including oculomotor or pupillary abnormalities), or decreased/absent

spontaneous activity, or abnormal (distal flexion/

complete extension/decerebrate) posture, or absent/

weak suck, or incomplete/absent moro or

d. Clinical seizures

and

e. 30 minutes abnormal background activity or seizures in

 

16. Aikoh H, Sasaki M, Sugai K, et al. Effective immunoglobulin

therapy for brief tonic seizures in methylmalonic acidemia. Brain

Dev. 1997;19:502.

17. Chinnakaruppan NR, Marcus SM. Asymptomatic congenital

lead poisoning- case report. Clin Toxicol (Phila). 2010;48:563.

18. Demirel G, Erdeve O, Utras N, et al. Exchange transfusion as

rescue therapy in a severely premature child with acute renal failure. Pediatr Nephrol. 2011;26:821.

19. Sancak R, Kucukoduk S, Tasdemir HA, et al. Exchange transfusion treatment in a newborn with phenobarbital intoxication.

Pediatr Emerg Care. 1999;15:268.

20. Dolfin T, Pomerance A, Korzets Z, et al. Acute renal failure in a

neonate caused by the transplacental transfer of a nephrotoxic

paraprotein: successful resolution by exchange transfusion. Am J

Kidney Dis. 1999;34:1129.

21. Gunes T, Koklu E, Buyukkayhan D, et al. Exchange transfusion

or intravenous immunoglobulin therapy as an adjunct to antibiotics for neonatal sepsis in developing countries: a pilot study. Ann

Trop Paediatr. 2006;26:39.

22. Virdi VS, Goraya JS, Khadwal A, et al. Neonatal transfusion

malaria requiring exchange transfusion. Ann Trop Pediatr. 2003;

23:205.

 

9. Ramasethu J, Luban NLC. Alloimmune hemolytic disease of the

newborn. In: Kaushansky K, Lichtman MA, Beutler E, et al., eds.

Williams’ Hematology. 8th ed. New York: McGraw-Hill; 2010:799.

10. Naulaers G, Barten S, Vanhole C, et al. Management of severe

neonatal anemia due to fetomaternal transfusion. Am J Perinatol.

1999;16:193.

11. Ozek E, Soll R, Schimmel MS. Partial exchange transfusion to

prevent neurodevelopmental disability in infants with polycythemia. Cochrane Database Syst Rev. 2010;20:CD005089.

12. Sugiura T, Goto K, Nichonji T et al. Cytokine profiles before and

after exchange transfusion in a neonate with transient myeloproliferative disorder and hepatic fibrosis. J Pediatr Hematol Oncol.

2010;32:e164.

13. Park ES, Kim SY, Yeom JS, et al. Extreme thrombocytosis associated with transient myeloproliferative disorder with Down syndrome with t(11;17)(q13;q21). Pediatr Blood Cancer. 2008;50:

643.

14. Rand EB, Karpen SJ, Kelly S, et al. Treatment of neonatal hemochromatosis with exchange transfusion and intravenous immunoglobulin. J Pediatr. 2009;155:566.

15. Chen CY, Chen YC, Fang JT, et al. Continuous arteriovenous

hemodiafiltration in the acute treatment of hyperammonemia

due to ornithine transcarbamylase deficiency. Ren Fail. 2000;

22:823.

 

Chapter 44 ■ Exchange Transfusions 321

Exchange Transfusion by Isovolumetric

Technique (Central or Peripheral Lines)

1. Scrub as for major procedure.

2. Select two sites for line placement, and insert (See page

320).

a. Venous for infusion

(1) UVC or

(2) Peripheral IV that is at least 23 gauge

b. Arterial for removal

(1) Umbilical artery catheter

(2) Peripheral, usually radial if infant’s size permits

3. Connect arterial line to three-way stopcock.

a. Use short, connecting IV tubing to extend peripheral line.

b. Attach additional connecting tubing to stopcock

and place into sterile waste container.

c. Attach empty 3- to 10-mL syringe to stopcock, for

withdrawal of blood.

An additional stopcock may also be placed on

this port so that a syringe of heparinized saline (5 U/

mL) may be attached for use as needed. Be cautious

about total volume infused.

4. Connect venous line to single, three-way stopcock,

which in turn connects to empty 5- to 10-mL syringe

and to blood-warming coil.

5. Start exchange-transfusion record.

6. Withdraw and discard blood from arterial side at rate of

2 to 3 mL/kg/min, and infuse at same rate into venous

side. Keep flow as steady as possible, and volumetrically

equal for infusion and removal.

7. Intermittently, flush arterial line with heparinized

saline to clear.

The heparin solution remaining in tubing will be

removed with next withdrawal, thus reducing significantly

the total heparin dose actually received by the patient.

8. Follow steps as for push–pull technique until exchange

is complete.

9. Total duration for isovolumetric ET: 45 to 60 minutes,

may be longer in sick, unstable infant.

H. Postexchange for All Techniques

1. Continue to monitor vital signs closely for at least 4 to

6 hours.

2. Rewrite orders: Adjust any drug dosages as needed to

compensate for removal by exchange.

3. Keep infant NPO for at least 4 hours. Restart feeds if

clinically stable. Monitor abdominal girth and bowel

sounds every 3 to 4 hours for next 24 hours if exchange

has been performed using umbilical vascular lines.

Observe for signs of feeding intolerance.

4. Monitor serum glucose levels every 2 to 4 hours for

24 hours.

5. Repeat blood gases as often as clinically indicated.

6. Measure serum ionized calcium levels and platelet

counts in sick infants immediately after the ET and

then as indicated.

7. Repeat hemoglobin, hematocrit, and bilirubin measurements approximately 4 hours after exchange, and

further as clinically indicated. A double-volume ET

replaces 85% of the infant’s blood volume but eliminates only about 50% of the intravascular bilirubin.

Equilibration of intra- and extravascular bilirubin and

continued breakdown of sensitized and newly formed

red cells by persisting maternal antibody results in a

rebound of bilirubin levels following initial ET and

may necessitate repeated ET in severe HDN.

I. Complications

1. Risk of death or permanent serious sequelae is estimated to be <1% in healthy infants, but as high as 12%

in sick infants. There may be some uncertainty in

ascribing adverse events to the ET in infants who are

already critically ill (1,31)

2. Many of the adverse events are hematologic or biochemical laboratory abnormalities which may be

asymptomatic. The most common adverse effects noted

during or soon after the ET, usually in infants who are

preterm and/or sick.

a. Apnea and/or bradycardia

b. Hypocalcemia

c. Thrombocytopenia (<50,000 in 10% of healthy infants,

up to 67% in infants <32 weeks’gestational age)

d. Metabolic acidosis

e. Vascular spasm

3. Complications reported from ET are related to the

blood transfusion and to complications of vascular

access (see Chapters 29, 30, and 43).

4. Potential complications include

a. Metabolic: Hypocalcemia, hypo- or hyperglycemia,

hyperkalemia

b. Cardiorespiratory: Apnea, bradycardia, hypotension,

hypertension

c. Hematologic: Thrombocytopenia, dilutional coagulopathy, neutropenia, disseminated intravascular

coagulation

d. Vascular catheter related: Vasospasm, thrombosis,

embolization

e. Gastrointestinal: Feeding intolerance, ischemic

injury, necrotizing enterocolitis

f. Infection: Omphalitis, septicemia

References

1. Steiner LA, Bizzarro MJ, Ehrenkrantz RA, et al. A decline in the

frequency of neonatal exchange transfusions and its effect on

exchange transfusion related morbidity and mortality. Pediatrics.

2007;120:27.

2. Johnson L, Bhutani VK, Karp K, et al. Clinical report from the

pilot USA Kernicterus Registry (1992 to 2004). J Perinatol. 2009;

29:S25.

 

320 Section VIII ■ Transfusions

b. With symptoms or signs of hypocalcemia

(1) Change in QTc interval

(2) Agitation and tachycardia: These symptoms are

not reliably correlated with ionized calcium levels.

It is rarely necessary or advantageous to give

calcium during an ET if the infant is normocalcemic. When administered, the effect may last

only a few minutes. Calcium will reverse the

effect of the anticoagulant in the donor blood

and may cause clotting of the line, so administration through a peripheral IV line is preferred.

If calcium is given through the UVC, prior to

administration, clear the line of donor blood

with 0.9% NaCl. Give 1 mL of 10% calcium

gluconate per kilogram body weight. Administer

slowly, with careful observation of heart rate and

rhythm. Clear line again with 0.9% NaCl.

18. Perform calculated number of passes, until desired volume has been exchanged.

19. Be sure there is adequate volume of donor blood

remaining to infuse after last withdrawal, if a positive

intravascular balance is desired.

20. Clear umbilical line of banked blood and withdraw

amount of infant’s blood needed for laboratory testing,

including re-cross-matching.

21. Infuse IV fluids with 0.5 to 1 U heparin/mL of fluid

through UVC if further ETs are anticipated.

22. Total duration for double volume ET: 90 to 120 minutes.

23. Document procedure in patient’s hospital record.

Exchange Transfusion Using a Single

Umbilical Line and Two Three-Way

Stopcocks in Tandem

The principles and techniques for using either the special

stopcock or two three-way stopcocks in tandem are the

same. It is important to ensure that all junctions are tight to

produce a closed, sterile system. It is also essential to understand the working positions of the stopcocks before starting

the exchange.

1. Scrub as for major procedure. Wear sterile gown and

gloves.

2. Attach stopcock and tubing in sequence (Fig. 44.5).

a. Proximal stopcock

(1) Umbilical catheter

(2) IV extension tubing to sterile waste container

b. Distal stopcock

(1) Tubing from blood-warming coil

(2) 10- or 20-mL syringe

3. Clear lines of air bubbles.

4. Start exchange record.

5. Follow steps of push–pull technique until exchange is

completed.

Fig. 44.5. Three-way stopcocks in tandem. Step 1: Stopcocks positioned for withdrawing blood from

infant. Step 2: Stopcocks positioned for emptying withdrawn blood to waste container. Step 3: Stopcocks

positioned for filling syringe from blood bag. Step 4: Stopcocks positioned for injecting blood into infant line.

 

Monitor cardiorespiratory status, continuous pulse

oximetry. Determine blood gases as often as indicated

by pre-existing clinical condition and stability.

11. Draw blood for diagnostic studies.

12. Usual rate of removal and replacement of blood during

the ET is 5 mL/kg over a 2- to 4-minute cycle.

13. If infant is hypovolemic or has low CVP, start exchange

with transfusion of aliquot into catheter. If infant is

hypervolemic or has high CVP, start by withdrawing

precalculated aliquot.

14. Remeasure CVP if indicated. Expect rise as plasma

oncotic pressure increases, if CVP low at start.

15. Ensure that the stages of drawing and infusing blood

from and into the infant are done slowly, taking at

least a minute each to avoid fluctuations in blood

pressure. Rapid fluctuations in arterial pressure in the

push–pull technique may be accompanied by

changes in intracranial pressure (28). Rapid withdrawal from the umbilical vein induces a negative

pressure that may be transmitted to the mesenteric

veins and contribute to the high incidence of ischemic

bowel complications.

16. Gently agitate the blood bag every 10 to 15 minutes to

prevent red cell sedimentation, which may lead to

exchange with relatively anemic blood toward the end

of the exchange.

17. Consider giving calcium supplement.

a. When hypocalcemia is documented

Fig. 44.3. Special four-way stopcock. A: Male adapter to infant

line. B: Female adapter to waste container. C: Attachment to

blood tubing. D: “Off” position (180 degrees from adapter to waste

container), allowing injection through rubber-stoppered port

“below” syringe. The stopcock is used in clockwise rotation when

correctly assembled.

A B

Waste blood

bag connection

UVC

from

blood

warmer

Fig. 44.4. A, B: ET using special four-way stopcock.

 

a. Verify identification of blood product (see Chapter

43).

(1) Type and cross-match data

(2) Expiration date

(3) Donor and recipient identities

b. Attach blood administration set to blood-warmer

tubing and to blood bag.

c. Allow blood to run through blood warmer.

G. Technique (See also Website for

Procedure Video)

Exchange Transfusion by Push–Pull

Technique through Special Stopcock with

Preassembled Tray

1. Read instructions provided by manufacturer carefully.

2. Wear head cover and mask. Scrub as for major procedure. Wear sterile gown and gloves.

3. Open preassembled equipment tray, using aseptic technique.

4. Identify positions on special stopcock in clockwise rotation (Figs. 44.3 and 44.4). The direction that the handle is pointing indicates the port that is open to syringe.

The special stopcock allows clockwise rotation in the

order used: (a) withdraw from patient, (b) clear to waste

bag, (c) draw new blood, (d) inject into patient. Always

rotate in clockwise direction to follow proper sequence,

and keep connections tight.

a. Male adapter to umbilical or peripheral line

b. Female adapter to the extension tubing to which

waste bag will be attached.

c. Connection to tubing for attachment to bloodwarmer coil

d. Neutral “off” position in which additives may be

administered through rubber stopper (180 degrees

from waste-receptacle port)

5. Follow steps as illustrated by manufacturer to make all

connections to blood and waste bags.

6. With stopcock open to blood source, clear all air into

syringe. Turn in clockwise direction 270 degrees and

evacuate into waste.

Chapter 44 ■ Exchange Transfusions 319

7. Turn stopcock to “off,” and replace onto sterile field.

8. Use pre-existing umbilical venous line or insert UVC,

as described in Chapter 30.

a. Place a single-lumen UVC whenever possible. The

internal lumen of a double-lumen UVC is smaller

and makes it more difficult to perform the ET.

b. Consider central venous pressure (CVP) measurement, using pressure transducer, in unstable baby.

c. Place catheter in inferior vena cava (IVC) and verify

position by radiograph.

d. If catheter cannot be positioned in IVC, it may still

be used cautiously in an emergency, when placed in

the umbilical vein, if adequate blood return is

obtained.

9. Have an assistant document all vital signs, in and out

volumes, and other data, on the exchange record.

10. Check peripheral glucose levels every 30 to 60 minutes.

 

316 Section VIII ■ Transfusions

2. Resuscitation equipment and medication (immediately

available)

3. Infant restraints

4. Orogastric tube

5. Suctioning equipment

6. Equipment for central and peripheral vascular access

7. Blood warmer and appropriate cartridge (see E7)

8. Sterile exchange transfusion equipment

a. Preassembled disposable set with special four-way

stopcock or

b. Nonassembled

(1) Two three-way stopcocks with locking connections

(2) 5-, 10-, or 20-mL syringes

(3) Waste receptacle (empty IV bottle or bag)

(4) IV connecting tubing

9. Appropriate blood product

10. Syringes and tubes for pre- and postexchange blood tests

E. Precautions

1. Stabilize infant before initiating exchange procedure.

2. Do not start exchange procedure until personnel are

available for monitoring and as backup for other emergencies.

3. Monitor infant closely during and after procedure.

4. Do not rush procedure.

a. May necessitate repeat if efficacy is decreased by

haste

b. Stop or slow if patient becomes unstable.

5. Use blood product appropriate to clinical indication.

Use freshest blood available, preferably <5 to 7 days.

6. Check potassium level of donor blood if patient has

hyperkalemia or renal compromise.

7. Use only thermostatically controlled blood-warming

device that has passed quality control for temperature

and alarms. Be sure to review operating and safety procedures for specific blood warmer. Do not overheat

blood (i.e., beyond 38°C).

8. Do not apply excessive suction if it becomes difficult to

draw blood from line. Reposition line or replace

syringes, stopcocks, and any adapters connected to line.

9. Leave anticoagulated, banked blood in line or clear

line with heparinized saline if the procedure is interrupted.

10. Clear line with heparinized saline if administering calcium.

F. Preparation for Total or Partial

Exchange Transfusion

1. Blood Product and Volume

Blood Product

a. Communicate with blood bank or transfusion medicine specialist to determine most appropriate blood

product for transfusion.

(1) Plasma reduced whole blood or packed red cells

reconstituted with plasma may be used (23).

Fig. 44.1. Guidelines for exchange transfusion

in infants 35 or more weeks gestation. (From

American Academy of Pediatrics. Subcommittee on Hyperbiliru-binemia. Clinical

Practice Guideline. Management of hyperbilirubinemia in the newborn infant 35 or more

weeks gestation. Pediatrics. 2004;114:297.)