Predicting the Need for Phototherapy After Discharge

Abstract

BACKGROUND AND OBJECTIVES: Bilirubin screening before discharge is performed to identify neonates at risk for future hyperbilirubinemia. The American Academy of Pediatrics recommends using a graph of bilirubin levels by age (the Bhutani Nomogram) to guide follow-up and a different graph to determine phototherapy recommendations. Our objective was to evaluate predictive models that incorporate the difference between the last total serum bilirubin (TSB) before discharge and the American Academy of Pediatrics phototherapy threshold (D-TSB) to predict a postdischarge TSB above the phototherapy threshold by using a single graph. METHODS:We studied 148 162 infants born at $35 weeks' gestation at 11 Kaiser Permanente Northern California facilities from 2012 to 2017 whose TSB did not exceed phototherapy levels and who did not receive phototherapy during the birth hospitalization. We compared 3 logistic models (D-TSB; D-TSB-Plus, which included additional variables; and the Bhutani Nomogram) by using the area under the receiver operating characteristic curve (AUC) in a 20% validation subset.RESULTS: A total of 2623 infants (1.8%) exceeded the phototherapy threshold postdischarge. The predicted probability of exceeding the phototherapy threshold after discharge ranged from 56% for a predischarge D-TSB 0 to 1 mg/dL below the threshold to 0.008% for D-TSB .7 mg/dL below the threshold. Discrimination was better for the D-TSB model (AUC 0.93) and the D-TSB-Plus model (AUC 0.95) than for the Bhutani Nomogram (AUC 0.88). CONCLUSIONS:The use of D-TSB models had excellent ability to predict postdischarge TSB above phototherapy thresholds and may be simpler to use than the Bhutani Nomogram.

Neonatal hyperbilirubinemia: Assessing variation in knowledge and practice

“…1 Survey text with correct answers highlighted can be found in S1 File 2 Kruskal-Wallis test and Mann-Whitney test were used for continuous variables, and the Chi-square test and the Fisher's exact test were used for categorical variables. 3 "Percent Affirm" reports percentage of survey responses that indicate "strongly agree" or "somewhat agree" 4 Five category scale of agreement: "strongly agree", "somewhat agree", "neither agree nor disagree", "somewhat disagree", "strongly disagree" 5 Three category scale of agreement: ["strongly agree"+"somewhat agree"], ["neither agree nor disagree"], ["somewhat disagree"+ "strongly disagree"]…”

“…Our survey incorporated questions about basic bilirubin physiology [3][4][5][6] in addition to management that was articulated in the 2004 and 2009 updated AAP Clinical Practice Guidelines on NH [1]. Our results reflect suboptimal knowledge and compliance with the guidelines that were published almost twenty years ago.…”

“…In August 2022, the AAP published a revised CPG which updated the common risk factors for severe NH and adjusted phototherapy thresholds across all gestational age categories based on extensive review of new evidence [ 2 , 3 ]. It is anticipated that providers will promptly begin using the new guidelines to inform their clinical decision-making regarding NH.…”

“…Pediatricians commonly diagnose and manage neonatal hyperbilirubinemia (NH) in various healthcare settings [1][2][3][4][5][6]. Defined as an elevated total serum bilirubin (TSB) level, hyperbilirubinemia clinically manifests as jaundice and affects a majority of all newborn infants [4,5].…”

Analysis of the direct antiglobulin test for rates of phototherapy among ABO-incompatible newborns

“…The new clinical guideline, started in January 2021 (Supplementary Fig. 1), implemented the following interventions: newborns that were ABOi and DAT negative will be placed on the LRC (previously placed on MRC) on the phototherapy nomogram [13][14] , newborns that undergo phototherapy will be assessed immediately for need for supplementation, phototherapy will be discontinued when the total bilirubin is at least 2-3 mg/dL below the light level 17 , and rebound bilirubin level will be obtained only if the newborn is deemed at high risk for continued phototherapy or exhibiting a poor response to phototherapy. 18…”