Routine transcutaneous bilirubin measurements combined with clinical risk factors improve the prediction of subsequent hyperbilirubinemia

Abstract

Objective: To evaluate predischarge transcutaneous bilirubin (TcB) measurements combined with risk factors as predictors of the risk of a subsequent total serum bilirubin (TSB) X17 mg per 100 ml (291 mmol l À1).Study Design: Routine TcB measurements are obtained daily for all infants in our well baby nursery. We performed a nested case-control study comparing all 75 infants who had been readmitted with TSB were discharged from the well baby nursery. Seventy-five infants (0.65%) were readmitted at a mean age of 110 ± 29.9 h with a TSBX17 mg per 100 ml (291 mmol l À1 ). All received phototherapy. Using logistic regression analysis, three variables were statistically significant for predicting cases: the maximum predischarge TcB percentile group (P<0.0001, adjusted odds ratio (AOR), >95th percentile 148; 95% confidence interval (CI) 21 to >999, AOR 76 to 95th percentile 15; 95% CI 3.1 to 70, AOR 50 to 75th percentile 6.1; 95% CI 1.3 to 28 compared with <50th percentile), exclusive breastfeeding (P<0.0001, AOR 11; 95% CI 3.7 to 34) and gestational age (P ¼ 0.0057, AOR 35 to 36 6/7 week 21; 95% CI 2.3 to 185, AOR 37 to 37 6/7 week 15; 95% CI 1.9 to 115, AOR 38 to 38 6/7 week 1.8; 95% CI 0.3 to 11, AOR 39 to 39 6/7 week 1.1; 95% CI 0.2 to 7 AOR X41 week 0.88; 95% CI 0.1 to 10 compared with 40 to 40 6/7 week infants). These three variables provided the best prediction of a case (c ¼ 0.885, area under the receiver operating characteristic curve) and this prediction was significantly better than the use of the clinical risk factors, gestation and exclusive breastfeeding, alone (c ¼ 0.770, P<0.001) or the TcB percentile grouping alone (c ¼ 0.766, P<0.001).Substituting the TcB rate of rise (c ¼ 0.903, P ¼ 0.316) or the last measured TcB (c ¼ 0.873, P ¼ 0.292) for the maximum TcB measurement did not significantly improve the predictors of a case. Conclusion:Combining predischarge TcB levels with two clinical risk factorsFgestational age and exclusive breastfeedingFsignificantly improves the prediction of subsequent hyperbilirubinemia.

Predicting Nonhemolytic Neonatal Hyperbilirubinemia

“…However, infants born at 38 weeks' gestation were categorized as low-risk infants, 29 possibly because of observations (n = 48 patients treated for hyperbilirubinemia) of no significant difference in rates of hyperbilirubinemia between infants born at 38 to 39 weeks and infants born at $40 weeks' gestation. 30 Our study confirms several smaller (n = 73-270 patients) US studies 12,[31][32][33] documenting an impact of each decreasing week of gestation on the risk of developing severe hyperbilirubinemia. Given that infants born not only after 37 but also after 38 weeks' gestation were, in most combinations of other perinatal risk factors, found to be at moderate to high risk for hyperbilirubinemia (Figure 1), we suggest that a GA of 38 weeks should be listed as a major risk factor in coming updates of neonatal hyperbilirubinemia guidelines.…”

Early breastfeeding initiation and incidence of severe neonatal jaundice in Chipinge district Zimbabwe

“…8 However, it is also important to consider breastmilk jaundice in this aspect as studies have also shown that breastmilk can cause jaundice because of the substance contained in human milk that interferes with conjugation and excretion of bilirubin. 4 Nevertheless, breastmilk jaundice usually features after a week post-delivery, peaks at day 14 and persists up to 3 months whereas nonbreastfeeding jaundice occurs as early as 2 to 7 days postdelivery. 4 Despite the documented variations in the causes of neonatal jaundice, EBFI still holds an upper position in averting neonatal jaundice in the first week of life…”

“…4 Nevertheless, breastmilk jaundice usually features after a week post-delivery, peaks at day 14 and persists up to 3 months whereas nonbreastfeeding jaundice occurs as early as 2 to 7 days postdelivery. 4 Despite the documented variations in the causes of neonatal jaundice, EBFI still holds an upper position in averting neonatal jaundice in the first week of life…”

“…6 The detection of abnormal levels will often pose a challenge when only clinical assessment of neonatal jaundice is the practice as in developing countries as some babies with severe jaundice may be missed. 4 …”

Early Discharge of Infants and Risk of Readmission for Jaundice

“…29 Infants below standard TcB or TSB cut-offs may still develop hyperbilirubinemia, so even infants who have low pre-discharge screening levels should receive postnatal follow-up. 31 Studies have shown that the use of TcB and TSB in outpatient settings are also reliable 32,33 and can reduce readmissions for phototherapy. 34 The results of this study could be used by hospital postnatal discharge programs to ensure the most at-risk infants receive adequate information or screening before discharge and follow-up at home.…”