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

A review of existing neonatal hyperbilirubinemia guidelines in Indonesia

Background

Neonatal hyperbilirubinemia is one of the most common conditions for neonate inpatients. Indonesia faces a major challenge in which different guidelines regarding the management of this condition were present. This study aimed to compare the existing guidelines regarding prevention, diagnosis, treatment and monitoring in order to create the best recommendation for a new hyperbilirubinemia guideline in Indonesia.

Methods

Through an earlier survey regarding adherence to the neonatal hyperbilirubinemia guideline, we identified that three main guidelines are being used in Indonesia. These were developed by the Indonesian Pediatric Society (IPS), the Ministry of Health (MoH), and World Health Organization (WHO). In this study, we compared factors such as prevention, monitoring, methods for identifying, risk factors in the development of neonatal jaundice, risk factors that increase brain damage, and intervention treatment threshold in the existing guidelines to determine the best recommendations for a new guideline.

Results

The MoH and WHO guidelines allow screening and treatment of hyperbilirubinemia based on visual examination (VE) only. Compared with the MoH and WHO guidelines, risk assessment is comprehensively discussed in the IPS guideline. The MoH guideline recommends further examination of an icteric baby to ensure that the mother has enough milk without measuring the bilirubin level. The MoH guideline recommends referring the baby when it looks yellow on the soles and palms. The WHO and IPS guidelines recommend combining VE with an objective measurement of transcutaneous or serum bilirubin. The threshold to begin phototherapy in the WHO guideline is lower than the IPS guideline while the exchange transfusion threshold in both guidelines are comparably equal.

Conclusions

The MoH guideline is outdated. MoH and IPS guidelines are causing differences in approaches to the management hyperbilirubinemia. A new, uniform guideline is required.

[Interpretation of the 2022 American Academy of Pediatrics guidelines for the management of hyperbilirubinemia in newborn infants]

The American Academy of Pediatrics updated the guidelines for the management of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks in September 2022. Based on the evidence over the past 18 years, the guidelines are updated from the aspects of the prevention, risk assessment, intervention, and follow-up of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks. This article gives an interpretation of the key points in the guidelines, so as to safely reduce the risk of bilirubin encephalopathy and unnecessary intervention.

Sixth-Hour Trancutaneous Bilirubin and Need for Phototherapy in DAT Positive Newborns

OBJECTIVES

To characterize the outcomes of ABO incompatible direct antiglobulin test (DAT) positive newborns and determine the predictive ability of a sixth-hour transcutaneous bilirubin (TcB for needing phototherapy ≤24 hours of age.

METHODS

Retrospective, cross-sectional study from May 2013 to March 2017. Of 10 942 consecutive newborns ≥35 weeks estimated gestational age, 829 were ABO incompatible and DAT positive. After excluding for antibodies other than ABO (51), missing data (4), miscategorization of blood type O (1), and duplicate record (1), 772 newborns remained. Of 772, a subsample of 346 newborns with both TcB and total serum bilirubin (TSB) tests within 1 hour of the sixth hour was analyzed to determine the predictive ability.

RESULTS

Phototherapy was required in 281 of 772 (36.4%); 156 (20.2%) in the first 24 hours. There were 10 (1.3%) admissions for hyperbilirubinemia to the NICU for intravenous immunoglobin. Birth weight, infant blood type B, TSB, reticulocyte count, and TcB were all significantly associated with phototherapy ≤24 hours. On multivariate analysis, significant predictors of phototherapy ≤24 hours were TSB and reticulocyte count if no TcB was done and TcB alone if no blood tests were done. TcB was highly predictive (odds ratio 3.1, 95% confidence interval: 2.4-4.0) and nearly as accurate as the TSB and reticulocyte count (area under the curve, 0.90 and 0.96, respectively). Low (<3.0 mg/dL) and high (≥5.3 mg/dL) risk TcB cutoffs demonstrated a negative predictive value of 98% and positive predictive value of 85%, respectively.

CONCLUSIONS

Among high-risk ABO incompatible DAT positive newborns, the sixth-hour TcB is highly predictive of the need for phototherapy ≤24 hours.

Primary risk stratification for neonatal jaundice among term neonates using machine learning algorithm

BACKGROUND

Neonatal jaundice occurs in approximately 60% of term newborns. Although risk factors for neonatal jaundice have been studied, all the suggested strategies are based on various newborn tests for bilirubin levels. We aim to stratify neonates into risk groups for clinically significant neonatal jaundice using a combined data analysis approach, without serum bilirubin evaluation.

STUDY DESIGN

Term (gestational week 37-42) neonates born in a single medical center, 2005-2018 were identified. Anonymized data were analyzed using machine learning. Thresholds for stratification into risk groups were established. Associations were evaluated statistically using neonates with and without clinically significant neonatal jaundice from the study population.

RESULTS

A total of 147,667 consecutive term live neonates were included. The machine learning diagnostic ability to evaluate the risk for neonatal jaundice was 0.748; 95% CI 0.743-0.754 (AUC). The most important factors were (in order of importance) maternal blood type, maternal age, gestational age at delivery, estimated birth weight, parity, CBC at admission, and maternal blood pressure at admission. Neonates were then stratified by risk: 61% (n = 90,140) were classed as low-risk, 39% (n = 57,527) as higher-risk. Prevalence of jaundice was 4.14% in the full cohort, and 1.47% and 8.29% in the low- and high-risk cohorts, respectively; OR 6.06 (CI: 5.7-6.45) for neonatal jaundice in high-risk group.

CONCLUSION

A population tailored "first step" screening policy using machine learning model presents potential of neonatal jaundice risk stratification for term neonates. Future development and validation of this computational model are warranted.

Predicting the Need for Phototherapy After Discharge

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 (Δ-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 (Δ-TSB; Δ-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 Δ-TSB 0 to 1 mg/dL below the threshold to 0.008% for Δ-TSB >7 mg/dL below the threshold. Discrimination was better for the Δ-TSB model (AUC 0.93) and the Δ-TSB-Plus model (AUC 0.95) than for the Bhutani Nomogram (AUC 0.88).

CONCLUSIONS

The use of Δ-TSB models had excellent ability to predict postdischarge TSB above phototherapy thresholds and may be simpler to use than the Bhutani Nomogram.

Natural history of early neonatal bilirubinemia: a global perspective

BACKGROUND AND OBJECTIVE

Due to selection bias and other issues, the only available serum bilirubin-based nomogram does not reflect the natural history of early neonatal bilirubinemia. Our objective was to obtain a global picture of the natural history of early post-natal bilirubin trajectories.

STUDY DESIGN

We pooled readings from 19 published transcutaneous bilirubin nomogram reports including many newborns at multiple sites. We constructed a universal transcutaneous bilirubin nomogram which included the 25th, 50th, 75th, and 95th percentiles from 12 to 120 h.

RESULTS

The global transcutaneous bilirubin nomogram included >119,000 readings from 44,392 apparently normal, predominantly breastfed newborns ≥35 weeks gestation. The pooled transcutaneous bilirubin trajectories increased during the first 3 post-natal days, and peaked or plateaued between the 3rd and 4th days.

CONCLUSIONS

We provide the first globally derived transcutaneous bilirubin nomogram that reflects the natural history of early neonatal bilirubinemia in neonates ≥35 weeks gestation.

Value of the Direct Antiglobulin Test in Predicting the Need for Phototherapy in Newborns

Purpose

Guidelines for managing neonatal hemolytic disease of the newborn (HDN) recommend a selective approach in the use of direct antiglobulin test (DAT). In Saudi Arabia, many hospitals still perform routine DAT for all newborns. This study assessed the need for phototherapy in relation to DAT results in full-term healthy newborns.

Patients and Methods

A retrospective analysis of all healthy newborns admitted during 2018 was performed. The primary outcome was the association of positive DAT results with phototherapy.

Results

There were 1463 newborns born during the study period. The DAT was positive at 4.4%. The 24-hour bilirubin levels were higher in DAT-positive cases (P=0.06); however, peak bilirubin levels were not correlated with the DAT results (P=0.717). Thirty-six neonates (2.46%) required phototherapy, and the need was similar among DAT-positive and DAT-negative cases (P=0.271). The most common indication for phototherapy was clinical jaundice in 22 neonates (61.1%), followed by DAT positivity in 12 (33.3%) and hospital protocol in 2 patients (5.6%) (P <0.01 by chi-square overall comparison).

Conclusion

Our results indicate that factors other than DAT positivity are important in assessing the need for phototherapy in newborns. Clinical signs of jaundice were indicators of high serum bilirubin levels and subsequent phototherapy, further indicating that the DAT test was overused in predicting the need for phototherapy.

Accuracy of enhanced transcutaneous bilirubinometry according to various measurement sites

Objective

The goal of the study was to provide missing data on the accuracy of enhanced transcutaneous bilirubinometry in a monoracial population of term neonates, considering three different measurement sites.

Material and Methods

Transcutaneous bilirubin was measured using the JM-105 device on the forehead, chest, and abdomen. Blood sampling for total serum bilirubin concentration has been performed within 10 minutes of transcutaneous measurements. Paired transcutaneous bilirubin and total serum bilirubin measurements were statistically analyzed.

Results

The study group consisted of 102 healthy term Slovak infants. The correlation between total serum bilirubin and transcutaneous bilirubin was significant (coefficient of determination R2: 0.9045 forehead, 0.8808 sternum, 0.8467 abdomen). Transcutaneous measurements underestimated serum bilirubin levels significantly when total serum bilirubin values were higher than 15 mg/dL, irrespective of the site of transcutaneous measurements. The lowest mean difference between total serum bilirubin and transcutaneous bilirubin was identified on the sternum (median: -1.1 mg/dL). The area under the curve was >0.97 and >0.93 for detecting total serum bilirubin levels >10 mg/dL and >13 mg/dL, respectively, for all measurement sites. Transcutaneous measurements on the forehead and sternum provided very high sensitivity, with the best performance at the forehead.

Conclusion

Transcutaneous bilirubinometry using an enhanced device is an accurate, sensitive, and convenient screening method in term Caucasian neonates. Transcutaneous bilirubin measurements on the forehead, sternum, and abdomen are reliable, with the best performance on the forehead. It is necessary to confirm higher transcutaneous bilirubin values with a total serum bilirubin measurement.

Decision Accuracy and Safety of Transcutaneous Bilirubin Screening at Intermountain Healthcare

OBJECTIVE

To quantify the risk that transcutaneous bilirubin (TcB) screening would fail to recommend phototherapy for a neonate who would have qualified for it if total serum bilirubin (TSB) screening were used.

STUDY DESIGN

We conducted a quality improvement project where simultaneous TcB and TSB were obtained on neonates ≥35 weeks of gestation during birth hospitalizations in our hospital system. Using our Utah bilirubin management algorithm, we quantified the risk that TcB screening would fail to identify the need for a confirmatory TSB when TSB screening alone would have revealed that phototherapy was indicated.

RESULTS

In 3 hospitals, we obtained 727 paired TcB/TSB measurements. Two instances utilized a blood gas radiometer for TSB, and 725 utilized the clinical laboratory-based TSB method. One of the 727 instances had a TcB indicating NO PHOTOTHERAPY, when the simultaneous TSB indicated PHOTOTHERAPY NEEDED. The TSB from that instance was 1 of the 2 from the blood gas radiometer. We estimate the risk of such an error occurring is 1.4 per 1000 TcB measurements (95% CI 0.03-7.6 per 1000). When only the laboratory TSB is used, we estimate the risk of such an error occurring to be 0 per 1000 TcB measurements (95% CI 0.0-5.1 per 1000).

CONCLUSIONS

Using TcB for screening at the birth hospital can identify those qualifying for phototherapy, using the Utah guidelines, with 1 of 727 neonates with a blood gas bilirubin and none of 725 with a laboratory-based analysis misidentified as not needing phototherapy when by TSB they did.

Differentiating Hepatic Epithelioid Angiomyolipoma From Hepatocellular Carcinoma and Focal Nodular Hyperplasia via Radiomics Models

Background: We conduct a study in developing and validating two radiomics-based models to preoperatively distinguish hepatic epithelioid angiomyolipoma (HEAML) from hepatic carcinoma (HCC) as well as focal nodular hyperplasia (FNH).

Methods: Totally, preoperative contrast-enhanced computed tomography (CT) data of 170 patients and preoperative contrast-enhanced magnetic resonance imaging (MRI) data of 137 patients were enrolled in this study. Quantitative texture features and wavelet features were extracted from the regions of interest (ROIs) of each patient imaging data. Then two radiomics signatures were constructed based on CT and MRI radiomics features, respectively, using the random forest (RF) algorithm. By integrating radiomics signatures with clinical characteristics, two radiomics-based fusion models were established through multivariate linear regression and 10-fold cross-validation. Finally, two diagnostic nomograms were built to facilitate the clinical application of the fusion models.

Results: The radiomics signatures based on the RF algorithm achieved the optimal predictive performance in both CT and MRI data. The area under the receiver operating characteristic curves (AUCs) reached 0.996, 0.879, 0.999, and 0.925 for the training as well as test cohort from CT and MRI data, respectively. Then, two fusion models simultaneously integrated clinical characteristics achieved average AUCs of 0.966 (CT data) and 0.971 (MRI data) with 10-fold cross-validation. Through decision curve analysis, the fusion models were proved to be excellent models to distinguish HEAML from HCC and FNH in comparison between the clinical models and radiomics signatures.

Conclusions: Two radiomics-based models derived from CT and MRI images, respectively, performed well in distinguishing HEAML from HCC and FNH and might be potential diagnostic tools to formulate individualized treatment strategies.

Clinical predictive score of predischarge screening for severe hyperbilirubinemia in late preterm and term infants

BACKGROUND

Early identification and appropriate follow-up of infants at risk of severe hyperbilirubinemia are part of preventing complications. This study aims to develop the clinical predictive score to predict subsequent severe hyperbilirubinemia in healthy Thai infants.

METHODS

A case-control study was conducted using medical records of 147 hyperbilirubinemia cases and 147 age-matched controls among healthy late preterm and term Thai newborn infants during January 2015 and December 2016. The routinely measured TcB values at 48-54 hours of age and all predischarge clinical characteristics were collected. Multivariable logistic regression was used to find a clinical prediction model to predict subsequent severe hyperbilirubinemia within 7 days after birth which defined as a postdischarge bilirubin level exceeding the hour-specific recommended threshold for phototherapy by the American Academy of Pediatrics (AAP).

RESULTS

The best clinical predictors for subsequent severe hyperbilirubinemia were TcB values at 48-54 hours and gestational age of infants. Predischarge TcB at 48-54 hours of life was classified into 3 levels: < 10 mg/dL, 10-12 mg/dL and > 12 mg/dL. Gestational age was categorized into 5 groups. The risk score derived from these 2 significant factors predicted subsequent severe hyperbilirubinemia with an AuROC curve of 81.0% (95% CI: 76.2-85.9%) in 3 risk group, high, moderate and low. The positive likelihood ratio for subsequent severe hyperbilirubinemia of the high-risk group (score > 5) was 4.53 (95% CI: 2.91-7.04) with specificity of 87.1%. The negative predictive value of low-risk group (score < 3) was 81%.

CONCLUSIONS

A simple predischarge prediction score using gestational age and TcB values at 48-54 hours of life was developed. This score classified late preterm and term newborn infants into 3 distinct risk levels and may be useful to identify high-risk infants for outpatient follow-up of subsequent severe hyperbilirubinemia.

Large scale validation of a new non-invasive and non-contact bilirubinometer in neonates with risk factors

The study was aimed to evaluate the performance of a newly developed non-invasive and non-contact bilirubin measurement device (AJO-Neo) as an alternative to the conventional invasive biochemical method of total serum bilirubin (TSB) estimation in preterm and term neonates suffering from hyperbilirubinemia associated with risk factors, and/or undergoing phototherapy. The safety and efficacy of the device were assessed in 1968 neonates with gestational ages ranging from 28 to 41 weeks and suffering from incidences of hyperbilirubinemia. Linear regression analysis showed a good correlation between AJO-Neo and the conventional method of TSB (Pearson’s coefficient, r = 0.79). The small bias (0.27 mg/dL) and limits of agreements (− 3.44 to 3.99 mg/dL) were within the range of clinical acceptance. The device was also precise in the measurement of bilirubin levels in all subgroups of the study. The receiver operator curve (ROC), that takes account of both sensitivity and specificity of a device showed high efficacy of the device (area under the curve, AUC = 0.83) in the detection of bilirubin. While monitoring the bilirubin level during phototherapy, the device indicated promising results showing good agreement with TSB. Specificities and sensitivities of the device indicated a much higher accuracy in neonates with associated risk factors for hyperbilirubinemia. Hence, the newly developed device (AJO-Neo) is reliable in measuring bilirubin level in preterm, and term neonates irrespective of gestational or postnatal age, sex, risk factors, feeding behavior or skin color.

Improving the Bilirubin Management Program in the Newborn Nursery: Background, Aims, and Protocol

BACKGROUND

Practices to detect and manage hyperbilirubinemia in newborn nurseries are highly variable. American Academy of Pediatrics guidelines in 1999, 2004, and 2009 have generated, perhaps unintentionally, divergent practices that might not all be of equivalent value. Evidence-based progress is needed to define less invasive, less expensive, uniform, and safe methods to reduce ER visits and hospital readmissions for jaundice treatment and bilirubin encephalopathy.

OBJECTIVES

This research briefing is intended to inform readers of a new prospective quality improvement program aimed at testing the value of specific changes in newborn nursery hyperbilirubinemia detection and management. This new program includes predetermined means of assessing those specific changes, which relate to diagnosis, safety, outcomes, and cost.

METHODS

In this briefing, we present the perceived problems in our present bilirubin management system, as voiced by stakeholders. We report our proposed means to test minimization of those problems utilizing already acquired data on approximately 400,000 well babies in the Intermountain Healthcare system of hospitals in the western USA. We then describe our methods of assessing specific outcomes in a pre- versus postpractice change analysis.

RESULTS AND CONCLUSIONS

The University of Utah Newborn Nursery will implement a quality improvement project in bilirubin management during 2020 to test the feasibility and effectiveness of several changes to our current bilirubin management program. We maintain that the improved understanding generated by this project will be a step toward new evidence-based strategies for reducing ER visits and hospital readmissions for jaundice treatment and preventing bilirubin encephalopathy.

Neonatal jaundice: aetiology, diagnosis and treatment

A significant proportion of term and preterm infants develop neonatal jaundice. Jaundice in an otherwise healthy term infant is the most common reason for readmission to hospital. Jaundice is caused by an increase in serum bilirubin levels, largely as a result of breakdown of red blood cells. Bilirubin is conveyed in the blood as 'unconjugated' bilirubin, largely bound to albumin. The liver converts bilirubin into a conjugated form which is excreted in the bile. Very high levels of unconjugated bilirubin are neurotoxic. Phototherapy is a simple and effective way to reduce the bilirubin level. Most term babies have 'physiological' jaundice which responds to a short period of phototherapy, and requires no other treatment. A few babies have rapidly rising bilirubin levels which place them at risk of kernicterus. Current management of jaundice in the UK is guided by the NICE guideline. Any infant with high serum bilirubin or a rapidly rising bilirubin level needs to be treated urgently to avoid neurotoxicity. High levels of conjugated bilirubin in a term baby can indicate biliary atresia, and babies with persisting jaundice must have their level of conjugated bilirubin measured. Preterm infants on long-term parenteral nutrition may develop conjugated jaundice which generally improves with the introduction of enteral feed and weaning of intravenous nutrition.

Transcutaneous bilirubin nomogram for the first 144 hours in Thai neonates

Objectives: To develop an hour-specific transcutaneous bilirubin (TcB) nomogram for Thai neonates and to compare the ability of this nomogram with that of Bhutani's total serum bilirubin (TSB) nomogram for prediction of significant hyperbilirubinemia requiring phototherapy.Methods: Healthy Thai neonates, gestational age ≥35-week-gestation and birth weight ≥2000 grams were enrolled. Neonates who could not attend the postdischarge follow-up at our center were excluded. TcB measurements were routinely performed at 6 am and 6 pm using JM103 transcutaneous bilirubinometer until the neonates were discharged or received phototherapy. TcB levels were also measured at least once during 24-72 hours after discharge and thereafter depending on the pediatricians' decision. The nomogram was developed from the TcB data during age 12-144 hours of neonates who did not require phototherapy. The TcB values that obtained predischarge or before receiving phototherapy of all neonates were used to determine the predictive ability of this nomogram and Bhutani's TSB nomogram.Results: A total of 1071 neonates were included. Two hundred forty-one neonates (22.5%) required phototherapy. The nomogram was constructed using 4834 hour-specific TcB values. It provided a good prediction with the area under curve (AUC) of 0.89. The 75th percentile tract revealed sensitivity and negative predictive value (NPV) of 87.1 and 95.4% while that of the 40th percentile tract were 97.9 and 98.5% respectively. When Bhutani's nomogram was used, the AUC was 0.84. The sensitivity and NPV of the 75th percentile tract were 56.4 and 88.2%, and for the 40th percentile tract were 97.1 and 98.0% respectively.Conclusion: The newly developed TcB nomogram revealed slightly better predictive ability than Bhutani's TSB nomogram for term and late preterm Thai neonates who were the population with high prevalence of significant hyperbilirubinemia. The 40th percentile curve of both nomograms should be considered as an appropriate cut-off level for prediction.

Israel transcutaneous bilirubin nomogram predicts significant hyperbilirubinemia

OBJECTIVE

We constructed a transcutaneous bilirubin (TcB) nomogram to represent major sectors of the Israeli population. We studied the risk of hyperbilirubinemia, defined as meeting the requirements for phototherapy, per percentile risk category.

STUDY DESIGN

Newborns ⩾36 weeks gestation were tested daily for TcB, using Drager JM-103 devices, during birth hospitalization. A nomogram was constructed and divided into four risk groups and validated by calculating the need for phototherapy for each group.

RESULTS

A total of 3303 measurements were performed on 1059 consecutive newborns including Ashkenazi, Sephardic and mixed Ashkenazi/Sephardic Jews, Arab and Ethiopian Jewish. Phototherapy risk increased progressively and more than 100-fold, from 0/225 in the <40th percentile group through 27/120 (22.5%) for those >95th percentile (relative risk (95% confidence interval) 102 (6 to 1669) for those >95th percentile compared with those <40th percentile). The optimal risk for discriminating the need for phototherapy was >75th percentile (sensitivity 93.33, specificity 59.47).

CONCLUSION

The risk of significant hyperbilirubinemia increased progressively with increasing percentile. Newborns >75th percentile groups are at high risk for phototherapy and should be closely monitored.

[Guidelines for prevention, detection and management of hyperbilirubinaemia in newborns of 35 or more weeks of gestation]

Hyperbilirubinaemia is one of the most frequent causes of hospital readmission during the first week of life. Its detection is still a big challenge, mainly due to the early discharge from the hospital that can be associated with a delay of the diagnosis. The identification of those newborns at risk of developing significant hyperbilirubinaemia is one of the main priorities in the public health care system. An approach to the management of newborn jaundice is presented in this article, following the recommendations based on the medical evidence and on the opinion of the Standards Committee of the Spanish Society of Neonatology.

Transcutaneous bilirubin nomograms in African neonates

Background

The use of transcutaneous bilirubin (TcB) as a screening tool, based on relevant population-specific nomogram, or proxy for total serum bilirubin (TSB) levels in assessing the risk of subsequent hyperbilirubinemia is supported by several clinical guidelines on the management of neonatal hyperbilirubinemia. However, while TcB has been found to significantly over-estimate TSB in neonates of African-American ancestry, with variations across TcB devices, no nomogram has been specifically reported for this racial group. This study therefore set out to develop TcB nomograms for healthy late pre-term and term black African neonates derived from two widely used bilirubinometers.

Methods

A retrospective analysis of 12,377 TcB measurements obtained from 6,373 neonates in the first postnatal week, over a period of 48 months using Bilichek and JM-103 bilirubinometers. TcB percentiles were computed from hour-specific TcB values and nomograms developed for each of the screening devices. Predictive ability of the 75^th and 95th percentiles to detect significant hyperbilirubinemia was evaluated between 24–96 hours of age. The 95^th percentile curve was compared with those from other populations.

Results

The velocity of TcB rise at 75^th and 95^th percentiles was generally higher with JM-103 than Bilichek. Both percentiles also peaked at higher TcB levels with JM-103. The 95^th percentile for both instruments showed a downward trend as from approximately 114 hours. Both instruments had high negative predictive values across the selected time-epochs and lower discriminatory ability than reported in non-black populations.

Conclusions

The predictive utility of TcB as a potential screening tool varies across devices in black African neonates with or without risk of significant hyperbilirubinemia, and lower than levels reported in non-black populations. Equipment-specific nomograms should be considered for TcB monitoring in this racial population where TSB is not routinely available.

Predicting Nonhemolytic Neonatal Hyperbilirubinemia

BACKGROUND

Before hospital discharge, newborn infants should be assessed for the risk of excessive hyperbilirubinemia. We determined maternal and obstetric risk factors for hyperbilirubinemia in infants born at term (gestational age ≥37 weeks) to form an individualized risk assessment tool for clinical use.

METHODS

This was a population-based study with data from the Swedish Medical Birth Register from 1999 to 2012, including 1,261,948 singleton infants. Outcome was defined as infants diagnosed with hyperbilirubinemia (N = 23,711), excluding all cases of hemolytic (immune-mediated or other specified hemolytic) diseases of the newborn.

RESULTS

Risk factors with an adjusted odds ratio (aOR) for neonatal hyperbilirubinemia of ≥1.5 (medium-sized effect or more) were gestational age 37 to 38 weeks (aOR = 2.83), failed vacuum extraction (aOR = 2.79), vacuum extraction (aOR = 2.22), Asian mother (aOR = 2.09), primipara (aOR = 2.06), large-for-gestational-age infant (aOR = 1.84), obese mother (aOR = 1.83), and small-for-gestational-age infant (aOR = 1.66). Planned cesarean delivery (CD) was associated with a reduced risk (aOR = 0.45). Without any of these risk factors (normal birth weight infant delivered vaginally at 39 to 41 weeks' gestation by a non-Asian, nonobese, multiparous mother) the rate of nonhemolytic neonatal hyperbilirubinemia was 0.7%. In relation to the combined load of different risk factors, rates of neonatal hyperbilirubinemia ranged from 0.2% to 25%.

CONCLUSIONS

Collection of a few easily available maternal and obstetric risk factors predicts >100-fold variation in the incidence of neonatal hyperbilirubinemia. The information provided herein enables individualized risk prediction with interactions between different risk factors taken into account.

Early discharge of infants and risk of readmission for jaundice

OBJECTIVES

To examine the association between early discharge from hospital after birth and readmission to hospital for jaundice among term infants, and among infants discharged early, to investigate the perinatal risk factors for readmission for jaundice.

METHODS

Birth data for 781,074 term live-born infants born in New South Wales, Australia from 2001 to 2010 were linked to hospital admission data. Logistic regression models were used to investigate the association between postnatal length of stay (LOS), gestational age (GA), and readmission for jaundice in the first 14 days of life. Other significant perinatal risk factors associated with readmission for jaundice were examined for infants discharged in the first 2 days after birth.

RESULTS

Eight per 1000 term infants were readmitted for jaundice. Infants born at 37 weeks' GA with an LOS at birth of 0 to 2 days were over 9 times (adjusted odds ratio [aOR] 9.43; 95% CI, 8.34-10.67) and at 38 weeks' GA were 4 times (aOR 4.05; 95% CI, 3.62-4.54) more likely to be readmitted for jaundice compared with infants born at 39 weeks' GA with an LOS of 3 to 4 days. Other significant risk factors for readmission for jaundice for infants discharged 0 to 2 days after birth included vaginal birth, born to mothers from an Asian country, born to first-time mothers, or being breastfed at discharge.

CONCLUSIONS

This study can inform guidelines or policy about identifying infants at risk for readmission for jaundice and ensure that appropriate post-discharge follow-up is received.

Transcutaneous bilirubinometry

Although the modern era of transcutaneous bilirubin monitoring (TcB) began only about 35 years ago, this screening tool is now widely used in newborn nurseries and outpatient clinics, offices, and emergency departments to obtain a rapid and non-invasive estimate of the degree of hyperbilirubinemia. TcB devices have become more sophisticated, and major breakthroughs include the following: (a) ability to report a bilirubin value rather than an index value, (b) enhanced correction for chromophores other than bilirubin, and (c) technologic improvements including interface with electronic medical records. Good agreement with laboratory bilirubin measurement has been demonstrated, and the ability of TcB screening to predict and decrease the incidence of subsequent hyperbilirubinemia has been well-documented. To date, it has not been shown that this screening results in improved long-term outcomes.

Bilirubin nomograms for identification of neonatal hyperbilirubinemia in healthy term and late-preterm infants: a systematic review and meta-analysis

BACKGROUND

Hyperbilirubinemia occurs in most healthy term and late-preterm infants, and must be monitored to identify those who might develop severe hyperbilirubinemia. Total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) nomograms have been developed and validated to identify neonatal hyperbilirubinemia. This study aimed to review previously published studies and compare the TcB nomograms with the TSB nomogram, and to determine if the former has the same predictive value for significant hyperbilirubinemia as TSB nomogram does.

METHODS

A predefined search strategy and inclusion criteria were set up. We selected studies assessing the predictive ability of TSB/TcB nomograms to identify significant hyperbilirubinemia in healthy term and late-preterm infants. Two independent reviewers assessed the quality and extracted the data from the included studies. Meta-Disc 1.4 analysis software was used to calculate the pooled sensitivity, specificity, and positive likelihood ratio of TcB/TSB nomograms. A pooled summary of the receiver operating characteristic of the TcB/TSB nomograms was created.

RESULTS

After screening 187 publications from electronic database searches and reference lists of eligible articles, we included 14 studies in the systematic review and meta-analysis. Eleven studies were of medium methodological quality. The remaining three studies were of low methodological quality. Seven studies evaluated the TcB nomograms, and seven studies assessed TSB nomograms. There were no differences between the predictive abilities of the TSB and TcB nomograms (the pooled area under curve was 0.819 vs. 0.817).

CONCLUSIONS

This study showed that TcB nomograms had the same predictive value as TSB nomograms, both of which could be used to identify subsequent significant hyperbilirubinemia. But this result should be interpreted cautiously because some methodological limitations of these included studies were identified in this review.

Identifying term breast-fed infants at risk of significant hyperbilirubinemia

BACKGROUND

The aim of this study was to establish a model to identify term breast-fed infants who are at risk of developing significant neonatal hyperbilirubinemia.

METHODS

A prospective study was designed to investigate the effects of birth weight, mode of delivery, cephalohematoma, glucose-6-phosphate dehydrogenase (G6PD) deficiency, predischarge total serum bilirubin, variant uridine 5'diphospho-glucuronosyltransferase 1A1 (UGT1A1) gene, and hepatic solute carrier organic anion transporter 1B1 (SLCO1B1) gene on significant hyperbilirubinemia in term breast-fed neonates. Significant hyperbilirubinemia was defined as a bilirubin level exceeding the hour-specific phototherapy treatment threshold recommended by the American Academy of Pediatrics in 2004.

RESULTS

Of 240 exclusively breast-fed term neonates, 26 (10.8%) had significant hyperbilirubinemia. The predischarge total serum bilirubin on the third day (odds ratio (OR) = 2.63; 95% confidence interval (CI): 1.87-3.70; P < 0.001) and the variant UGT1A1 gene at nucleotide 211 (OR = 5.00; 95% CI: 1.08-23.03; P < 0.05) were significant risk factors. The area under the receiver operating characteristic (ROC) curve of the predictive probability was 0.964 (95% CI: 0.932-0.984; P < 0.0001).

CONCLUSION

Combining the total serum bilirubin on the third day and the variant UGT1A1 gene at nucleotide 211 can predict hyperbilirubinemia well in term breast-fed infants.

BiliCheck vs JM-103 in identifying neonates not at risk of hyperbilirubinaemia

Background

Transcutaneous bilirubinometry is widely used to predict hyperbilirubinemia by using several devices. The aim of this study was to compare the predictive ability of BiliCheck vs JM-103 in identifying neonates not at risk of significant hyperbilirubinemia, putting the data obtained with the two instruments on our transcutaneous bilirubin nomogram built with the BiliCheck.

Methods

Transcutaneous bilirubin (TcB) measurement was performed when jaundice appeared in newborn babies and/or just before discharge from the hospital. It was performed at the forehead with the two instruments within 5 minutes by two experienced neonatologists, each one blind to the value obtained by the other. Blood samples were drawn to obtain total serum bilirubin (TSB) levels soon after TcB measurements.

Results

A total of 627 paired-sample measurements were obtained from 298 newborn babies. Out of the total population studied, 16 newborn babies (5.4%) showed significant hyperbilirubinemia defined as TSB value >17 mg/dL, or as need for phototherapy treatment according to the AAP guidelines. TcB measurements showed false negative results in the first 60 hours of life using both devices. After the 60^th hour of life, TcB measurements using both devices successfully predicted newborn babies not at risk of significant hyperbilirubinemia, being the JM-103 more reliable than BC because of fewer false positive results.

Conclusions

Our study shows that both BC and JM-103 can exclude subsequent significant hyperbilirubinemia when the measurements are performed after the 60^th hour of life. Nevertheless, the transcutaneous pre-discharge screening should be considered only as the first step, and it has to be followed by a follow-up through the first days after discharge.

Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy

OBJECTIVE

To test whether the combined use of total plasma/serum bilirubin (TSB) levels and clinical risk factors more accurately identifies infants who receive phototherapy than does the use of either method alone.

STUDY DESIGN

We recruited healthy infants of ≥35 weeks' gestation at 6 centers that practiced universal predischarge TSB screening. Transcutaneous bilirubin (TcB) was measured at 24 hours, with TSB at 24-60 hours and at 3- to 5- and 7- to 14-day follow-up visits. Clinical risk factors were identified systematically.

RESULTS

Of 1157 infants, 1060 (92%) completed follow-up, and 982 (85%) had complete datasets for analysis. Infant characteristics included 25% were nonwhite and 55% were Hispanic/Latino; >90% were breastfed. During the first week, jaundice was documented in 84% of subjects. Predischarge TSB identified the 41 (4.2%) and 34 (3.5%) infants who received phototherapy before and after discharge, respectively. Prediction of postdischarge phototherapy was similar for combined clinical risk factors (earlier gestational age [GA], bruising, positive direct antiglobulin test, Asian race, exclusive breastfeeding, blood type incompatibility, jaundice extent) and age-adjusted TSB (area under the curve [AUC] = .86 vs .87), but combined screening was better (AUC = .95). TcB/TSB combined with GA alone was equally predictive (AUC = .95; 95% CI .93-.97).

CONCLUSIONS

Jaundice is present in 4 of 5 (84%) healthy newborns. Predischarge TcB/TSB (adjusted for postnatal age) combined with specific clinical factors (especially GA) best predicts subsequent phototherapy use. Universal implementation of this strategy in the US should improve outcomes of healthy newborns discharged early.

Neonatal hyperbilirubinemia in the low-intermediate-risk category on the bilirubin nomogram

OBJECTIVE

Predischarge bilirubin screening predicts neonatal hyperbilirubinemia. We evaluated the incidence of false-negative bilirubin screening among readmissions for hyperbilirubinemia.

METHODS

In healthy term and late preterm, predominantly breastfeeding newborns, predischarge transcutaneous bilirubin values were plotted on the hour of life-specific bilirubin nomogram and confirmed with plasma total bilirubin in those with a transcutaneous reading ≥ 75th percentile, or between the 41st and 75th percentiles in the presence of predictive icterogenic risk factors. False-negative bilirubin screen was defined as a predischarge bilirubin value ≤ 75th percentile in a newborn who was subsequently readmitted for phototherapy.

RESULTS

Of a total of 25439 neonates born between 2008 and 2009, 143 (0.56%) were readmitted with a mean plasma total bilirubin of 18.7 ± 1.7 mg/dL at 125 ± 54 hours. False-negative predischarge bilirubin screen was identified in 46 (32.2%). Of these, 6 (4.2%) were in the low-risk zone (≤ 40th percentile, relative risk [RR] = 1) and 40 (28%) in the intermediate-low-risk zone (41st-75th percentile, RR 7.62 [95% confidence interval 3.23-17.96]). Of those in the high-risk zones, 76 (53.1%) were in the intermediate-high-risk zone (76th-95th percentile, RR 25.32 [11.03-58.10]) and 21 (14.7%) in the high-risk zone (>95th percentile, RR 27.78 [11.23-68.70]).

CONCLUSIONS

Predischarge bilirubin levels in newborns classified as low risk did not eliminate the risk of readmission for hyperbilirubinemia. All newborns including those at low risk must be vigilantly observed for subsequent hyperbilirubinemia.

Is it worthwhile using a transcutaneous bilirubinometer in the nursery?

Jaundice is a potential threat to neonatal health and/or life. The advantages and limitations of transcutaneous determination of bilirubin concentration and current devices are briefly discussed in this paper.

Impact of a transcutaneous bilirubinometry program on resource utilization and severe hyperbilirubinemia

OBJECTIVES

Our goal was to assess the impact of programmatic and coordinated use of transcutaneous bilirubinometry (TcB) on the incidence of severe neonatal hyperbilirubinemia and measures of laboratory, hospital, and nursing resource utilization.

METHODS

We compared the neonatal hyperbilirubinemia-related outcomes of 14 796 prospectively enrolled healthy infants ≥35 weeks gestation offered routine TcB measurements in both hospital and community settings by using locally validated nomograms relative to a historical cohort of 14 112 infants assessed by visual inspection alone.

RESULTS

There was a 54.9% reduction (odds ratio [OR]: 2.219 [95% confidence interval (CI): 1.543-3.193]; P < .0001) in the incidence of severe total serum bilirubin values (≥342 µmol/L; ≥20 mg/dL) after implementation of routine TcB measurements. TcB implementation was associated with reductions in the overall incidence of total serum bilirubin draws (134.4 vs 103.6 draws per 1000 live births, OR: 1.332 [95% CI: 1.226-1.446]; P < .0001) and overall phototherapy rate (5.27% vs 4.30%, OR: 1.241 [95% CI: 1.122-1.374]; P < .0001), a reduced age at readmission for phototherapy (104.3 ± 52.1 vs 88.9 ± 70.5 hours, P < .005), and duration of phototherapy readmission (24.8 ± 13.6 vs 23.2 ± 9.8 hours, P < .05). There were earlier (P < .01) and more frequent contacts with public health nurses (1.33 vs 1.66, P < .01) after introduction of the TcB program.

CONCLUSIONS

Integration of routine hospital and community TcB screening within a comprehensive public health nurse newborn follow-up program is associated with significant improvements in resource utilization and patient safety.

Validation of transcutaneous bilirubin nomogram in identifying neonates not at risk of hyperbilirubinaemia: a prospective, observational, multicenter study

BACKGROUND

Transcutaneous bilirubin (TcB) measurement is widely used as screening for neonatal hyperbilirubinaemia.

AIMS

To prospectively validate TcB measurement using hour-specific nomogram in identifying newborn infants not at risk for severe hyperbilirubinaemia.

STUDY DESIGN

prospective, observational, multicenter.

SUBJECTS

2167 term and late preterm infants born in 5 neonatal units in the Lazio region of Italy.

METHODS

All neonates had simultaneous TcB and total serum bilirubin (TSB) measurements, when jaundice appeared and/or before hospital discharge. TcB and TSB values were plotted on a percentile-based hour-specific transcutaneous nomogram previously developed, to identify the safe percentile able to predict subsequent significant hyperbilirubinaemia defined as serum bilirubin >17 mg/dL or need for phototherapy.

RESULTS

Fifty-five babies (2.5%) developed significant hyperbilirubinaemia. The 50th percentile of our nomogram was able to identify all babies who were at risk of significant hyperbilirubinaemia, but with a high false positive rate. Using the 75th percentile, two false negatives reduced sensitivity in the first 48 hours but we were able to detect all babies at risk after the 48th hour of age.

CONCLUSIONS

This study demonstrates that the 75th percentile of our TcB nomogram is able to exclude any subsequent severe hyperbilirubinaemia from 48 h of life ahead.

Predictors of significant jaundice in late preterm infants

OBJECTIVES

To study (i) the incidence and course of jaundice, and (ii) the predictors of significant jaundice in late preterm infants.

DESIGN

Prospective analytical study.

SETTING

Urban perinatal center.

PATIENTS

Inborn late preterm infants (post menstrual age of 34 0/7 to 36 6/7 weeks).

METHODS

Infants were followed till day 14 of life or till onset of significant jaundice. Relevant maternal, perinatal and neonatal variables were prospectively recorded. Transcutaneous bilirubin (TcB) was measured in each infant twice daily for the first 48 hours of life.

OUTCOMES

Significant jaundice defined as requirement of phototherapy/exchange transfusion as per hour specific total serum bilirubin (TSB) nomogram of AAP guidelines.

RESULTS

216 infants were enrolled, of which 123 (57%) had significant jaundice. 36% of the jaundiced infants had TSB greater than 15 mg/dL. The mean duration of onset of significant jaundice was 61 ± 32 hours. The mean duration of phototherapy was 49 ± 26 hours. Large for gestation, lower gestational age, birth trauma and previous sibling with jaundice predicted severe jaundice. TcB measured at 24-48 hrs was a better predictor of significant jaundice with onset after 48 hrs than clinical risk factors.

CONCLUSION

There is a high incidence of significant jaundice in late preterm infants. TcB measured at 24-48 hrs of life better predicts significant jaundice after 48 hours of life, in comparison with clinical risk factors.

Transcutaneous bilirubin nomogram for predicting neonatal hyperbilirubinemia in healthy term and late-preterm Chinese infants

Identifying infants that will develop significant hyperbilirubinemia with the risk of kernicterus, and planning appropriate follow-up strategies, is particularly challenging. In this study, 36,921 transcutaneous bilirubin (TcB) measurements were obtained from 6,035 healthy neonates (gestational age ≥ 35 weeks and birth weight ≥ 2,000 g) between January 1 and December 31, 2009. All measurements were performed with the JM-103 bilirubinometer at designated times between 0 and 168 postnatal hours. TcB percentiles were calculated and used to develop an hour-specific nomogram. The rate of increase in TcB was higher during the first 72 h of age, after which levels declined to a plateau by 72-108 h of age. We constructed a TcB nomogram by using the 40th, 75th, and 95th percentile values of TcB for every 12 h of the studied interval. The 75th percentile curve of the nomogram may be an ideal cutoff point for intensive follow-up of the neonate for hyperbilirubinemia as it carries very high sensitivity (78.7%) and negative predictive value (98.5%). The specificity (45.7%) and positive predictive value (15.5%) decreased to reach their lowest levels at the 40th percentile. Of the neonates in the high-risk zone, 167 (48.8%) infants had persistent subsequent hyperbilirubinemia post-discharge, compared with 292 (27.0%) infants in the high-intermediate-risk zone at discharge. One-hundred and seventeen (5.5%) infants in the low-intermediate-risk zone moved into the high-risk zone during follow-up. No newborn infants in the low-risk zone became high-risk during follow-up. We provide an hour-specific TcB nomogram to predict neonatal hyperbilirubinemia in healthy term and late-preterm Chinese infants.

Clinical and genetic risk factors for moderate hyperbilirubinemia in Brazilian newborn infants

OBJECTIVE

To identify clinical and genetic risk factors for moderate hyperbilirubinemia during the first week of life.

STUDY DESIGN

Using univariate and multivariate multiple regression analyses, the RR for clinical factors, the African variant of glucose-6-phosphate dehydrogenase (G6PD) deficiency (G202A/A376G), and (TA)(n) UGT1A1 polymorphisms were established in a cohort of 608 Brazilian newborn infants. Hyperbilirubinemia was monitored until 134.5 ± 49.8 h of life (IQR, 111.0 to 156.7). The dependent variable was total bilirubinemia (TB) ≥12.9 mg per 100 ml estimated by transcutaneous or plasma bilirubin measurements.

RESULT

The African variant of G6PD deficiency and (TA)(7)/(TA)(7) and (TA)(7)/(TA)(8) polymorphisms present in 6.1 and 12.0% of newborns, respectively, were not risk factors for moderate hyperbilirubinemia. Coexpression of G6DP deficiency and UGT1A1 polymorphisms occurred in 0.49% of the subjects. Independent clinical predictors for TB≥ 12.9 mg per 100 ml were gestational age <38 weeks and reference curve percentiles >P40th.

CONCLUSION

In this study, G6PD deficiency and UGT1A1 gene promoter polymorphisms were not risk factors for moderate hyperbilirubinemia. Genetic factors may vary considerably in importance among different populations.

Screening and early postnatal management strategies to prevent hazardous hyperbilirubinemia in newborns of 35 or more weeks of gestation

Although kernicterus is a rare condition, it is still being reported in North America and Western Europe in addition to less developed parts of the world. The majority of affected infants are term and late-preterm newborns who have been discharged from the nursery as 'healthy newborns' yet have subsequently developed extreme hyperbilirubinemia and the classic neurodevelopmental findings associated with kernicterus. Published guidelines provide the basic tools for preventing hazardous hyperbilirubinemia and the two most important of these are a systematic assessment, prior to discharge, of each infant, for the risk of severe hyperbilirubinemia, and appropriate follow-up based on the time of discharge and the risk assessment. The most recent recommendations call for a predischarge measurement of the serum or transcutaneous bilirubin in all infants. When combined with the gestational age and other risk factors for hyperbilirubinemia, this provides the best estimate of the risk, or lack of risk, for subsequent hyperbilirubinemia, and determines the timing of follow-up and the need for further evaluation and treatment. The application of these principles to the management of the jaundiced newborn might not eliminate every case of kernicterus, but should contribute to a reduction in its occurrence.

Assessing jaundice in infants of 35-week gestation and greater

PURPOSE OF REVIEW

In 2004, the American Academy of Pediatrics officially recommended universal predischarge risk assessment for severe neonatal hyperbilirubinemia with the goal of minimizing subsequent risk of chronic bilirubin encephalopathy (formerly known as kernicterus). In this article, we review recent research regarding jaundice predischarge risk assessment, current expert recommendations for universal predischarge bilirubin screening, and concerns expressed in the literature regarding these recommendations.

RECENT FINDINGS

A group of experts have recently recommended universal predischarge bilirubin screening to identify newborns at risk for developing severe neonatal hyperbilirubinemia. In contrast, the United States Preventive Services Task Force states that there is insufficient evidence to make this recommendation. Transcutaneous bilirubinometry has emerged as a noninvasive, quick method to screen for neonatal hyperbilirubinemia, although refinement and validation of transcutaneous bilirubin nomograms are needed. Newer studies suggest that the combined use of a predischarge bilirubin and gestational age risk assessment offers a simple, objective, and accurate way to identify infants at risk for subsequent, severe hyperbilirubinemia.

SUMMARY

All newborns should be systematically assessed for risk of developing severe hyperbilirubinemia prior to hospital discharge. Although limited data exist to recommend its use universally, predischarge bilirubin screening should be considered given recent expert opinion. The role of transcutaneous bilirubinometry remains promising, although further research evaluating and validating its use in varied and diverse populations is imperative. Combined models of risk assessment may offer the best approach to identifying infants at risk for subsequent, severe hyperbilirubinemia.

Neonatal hyperbilirubinemia and kernicterus - not gone but sometimes forgotten

The introduction of exchange transfusion made it possible to prevent severe hyperbilirubinemia and kernicterus, but kernicterus has never completely disappeared and it is still occurring in North America and, more frequently in Western Europe and the developing world. I discuss the epidemiology and major causes of severe hyperbilirubinemia and the potential root causes and system failures associated with the development of extreme hyperbilirubinemia and, subsequently, kernicterus. In the Western world, kernicterus remains a rare cause of cerebral palsy but, in contrast to the other causes of cerebral palsy, kernicterus should almost always be preventable. The key elements in preventing kernicterus are risk assessment and appropriate follow-up for the newborn infant and these are presented in a recently developed algorithm. Implementation of this approach might contribute to the prevention of severe hyperbilirubinemia and bilirubin encephalopathy.

Identification of neonates at risk for hazardous hyperbilirubinemia: emerging clinical insights

Hyperbilirubinemia is the most common condition requiring evaluation and treatment in neonates. Identifying among all newborns those few at risk to develop marked hyperbilirubinemia is a clinical challenge. Clinical, epidemiologic, and genetic risk factors associated with severe hyperbilirubinemia include late preterm gestational age, exclusive breastfeeding, glucose-6-phosphate dehydrogenase deficiency, ABO hemolytic disease, East Asian ethnicity, jaundice observed in the first 24 hours of life, cephalohematoma or significant bruising, and history of a previous sibling treated with phototherapy. It is increasingly apparent that the etiopathogenesis of severe hyperbilirubinemia is often multifactorial, and emerging evidence suggests that combining risk factor assessment with measurement of predischarge total serum or transcutaneous bilirubin levels will improve hyperbilirubinemia risk prediction.