Susan Wu, MD, FAAP, Editor - American Academy of Pediatrics

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Severe hyperbilirubinemia and kernicterus have been the focus of renewed attention 1,2 . These preventable events cause significant morbidity and mortality, and so various strategies for prevention have been identified. In 2004, the American Academy of Pediatrics (AAP) issued a Clinical Practice Guideline, “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation” 3 . After the issuance of this guideline, many clinical institutions have begun universal bilirubin screening of newborns prior to discharge, often in the form of transcutaneous bilirubin (TcB) measurement. In this article, we seek to examine the effectiveness of this practice in reducing hospital readmissions, reducing the incidence of severe hyperbilirubinemia, reducing overall costs and providing better patient care. The goal of the AAP guideline was to decrease severe hyperbilirubinemia and kernicterus without increasing harm due to maternal anxiety, decreased breastfeeding, or unnecessary increase in testing or cost. This guideline recommended that physicians: 1. Promote and support successful breastfeeding 2. 3. 4. NeoNataL meDiCiNe UPDate — Ursula Kneissl, MD, FAAP, Editor Predischarge Bilirubin Screening: Are We Impacting Severe Hyperbilirubinemia? Kimberly S. Stump, MD, KStump@crhc.org, and Ursula S. Kneissl, MD, FAAP, UKneissl@crhc.org New Hampshire Dartmouth Family Medicine Residency, Concord Hospital, Concord NH Perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia Provide early and focused follow-up based on the risk assessment When indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus) 3 The AAP recommends 2 clinical options used individually or in combination for the systematic assessment of risk: predischarge measurement of the bilirubin level using total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) 14 | American Academy of Pediatrics and/or assessment of clinical risk factors. Further studies have shown predischarge assessment of total serum bilirubin to be the most reliable predictor of risk for severe hyperbilirubinemia, although neither strategy alone has both high sensitivity and high specificity 4 . Transcutaneous bilirubin measurement has gained popularity as a screening tool because it is a fast and painless alternative to drawing blood for a total serum bilirubin measurement and can be used in any clinical environment. The BiliCheck device, specifically, has been shown to produce TcB estimates that are accurate and reliable predictors of TSB in newborns with varying degrees of skin pigmentation, including indigenous African populations 5, 6 . All commonly used TcB instruments will underestimate bilirubin levels at high concentrations and should not be considered a replacement for TSB measurement. It is important for clinical institutions to define cut-off levels above which TcB should be confirmed by further testing 7 . Depending on the instrument, studies have shown this cut-off level to be between 11 and 13.1 mg/dL 7,8 . Predischarge bilirubin measurement is typically assessed through the use of hour-specific nomograms 9 . These nomograms plot bilirubin levels at various hours of age along low, intermediate, and high-risk standard curves. They are based on the concept that if a baby’s risk factors for hyperbilirubinemia are present at birth, then early bilirubin levels should be indicative of the trend that the baby’s bilirubin will follow as it peaks (usually after hospital discharge). This can be an accurate predictor of necessary follow-up when used appropriately. Clinical risk factors for hyperbilirubinemia have also been outlined by the AAP guidelines. However, the AAP has not provided clear indices for how combinations of these risk factors should be used to predict risk for subsequent hyperbilirubinemia and necessary intervention. When used in combination with predischarge bilirubin measurement/nomogram graphing, this information could provide additional predictive value 4 . Have the AAP guidelines worked? Are we accurately predicting which newborns require intervention for hyperbilirubinemia and preventing the development of severe hyperbilirubinemia? We were able to find three studies examining this question; all indicate that the answer is yes. Bhutani et al. published an observational study looking at the development of a systems approach to hyperbilirubinemia and its impact on the need for exchange transfusion, intensive phototherapy and need for readmission 10 . They followed over 31,000 well babies throughout the evolution of their intervention and saw a decrease in all adverse outcomes. The effect of the final, systems-based approach was a rate of intensive phototherapy of 1.3% and of exchange transfusion of 1 per almost 12,000 infants. This compares favorably to their rate with the initial phase of intervention (selective TSB measurement) of 3.65% receiving intensive phototherapy and 1:2137 requiring exchange transfusion. In this observational study, comparison statistics were not performed and the statistical significance of this data is not known. Eggert et al. performed a historic cohort study, examining 101,272 newborns of 35 weeks gestation or greater, before and after the initiation of a universal Are we accurately predicting which newborns require intervention for hyperbilirubinemia and preventing the development of severe hyperbilirubinemia?
predischarge bilirubin screening program 11 . The rate of hospital readmission for hyperbilirubinemia fell from 0.55% to 0.43%. The percentage of newborns with total bilirubin greater than 20 mg/dl fell by almost 50%, and the number of newborns with a TSB greater than 25 mg/dL fell from 1 in 1522 to 1 in 4037. However, these authors included in their analysis only those infants screened with a total serum bilirubin, and did not include the greater than 2,000 babies screened with TcB. In addition, they developed an institutionspecific version of the standard hourly nomograms, so their data may not be comparable to that of other institutions. Peterson et al. retrospectively examined the records of 6603 normal newborns at the University of Texas Medical Branch at Galveston for 8 months before and after the initiation of assessment and risk-based TcB testing 12 . They showed that the mean length of hospital stay and the number of laboratory TSBs ordered did not change. There were more infants treated with phototherapy prior to discharge, and the number of readmissions for hyperbilirubinemia per 1000 newborns per month decreased significantly. In addition, the results of the study were used to roughly estimate the financial impact of TcB screening on overall hospital costs. Savings were gained from decreased hospital admissions, while expenditures were increased by more TcB measurements and more phototherapy. Overall costs were raised a small but statistically insignificant amount. In summary, the practice of universal predischarge bilirubin screening has been shown to decrease hospital readmissions for hyperbilirubinemia. It appears to do so without significant increase in cost, with the primary cost of the practice seems to be in the initial purchase and use of the TcB devices. It could be reasonably argued that this front-loaded spending is far outweighed by the potential savings found in preventing the lifethreatening consequences of severe hyperbilirubinemia and kernicterus. The reviewed studies have not addressed the question of increased maternal anxiety, nor the implied pressures to discontinue breastfeeding that might accompany the knowledge that hyperbilirubinemia and breastfeeding are closely linked. In addition, more studies need to be done looking prospectively at outcomes and costs under the 2004 guidelines. REFERENCES 1. Centers for Disease Control. Kernicterus in Full-Term Infants ---United States, 1994-1998. MMWR Weekly 2001; 50(23): 491-494. 2. The Joint Commission Sentinel Event Alert. Kernicterus Threatens healthy Newborns 2001. 3. AAP Subcommittee on Hyperbilirubinemia. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2004; 114: 297-316. 4. Keren R, Bhutani VK. Predischarge Risk Assessment for Severe Neonatal Hyperbilirubinemia. NeoReviews 2007; 8:e68-76. 5. Bhutani VK, Gourley GR, Adler S, Kreamer B, Dalin C and Johnson LH. Noninvasive Measurement of Total Serum Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia. Pediatrics 2000; 106: e17 Pediatric Hospitalist Associates, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, continued from page 5 Teaching Activities The PHA has a significant role in medical student and resident education. The hospitalists round individually with pediatric housestaff on the inpatient wards. In addition, they are responsible for teaching noon conferences for two months of the year. Medicinepediatric residents from the University of Minnesota spend one month working with the PHA service. During this month, they learn newborn care, procedures, peri-operative management, and inpatient care. The hospitalists also spend two mornings a week with third year medical students from the University, teaching them how to perform physical exams on newborn infants. New Directions With a rapidly growing service, the hospitalist group has been working hard to keep up with clinical demands. In the future they plan to further develop programs in the transition services and research areas. For more information, contact Dr. Peter Melchert at melch001@umn.edu Interested in submitting an article to Practice Profile? Contact Susan Wu at suwu@chla.usc.edu. 6. Slusher TM, Angyo IA, Bode-Thomas F, Akor F, Pam SD, Adetunji, AA, McLaren DW, Wong RJ, Vreman HJ, Stevenson DK. Transcutaneous Bilirubin Measurements and Serum Total Bilirubin Levels in Indigenous African Infants. Pediatrics 2004; 113:1636-1641 7. Grohmann K, Roser M, Rolinski B, Kadow I, Mueller C, Goerlach-Graw A, Nauck M, Kuester H. Bilirubin Measurement for Neonates: Comparison of 9 Frequently Used Methods. Pediatrics 2006; 117: 1174-1183. 8. Nanjundaswamy S, Petrova A, Mehta R, Bernstein W, and Hegyi T. The Accuracy of Transcutaneous Bilirubin Measurements in Neonates: A Correlation Study. Biology of the Neonate 2004; 85(1):21-25. 9. Bhutani VK, Johnson L, Siveiri EM. Predictive Ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and nearterm newborns. Pediatrics 1999; 103:6-14. 10. Bhutani VK, Johnson LH, Schwoebel A, Gennaro S. A Systems Approach for Neonatal Hyperbilirubinemia in Term and Near-Term Newborns. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2006; 35(4): 444-455. 11. Eggert LD, Wiedmeier SE, Wilson J, Christenson RD. The Effect of Instituting a Prehospital-Discharge Newborn Bilirubin Screening Program in an 18-Hospital Health System. Pediatrics 2006; 117:e855-e862. 12. Peterson JR, Ocorodudu AO, Mohammad AA, Fernando A, Shattuck KE. Association of Transcutaneous Bilirubin Testing in Hospital with Decreased Readmission Rate for Hyperbilirubinemia. Clinical Chemistry 2005; 51(3):540-544. Interested in submitting an article to Neonatal Medicine Update? Contact Ursula Kneissl at Ukneissl@crhc.org Hospital Pediatrics | 15
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Page 3 and 4: Letter from the Chair of Sohm Makin
Page 5 and 6: PraCtiCe ProfiLe — Susan Wu, MD,
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Susan Wu, MD, FAAP, Editor - American Academy of Pediatrics

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