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Indian Pediatr 2013;50: 248 |
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Effectiveness of a Pre-discharge Bilirubin
Screening in High-risk Neonates-
Is the Evidence Robust Enough?
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Alok Sharma
Consultant Neonatologist, Princess Anne Hospital,
Southampton SO16 5YA.
Email:
[email protected]
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I would like to commend the authors on their prospective
study looking at the incidence and predictors of significant
jaundice in late preterm infants [1]. Pre discharge
transcutaneous bilirubin on its own might help identify
significant hyperbilirubinemia but there no randomized
trials demonstrating a decrease in hospital readmission or
bilirubin encephalopathy with its use. There are two studies
looking at this. Bhutani, et al. [2] highlight the
importance of the universal approach not just measurement of
TcB in their study. In the systems-based approach, all
babies had pre-discharge bilirubin estimation (serum
bilirubin or transcutaneous bilirubin), and follow-up care
for jaundice was provided either at the hospital (more than
85% of cases) or at home within 24–48 hours of discharge.
Other components of the approach included lactation support,
provision of information regarding jaundice to parents, and
close follow-up of jaundiced babies based on their
hour-specific bilirubin levels [2]. Eggert, et al.
[3] evaluated the effectiveness of a bilirubin screening
programme in a private healthcare organisation involving 18
hospitals. The authors concluded that a universal screening
program coupled with evaluation of bilirubin using a
percentile-based nomogram can lead to significant reduction
in the incidence of hyperbilirubinemia and hospital
readmissions for phototherapy. These studies are not
randomized control trials. There are no studies which
contemporaneously evaluate an approach of bilirubin
measurement for high risk newborns when clinically jaundiced
versus universal pre discharge screening of all high risk
neonates irrespective of whether they are clinically
jaundiced or not.
The predictive accuracy of clinical risk
factors, pre-discharge bilirubin levels expressed as risk
zones, and a combination of pre-discharge bilirubin and
additional risk factors have been evaluated prospectively
elsewhere. Keren, et al. [4] demonstrate that the
predictive accuracy of pre-discharge bilirubin risk zone
assignment was not significantly different from that of
multiple risk factors. After combining clinical risk factors
with pre-discharge bilirubin risk zone assignment, the only
factors that remained statistically significant were
gestational age and percentage weight loss per day. This
combination model showed improved predictive accuracy when
compared with the pre-discharge bilirubin alone.
National Recommendations in the United
Kingdom feel there is a lack of high-quality evidence to
show that universal pre-discharge bilirubin measurement
reduces the frequency of hospital readmission, exchange
transfusions and bilirubin encephalopathy. The UK National
Institute for Clinical Excellence (NICE) guidelines on
neonatal jaundice recommends neonates with a gestational age
under 38 weeks, a previous sibling with neonatal jaundice
requiring phototherapy, and mother’s intention to breastfeed
exclusively receive an additional visual inspection by a
healthcare professional within 48 hours of birth if
discharged early without clinical jaundice [5].
In the study by Lavanya, et al.
[1] pre discharge TcB as a predictor variable was similar or
sometimes even better than clinical risk factors alone for
prediction of significant jaundice. The measured bilirubin
was compared with the hour specific total serum bilirubin
(TSB) nomogram of AAP guidelines. A major limitation of the
hour-specific bilirubin nomogram was that babies with
conditions such as ABO incompatibility were excluded. The
nomogram may not, therefore, be applicable to other
populations of newborn infants. Would it be better to devise
a local nomogram for Indian conditions to better evaluate
the question from a sub continental perspective?
References
1. Lavanya KR, Jaiswal A, Reddy P, Murki
S. Predictors of significant jaundice in late preterm
infants. Indian Pediatr. 2012;49:717-20.
2. Bhutani VK, Johnson LH, Schwoebel A,
Gennaro S. A systems approach for neonatal
hyperbilirubinemia in term and near-term newborns. JOGNN:
Journal of Obstetric, Gynecologic, and Neonatal Nursing.
2006;35:444-55.
3. Eggert LD, Wiedmeier SE, Wilson J,
Christensen RD. The effect of instituting a prehospital-discharge
newborn bilirubin screening program in an 18-hospital health
system. Pediatrics. 2006; 117:855-62.
4. Keren R, Luan X, Friedman S, Saddlemire
S, Cnaan A, Bhutani VK. A comparison of alternative
risk-assessment strategies for predicting significant
neonatal hyperbilirubinemia in term and near-term infants.
Pediatrics. 2008;121:e170-9.
5. National Institute for Clinical Excellence-CG98
Neonatal jaundice: full guideline. 2010;
http://www.nice.org.uk/nicemedia/live/12986/48678/48678.pdf.
Accessed on 22 September, 2012.
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