I am surprised by the results of our poll on obtaining bilirubin levels in newborns. Only about half of nearly 300 respondents indicate that they routinely obtain bilirubin levels prior to the discharge of newborn infants. The ease of obtaining the measure, my recent encounters with primary care providers in California and New York (AAP CME meeting), and the information that routine bilirubin measurement decreases the percentage of infants who ultimately develop very high bilirubin levels, led me to believe that practice had tipped substantially in favor of universal screening. And that’s why you collect data — impressions can be wrong.
Neonatal Jaundice: NICE New Guidelines
Neonatal Jaundice: NICE New Guidelines
The U.K. National Institute for Health and Clinical Excellence (NICE) has released a new comprehensive guideline on neonatal jaundice that covers all aspects of care, including evaluation, bilirubin measurement, management, and treatment. Highlights of the guideline include the following:
Risk factors for developing significant hyperbilirubinemia include:
Gestational age <38 weeks
A sibling who had neonatal jaundice requiring phototherapy
Visible jaundice during the first 24 hours
Infants with any of these risk factors should receive an additional visual inspection by a healthcare professional during the first 48 hours after birth.
Measure bilirubin levels in all newborns with visible jaundice. Do not rely on visual inspection to estimate bilirubin level.
Always obtain serum bilirubin measurement in preterm infants (<35 weeks' gestation), infants with jaundice during the first 24 hours, infants with transcutaneous bilirubin levels >14.6 mg/dL (250 µmol/L), and infants who receive phototherapy.
A bilirubin threshold table (rather than a nomogram) is provided in the guideline to direct management of infants ≥38 weeks' gestation with hyperbilirubinemia. The table shows bilirubin threshold levels according to postnatal age (in hours) and the recommended management action required: Repeat bilirubin measurement in 6 to 12 hours, consider phototherapy, start phototherapy, or perform exchange transfusion.
Treatment threshold graphs (for phototherapy or exchange transfusion) are provided for infants starting at a gestational age of 23 weeks to be used in conjunction with the recommendations in the bilirubin threshold table.
During therapy, continue breast-feeding, repeat bilirubin measurement 4 to 6 hours after initiating therapy and every 6 to 12 hours when the serum bilirubin level is stable or falling, and do not give additional fluids or feedings routinely.
Stop phototherapy once the serum bilirubin level is 2.9 mg/dL (50 µmol/L) below the phototherapy threshold, and repeat bilirubin measurement 12 to 18 hours after phototherapy is stopped.
This guideline is far more detailed than the American Academy of Pediatrics (AAP) recommendations, which are now 6 years old. For me, the key issue remains identification of infants at high risk for development of significant hyperbilirubinemia. During a speaking engagement at two recent conferences, about 90% of the 250 pediatricians and family practitioners indicated that they measure bilirubin in all newborns before discharge. Neither the AAP nor NICE guidelines mandate universal screening, although I sense that this approach has become the favored approach in the U.S. Early concerns that universal screening would dramatically increase rates of hospitalization and exchange transfusion have not occurred. Recent studies indicate that mandatory bilirubin screening before discharge reduces the percentage of infants who develop very high hyperbilirubinemia, with only a modest increase in hospitalization rates or longer initial hospital stays (JW Pediatr Adolesc Med May 26 2010 and JW Pediatr Adolesc Med Oct 21 2009). Unfortunately, no data to date indicate that universal predischarge screening reduces the number of infants who develop kernicterus — the most important outcome.