American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation

Development of a mobile phone camera-based transcutaneous bilirubinometer for low-resource settings

Newborns in high-income countries are routinely screened for neonatal jaundice using transcutaneous bilirubinometery (TcB). In low-and middle-income countries, TcB is not widely used due to a lack of availability; however, mobile-phone approaches for TcB could help expand screening opportunities. We developed a mobile phone-based approach for TcB and validated the method with a 37 patient multi-ethnic pilot study. We include a custom-designed snap-on adapter that is used to create a spatially resolved diffuse reflectance detection configuration with the illumination provided by the mobile-phone LED flash. Monte-Carlo models of reflectance from neonatal skin were used to guide the design of an adapter for filtered red-green-blue (RGB) mobile-phone camera reflectance measurements. We extracted measures of reflectance from multiple optimized spatial-offset regions-of-interest (ROIs) and a linear model was developed and cross-validated. This resulted in a correlation between total serum bilirubin and mobile-phone TcB estimated bilirubin with a R ²= 0.42 and Bland-Altman limits of agreement of +6.4 mg/dL to -7.0 mg/dL. These results indicate that a mobile phone with a modified adapter can be utilized to measure neonatal bilirubin values, thus creating a novel tool for neonatal jaundice screening in low-resource settings.

Molecular Genetic Screening of Neonatal Intensive Care Units: Hyperbilirubinemia as an Example

Objective

To explore the clinical value of newborn genomic screening (nGS) for neonatal intensive care units (NICU) infants (taking neonatal hyperbilirubinemia as an example).

Methods

Dried blood spots (DBSs) were collected after 72 hours of birth. The tandem mass spectrometry (TMS) screening and Angel Care genomic screening (GS, based on Targeted next-generation sequencing) were performed at the same time.

Results

Ninety-six hyperbilirubinemia newborns were enrolled in this study and none was identified with inborn errors of metabolism (IEM) by TMS, while 6 infants (6.25%, 6/96) were suspected to have a genetic disorder by Angel Care, including 2 cases of glucose-6-phosphate dehydrogenase deficiency (G6PD), and 1 case of maple syrup urine disease type 1B (MSUD1B), autosomal recessive deafness 1A (DFNB1A), Leber hereditary optic neuropathy (LHON), thyroid dyshormonogenesis 6 (TDH6) each. In addition, 44 infants (45.8%) were detected having at least one variant which conferred a carrier status for a recessive childhood-onset disorder. A total of 33 out of 60 variants (55.0%) reported for carrier status were pathogenic (P), 24 (40.0%) were likely pathogenic (LP), and 3 variants were variant of uncertain significance (VUS). Top six common genes of carrier status were GJB2, DUOX2, PRODH, ATP7B, SLC12A3, SLC26A4. Two newborns showed abnormalities in elementary screening of TMS, but were confirmed as false positive after recall. Their results of Angel Care did not found abnormality.

Conclusion

Using neonatal hyperbilirubinemia as an example, genome sequencing screening can find more evidence of genetic variation in NICU newborns, and “Angel Care” is an effective method.

Effectiveness of Dual-Blanket Phototherapy Compared With Combination Phototherapy on Rate of Bilirubin Decline and Treatment Duration

INTRODUCTION

The purpose of this study was to evaluate the effectiveness of dual light-emitting diode (LED) blanket phototherapy compared with combination LED phototherapy on the rate of total serum bilirubin (TSB) decline and treatment duration among full-term neonates with hyperbilirubinemia.

METHODS

A retrospective chart review of 255 newborns with hyperbilirubinemia admitted to a free-standing, university-affiliated, nonprofit, tertiary care Children's Hospital was conducted. Phototherapy type, duration, and rate of TSB decline were compared.

RESULTS

The rate of TSB decline was significantly higher among neonates treated with combination LED phototherapy than neonates treated with dual-blanket phototherapy (p <.0001). There was no significant difference in phototherapy duration.

DISCUSSION

Combination phototherapy resulted in a more rapid decline in TSB but did not shorten phototherapy duration compared to dual-blanket phototherapy. Phototherapy duration may have been confounded by variability in the timing of TSB laboratory draws. Further comparative effectiveness studies are recommended.

The Effect of Readmission for Phototherapy on Early Breast Milk Feeding

OBJECTIVES

To estimate the effect of readmission for inpatient phototherapy on parent-reported exclusive and any breast milk feeding at 2-month well-child visits.

METHODS

We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥35 weeks' gestation with outpatient total serum bilirubin levels ranging from 1 mg/dL below to 2.9 mg/dL above the American Academy of Pediatrics phototherapy threshold at <15 days of age. We compared breast milk feeding at 2-month well-child visits among those readmitted and not readmitted to the hospital for phototherapy, adjusting for bilirubin and other confounding variables.

RESULTS

Approximately one-quarter (26.5%) of the cohort (n = 7729) were readmitted for phototherapy. Almost half (48.5%) of the infants who were not readmitted for phototherapy received exclusively breast milk at the 2-month visit compared with slightly fewer infants who were readmitted (42.9%). In both groups of infants, most (82.2% not readmitted and 81.2% readmitted) received any breast milk. Readmission for phototherapy was associated with a lower adjusted risk of exclusive breast milk feeding (adjusted risk ratio 0.90; 95% confidence interval [CI], 0.84 to 0.96), corresponding to a marginal absolute reduction in exclusive breast milk feeding of 5.0% (95% CI, -7.9% to -2.1%). It was not associated with a reduction in any breast milk feeding (adjusted risk ratio, 1.00; 95% CI, 0.97 to 1.02).

CONCLUSIONS

Infants readmitted for phototherapy were more likely to receive any formula, but no less likely to receive any breast milk at 2-month well-child visits.

Exposure to air pollutants during pregnancy and after birth increases the risk of neonatal hyperbilirubinemia

OBJECTIVES

Exposure to air pollution is associated with increased risks of several adverse conditions in newborns, such as preterm birth. Whether air pollution is associated with neonatal hyperbilirubinemia remains unclear. We aimed to develop and validate an air-quality-based model to better predict neonatal hyperbilirubinemia.

METHODS

A multicenter, population-based cohort of neonates with a gestational age (GA) ≥35 weeks and birth weight ≥2000 g was enrolled in the study. The study was conducted in Shanghai, China, from July 2017 to December 2018. The daily average concentrations of particulate matter (PM) with aerodynamic diameters≤2.5 μm (PM2.5) and ≤10 μm (PM10), sulfur dioxide (SO₂), nitrogen dioxide (NO2) and carbon monoxide (CO) were measured. Neonatal hyperbilirubinemia was diagnosed according to the American Academy of Pediatrics (AAP) guidelines by trained neonatologists. We used logistic least absolute shrinkage and selection operator (LASSO) regression to screen air pollutant indicators related to neonatal hyperbilirubinemia and build an air-quality signature for each patient. An air-quality-based nomogram was then established to predict the risk of neonatal hyperbilirubinemia.

RESULTS

A total of 11196 neonates were evaluated. Prenatal PM10, CO and NO₂ exposure and postpartum SO₂ exposure were significantly associated with neonatal hyperbilirubinemia. The air-quality score was calculated according to the hyperbilirubinemia-related pollutants. The air-quality score of the hyperbilirubinemia group was significantly higher than that of the nonhyperbilirubinemia group (P < .01, odds ratio = 2.97). An air-quality-based logistic regression model was built and showed good discrimination (C-statistic of 0.675 [95% CI (confidence interval), 0.658 to 0.692]) and good calibration. Decision curve analysis showed that the air-quality-based model was better than the traditional clinical model in predicting neonatal hyperbilirubinemia.

CONCLUSIONS

The findings of this study suggest that ambient air pollution exposure is associated with an increased risk of neonatal hyperbilirubinemia. Our results encourage further exploration of this possibility in future studies.

Clinical Assessment of Neuroinflammatory Markers and Antioxidants in Neonates with Hyperbilirubinemia and Their Association with Acute Bilirubin Encephalopathy

Objective: To assess the oxidant and antioxidant status in neonates with and without hyperbilirubinemia and their association with early manifestations of acute bilirubin encephalopathy (ABE), in addition to eliciting the possible oxidative effects of phototherapy. Methods: This prospective observational study was conducted with 104 full-term newborns at Menoufia University Hospitals from January 2020 to January 2021 to help resolve the debate regarding whether bilirubin is an antioxidant. The cases group (Group I) included 52 full-term newborns (37−40 weeks) with hyperbilirubinemia during the neonatal period, while the control group (Group II) included 52 healthy, full-term age and sex-matched newborns who did not have hyperbilirubinemia. The cases group was further subdivided into Group Ia (n = 12), which included newborns who presented with neurological manifestations suggesting early ABE, and Group Ib (n = 40), which included newborns with no signs suggestive of ABE. All newborns were subjected to clinical and neurological examinations, as well as laboratory investigations. Results: Comparing the specific biological markers between the Group 1 subgroups before phototherapy, the mean plasma levels of prostaglandin-Em, prostaglandin E2, and TSB were significantly higher in Subgroup I(a) (all p < 0.05). After phototherapy, Subgroup I(a) patients had significantly higher levels of prostaglandin-Em, DSB, and TSB (p < 0.05). The biological marker levels improved after phototherapy in terms of TAC (0.811 vs. 0.903), MDA (8.18 vs. 5.13), prostaglandin-Em (37.47 vs. 27.23), prostaglandin E2 (81.09 vs. 31.49), DSB (1.21 vs. 0.55), and TSB (16.63 vs. 8.26; p-value < 0.05). Conclusion: Our study showed that an elevated level of serum bilirubin increases oxidative stress and decreases antioxidant capacity. The reduction in bilirubin levels by phototherapy is associated with a decrease in oxidative stress markers (MDA, PGEm, and PGE2) and an upsurge in TAC, highlighting the absence of oxidative stress effects arising from phototherapy. Neonates with neurological manifestations suggesting ABE had higher levels of oxidative stress markers and lower levels of total antioxidant capacity than those without.

Evaluation of a new transcutaneous bilirubinometer in newborn infants

To avoid brain damage in newborn infants, effective tools for prevention of excessive neonatal hyperbilirubinemia are needed. The objective of this study was to evaluate a new transcutaneous bilirubinometer (JAISY). For this purpose, 930 bilirubin measurements were performed in 141 newborn infants born near-term or at term (gestational age 35–41 weeks; postnatal age 1–6 days; 71 boys; including 29 infants with darker skin) and compared to those of a previously validated instrument (JM105). In each infant, the mean of three repeated measurements in the forehead was calculated for each instrument, followed by a similar measurement on the chest. The bilirubin values varied between 0 and 320 µmol/l (0–18.8 mg/dl). There was a high degree of agreement with significant correlations between bilirubin values measured with the two devices on the forehead (Pearson’s r = 0.94, p < 0.001) and the chest (r = 0.94, p < 0.001). The correlations remained after stratifying the data by gestational age, postnatal age and skin color. The coefficient of variation for repeated bilirubin measurements was 8.8% for JAISY and 8.0% for JM105 (p = 0.79). In conclusion, JAISY provides accurate and reproducible information on low to moderately high bilirubin levels in newborn infants born near-term or at term.

Machine learning approach identifies meconium metabolites as potential biomarkers of neonatal hyperbilirubinemia

Background

The gut microbiota plays an important role in the early stages of human life. Our previous study showed that the abundance of intestinal flora involved in galactose metabolism was altered and correlated with increased serum bilirubin levels in children with jaundice. We conducted the present study to systematically evaluate alterations in the meconium metabolome of neonates with jaundice and search for metabolic markers associated with neonatal jaundice.

Methods

We included 68 neonates with neonatal hyperbilirubinemia, also known as neonatal jaundice (NJ) and 68 matched healthy controls (HC), collected meconium samples from them at birth, and performed metabolomic analysis via liquid chromatography-mass spectrometry.

Results

Gut metabolites enabled clearly distinguishing the neonatal jaundice (NJ) and healthy control (HC) groups. We also identified the compositions of the gut metabolites that differed significantly between the NJ and HC groups; these differentially significant metabolites were enriched in aminyl tRNA biosynthesis; pantothenic acid and coenzyme biosynthesis; and the valine, leucine and isoleucine biosynthesis pathways. Gut branched-chain amino acid (BCAA) levels were positively correlated with serum bilirubin levels, and the area under the receiver operating characteristic curve of the random forest classifier model based on BCAAs, proline, methionine, phenylalanine and total bilirubin reached 96.9%, showing good potential for diagnostic applications. Machine learning-based causal inference analysis revealed the causal effect of BCAAs on serum total bilirubin and NJ.

Conclusions

Altered gut metabolites in neonates with jaundice showed that increased BCAAs and total serum bilirubin were positively correlated. BCAAs proline, methionine, phenylalanine are potential biomarkers of NJ.

Value of HbA1c in Obese Women with Gestational Diabetes

OBJECTIVE

We sought to assess the association of hemoglobin A1c (HbA1c) with adverse perinatal outcomes in obese women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This was a secondary analysis of a multicenter randomized controlled trial assessing early (14-20 weeks) versus routine (24-28 weeks) screening for GDM in obese women. Women were included if they were diagnosed with GDM at either time during pregnancy and had a HbA1c result available. The primary exposure was HbA1c at 24 to 28 weeks. The primary outcome was a composite of macrosomia, primary cesarean, pregnancy-induced hypertension, shoulder dystocia, neonatal hypoglycemia, or hyperbilirubinemia. Receiver operating characteristics (ROC) curves were used to assess the association of HbA1c with the composite outcome. The Liu method was used to select an optimal HbA1c cutoff, and the incidence of the outcome compared.

RESULTS

Of 125 women with GDM, 93 (74%) had a HbA1c at 24 to 28 weeks and 103 (82.4%) had a HbA1c at 14 to 20 weeks. Baseline characteristics were balanced between groups above and below the cutoff. The area under the ROC curve for HbA1c and its association with the adverse perinatal composite outcome was 0.6 (95% confidence interval [CI]: 0.5-0.7). The frequency of the primary outcome was similar among women with low and high HbA1c at 24 to 28 weeks (adjusted relative risk, 1.12, 95% CI: 0.97-1.29). Compared with women with a decreasing HbA1c during pregnancy, women with a stable or increasing HbA1c did not have a significant increase in the primary adverse perinatal composite outcome. However, the frequency of preterm delivery was higher among women with stable or increasing HbA1c compared with those with a decreasing HbA1c (26.1 vs. 6.7%, p = 0.03).

CONCLUSION

A single HbA1c in women with GDM is not associated with a composite perinatal adverse outcome, but a HbA1c that increases or remains stable between 14 to 20 and 24 to 28 weeks is associated with an increase in preterm delivery.

KEY POINTS

· A single HbA1c in GDM is not associated with a composite perinatal adverse outcome.. · HbA1c that increases or remains stable may be associated with an increase in preterm delivery.. · HbA1c at 24 to 28 weeks was not significantly associated with the adverse perinatal composite outcome..

Clinical and Genetic Etiologies of Neonatal Unconjugated Hyperbilirubinemia in the China Neonatal Genomes Project

OBJECTIVE

To investigate the clinical and genetic causes of neonatal unconjugated hyperbilirubinemia.

STUDY DESIGN

We included 1412 neonates diagnosed with unconjugated hyperbilirubinemia (total serum bilirubin >95 percentile for age), from the China Neonatal Genomes Project between August 2016 and September 2019, in the current study. Clinical data and targeted panel sequencing data on 2742 genes including known unconjugated hyperbilirubinemia genes were analyzed.

RESULTS

Among the 1412 neonates with unconjugated hyperbilirubinemia, 37% had severe unconjugated hyperbilirubinemia, with total serum bilirubin levels that met the recommendations for exchange transfusion. Known clinical causes were identified for 68% of patients. The most common clinical cause in the mild unconjugated hyperbilirubinemia group was infection (17%) and in the severe group was combined factors (21%, with infection combined with extravascular hemorrhage the most common). A genetic variant was observed in 55 participants (4%), including 45 patients with variants in genes associated with unconjugated hyperbilirubinemia and 10 patients with variants that were regarded as additional genetic findings. Among the 45 patients identified with unconjugated hyperbilirubinemia-related variants, the genes were mainly associated with enzyme deficiencies, metabolic/biochemical disorders, and red blood cell membrane defects. G6PD and UGT1A1 variants, were detected in 34 of the 45 patients (76%).

CONCLUSIONS

Known clinical causes, which varied with bilirubin levels, were identified in approximately two-thirds of the patients. Genetic findings were identified in 4% of the patients, including in patients with an identified clinical cause, with G6PD and UGT1A1 being the most common genes in which variants were detected.

Home phototherapy of term neonates improves parental bonding and stress: Findings from a randomised controlled trial

AIM

We aimed to evaluate whether in-home phototherapy for hyperbilirubinaemia could reduce the poorer parent-infant bonding and increased parental stress associated with neonatal hospital treatment.

METHODS

In this multicentre randomised controlled trial, we allocated families to either home phototherapy or standard hospital care. The primary outcome was parent-infant bonding measured on the Postpartum Bonding Questionnaire directly after therapy and 4 months later. Secondary outcomes were results on four other instruments measuring parental bonding, quality of life and mental health.

RESULTS

We randomised 78 of 147 newborn infants to intervention and 69 to the control group. No significant differences were detected in length of stay, mean bilirubin, or weight gain. Parents in the intervention group had better scores on bonding both at discharge (p = 0.034) and at 4 months (p = 0.008; effect size r = 0.2) and lower levels of stress at 4 months (p = 0.024) than controls. No statistically significant outcomes were found for the secondary outcomes.

CONCLUSION

In-home phototherapy improved bonding and reduced parental stress in comparison with usual in-hospital treatment. Caregivers should consider offering home phototherapy to families of non-immunised term infants with hyperbilirubinaemia.

Risk factors and predictive markers for early and late-onset neonatal bacteremic sepsis in preterm and term infants

BACKGROUND

The early detection and prediction of bacteremic sepsis in preterm and term neonates remains a challenging task because of their nonspecific clinical presentations. We aimed to investigate the risk factors associated with bacteremia and find the cutoff values of predictive markers to achieve accurate diagnosis of neonatal bacteremic sepsis.

METHODS

Not-doing-well preterm and term neonates with suspected sepsis were retrospectively enrolled between January 2015 and December 2017 in Taipei Veterans General Hospital. Blood culture, hemogram, serum procalcitonin (PCT), and C-reactive protein (CRP) were drawn at the onset of clinical signs and symptoms. All cases were divided to either early-onset or late-onset groups according to postpartum age. Nonparametric statistic, logistic regression, and receiver operating characteristic analysis were performed to evaluate the risk factors and cutoff values for predicting bacteremia.

RESULTS

A total of 169 suspected sepsis episodes were analyzed, 68.0% of which had cardiopulmonary dysfunction and 19.5% had perinatal stress. The early-onset group had 123 (72.8%) patients, 4 of which had bacteremia and 119 had nonbacteremia conditions. The late-onset group had 46 (27.2%) patients, 8 of which had bacteremia and 38 had nonbacteremia conditions. Gestational age, birth body weight, Apgar score at 5 minutes, serum PCT, CRP, and platelet (PLT) count in the early-onset group and white blood cell (WBC) count in the late-onset group were substantially different between the patients with bacteremia and nonbacteremia conditions. PCT greater than 27 µg/L (adjusted odd ratio [aOR], 21.6; 95% CI, 1.1-435.1) and thrombocytopenia less than 100 × 109/L (aOR, 38.6; 95% CI, 1.4-1030.3) were predictive markers for bacteremia in the early-onset group.

CONCLUSION

Early- and late-onset neonatal sepsis had different risk factors and predictive markers of bacteremia. PCT and PLT count in the early-onset group and WBC count in the late-onset group were accurate diagnostic serum markers for neonatal bacteremic sepsis.

Causative organisms and antimicrobial susceptibility in jaundiced infants with significant bacteriuria

BACKGROUND

Jaundice may be one of the first signs of urinary tract infection (UTI) in infants. The most common pathogen is Escherichia coli. Currently recommended antibiotic treatment for neonatal UTI is ampicillin and an aminoglycoside. Recently, increasing ampicillin and gentamicin resistance in strains of E. coli has been isolated. The aim of this study was to determine causative organisms and antimicrobial susceptibility in jaundiced infants with significant bacteriuria (SB).

METHODS

We evaluated admitted afebrile, asymptomatic infants younger than 1-month old with hyperbilirubinemia (total bilirubin >15 mg/dl) requiring phototherapy between January 2011 and December 2015. A total of 615 asymptomatic jaundiced infants were enrolled. Urinalysis and urine cultures were performed on all jaundiced infants. A urine culture was defined as SB if a single pathogen with more than 105-colony forming units per milliliter (CFU/ml) by sterile urinary collection bag or 104 CFU/ml by catheterization was isolated.

RESULTS

A total of 88 (14.3%) of 615 asymptomatic jaundiced infants had positive urinary culture. E coli was the most common cultured bacteria (40 cases, [45.5%]). Enterococcus faecalis was the second most common bacteria (17 cases, [19.3%]). Seven cases (8.0%) of Streptococcus agalactiae and six cases (6.8%) of Klebsiella pneumoniae were also identified. Ampicillin sensitivity was found in 22.5% of E. coli infections, gentamicin sensitivity was found in 84.2%, and extended-spectrum β-lactamases were found in 7.5%.

CONCLUSION

E. coli was the most common causative organism for infants with SB. We suggest modifying current empiric antibiotics by changing gentamicin to amikacin for neonatal Gram-negative bacterial infections.

Development and evaluation of a novel method "bilirubin color card" for screening of treatable jaundice in neonates: prospective comparative diagnostic study

BACKGROUND

Various methods of screening or diagnosis of severe hyperbilirubinemia like transcutaneous bilirubinometer and laboratory testing havemethodological or practical limitations. In this perspective, we designed and evaluated an invasive but simple screening Color Card method in rapid assessment of various levels of bilirubin categories.

OBJECTIVE

This prospective comparative diagnostic study objectives were to create "Color Card" initially by yellow color shades that fall into 4 bilirubin categories, i.e. TSB up to 7 mg/dl, 7.1 to 12 mg/dl, 12.1 to 18 mg/dl and >18 mg/dl from the samples analyzed by diazo method, and to study its sensitivity and specificity for the diagnosis of moderate or severe hyperbilirubinemia in comparison to total serum bilirubin (TSB) by diazo method.

RESULTS

Out of total 188 samples obtained, 134 were unique patients. The specificity, negative predictive value and accuracy of the color card for the observations made by observer 1 comparing with lab TSB were >95% for clinically important categories of <7 mg/dl and >18 mg/dl. The overall accuracy of color card in measuring various TSB ranges varied from 75% to 96.8%. The agreement between two observers was 85.6% (Cohen's kappa co-efficient: 0.61, p-value: .0001) overall and was 92.3%, 86%, 84%, 81.2% for each of the four bilirubin categories in ascending order.

CONCLUSION

Bilirubin color card has good accuracy and may be very useful in the low resource settings, especially in the first referral units and community settings, where laboratory TSB estimation is not available easily. However, it requires centrifugation and easier methods of centrifugation will make this method simpler.

Trends and Resource Utilization for Neonatal Jaundice Hospitalizations in the United States

OBJECTIVES

To evaluate the trends in hospitalization for neonatal jaundice and its management with phototherapy and exchange transfusion in the United States from 2006 through 2016.

METHODS

Repeated, cross-sectional analysis of the 2006 to 2016 editions of the Kids' Inpatient Database. All neonatal hospitalizations with an International Classification of Diseases, 9th or 10th Revision, Clinical Modification code for jaundice and admitted at age ≤28 days were included. The outcome measures were changes in the diagnosis of jaundice (expressed as a proportion) and its management over the years.

RESULTS

Among 16 094 653 neonatal hospitalizations from 2006 to 2016, 20.5% were diagnosed with jaundice. While the incidence of jaundice remained stable over the years, 20.9% to 20.5% (P = .1), the proportion with jaundice who received phototherapy increased from 22.5% to 27.0% (P < .0001) between 2006 and 2016. There was no significant change in the exchange transfusion rate per year among neonatal hospitalizations with jaundice.

CONCLUSIONS

While the proportion of newborns with jaundice remained stable between 2006 and 2016, the use of phototherapy significantly increased with no significant change in exchange transfusion rate. The impact of these changes on the prevention of acute bilirubin encephalopathy needs further examination in future studies.

Impact of Diagnostic Criteria on UTI Prevalence in Young Infants With Jaundice: A Meta-analysis

BACKGROUND AND OBJECTIVE

Previously reported prevalence of urinary tract infections (UTIs) in infants with jaundice range from <1% to 25%. However, UTI criteria are variable and, as demonstrated in a meta-analysis on UTI prevalence in bronchiolitis, disease prevalence is greatly impacted by disease definition. The objective of this study was to conduct a systemic review and meta-analysis examining the impact of including positive urinalysis (UA) results as a diagnostic criterion on the estimated UTI prevalence in young infants with jaundice.

METHODS

The data sources used were Medline (1946-2020) and Ovid Embase (1976-2020) through January 2020 and bibliographies of retrieved articles. We selected studies reporting UTI prevalence in young infants with jaundice. Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines. Random-effects models produced a weighted pooled event rate with 95% confidence intervals (CI).

RESULTS

We screened 526 unique articles by abstract and reviewed 53 full-text articles. We included 32 studies and 16 contained UA data. The overall UTI prevalence in young infants with jaundice from all 32 studies was 6.2% (95% CI, 3.9-8.9). From the 16 studies with UA data, the overall UTI prevalence was 8.7% (95% CI, 5.1-13.2), which decreased to 3.6% (95% CI, 2.0-5.8) with positive UA results included as a diagnostic criterion.

CONCLUSIONS

The estimated UTI prevalence in young infants with jaundice decreases substantially when UA results are incorporated into the UTI definition. Due to the heterogeneity of study subjects' ages and definitions of jaundice, positive UA results, and UTI, there is uncertainty about the exact prevalence and about which infants with hyperbilirubinemia warrant urine testing.

Immunohematology testing using umbilical cord blood: review of the literature, survey of practice and guidance development

BACKGROUND

Following delivery, blood tests are performed on umbilical cord blood (CB) to avoid neonatal venipuncture. Despite widespread and longstanding CB testing, no guidelines exist to suggest which immunohematology tests should be performed on CB.

STUDY DESIGN AND METHODS

We performed a scoping review, surveyed national practice, and developed guidance statements concerning CB testing. Database searches identified relevant articles. A survey was sent to all Canadian hospitals and transfusion laboratories that perform perinatal testing. A national panel of experts was convened to develop guidance statements.

RESULTS

A total of 116 articles met the inclusion criteria and were summarized. Literature on CB testing is limited; few studies have investigated laboratory testing methodologies or validated CB test results with peripheral samples. The survey was completed by 580/597 institutions (97%); 85% were community hospitals and 16% had a neonatal intensive care unit. There is diversity in the types of CB tests performed and variability in practice. While most centers order appropriately, some laboratories routinely perform CB tests that are not clinically indicated (e.g., direct antiglobulin testing for all neonates) and other do not perform CB tests when results would be beneficial (e.g., phenotype on CB when mother has a clinically significant antibody). Fifteen guidance statements were developed.

DISCUSSION

This study highlights variability in CB testing, likely reflecting evidence gaps, methodology differences between studies, and lack of guidelines. CB tests should only be performed when indicated and validated on this sample type. The presented guidance statements aim to standardize practice and encourage judicious CB sampling.

Impact of phototherapy type and duration on serum electrolytes and blood glucose in neonatal hyperbilirubinemia: a prospective single-center cohort study

Background

Neonatal hyperbilirubinemia (NH) is among the common neonatal morbidities. Phototherapy is its most used therapeutic intervention. Different delivering systems and types are currently available. This study aimed to detect and compare the effects of the different phototherapy types on serum electrolytes and blood glucose and to study the effect of phototherapy duration on them.

Results

Five hundred healthy newborns with indirect NH were treated by different phototherapy types (conventional, light emitting diode LED, intensive) according to severity and availability. Serum sodium (Na), potassium (K), calcium (Ca), blood urea nitrogen (BUN), creatinine (Cr), and blood glucose (Glu) were measured repeatedly over 48 h of phototherapy. In this prospective cohort study, 273 (54.6%) neonates were exposed to conventional phototherapy, 145 (29.0%) to LED, and 82 (16.4%) to intensive phototherapy. A highly significant negative correlation was found between phototherapy duration and serum levels of Na, K, Ca, BUN, and Cr (p < 0.001). There was a positive correlation between phototherapy duration and blood glucose level (p = 0.005). Each type of phototherapy individually significantly affected the Na, K, Bun, Cr, and Ca levels after 48 h. Comparing the effects of the 3 different phototherapy types together, no significant differences apart from a decline in potassium level at 48 h (p = 0.043) were recorded.

Conclusions

Serum electrolytes significantly decreased during phototherapy. These changes were affected by the phototherapy duration. The type of phototherapy had only some effect on serum potassium.

Periodic change of body position under phototherapy in term and preterm neonates with hyperbilirubinaemia

BACKGROUND

Phototherapy is the mainstay of treatment of neonatal hyperbilirubinaemia. Periodic change in position of the neonate under phototherapy (from supine to prone or lateral positions) may improve the efficiency of phototherapy by hastening the access of phototherapy light to bilirubin deposited in different parts of the skin and subcutaneous tissue.

OBJECTIVES

To evaluate the effects of periodic change of body position during phototherapy as compared to no prescribed change in body position, on serum total bilirubin level and duration of treatment in neonates with unconjugated hyperbilirubinaemia during the first 28 days of life. Secondary objectives of the review included evaluation of the efficacy of periodic change of body position on the need for or number of exchange transfusions, incidence of bilirubin-induced neurological damage (BIND), side effects of phototherapy, and sudden infant death syndrome (SIDS).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 3) in the Cochrane Library and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions on 5 March 2021. We also searched clinical trials databases and the reference lists of included studies and relevant reviews for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs if they enrolled neonates (term and preterm) of either gender with unconjugated hyperbilirubinaemia requiring phototherapy and compared periodic change of the body position of the infant under phototherapy with no prescribed change in body position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data, consulting with a third review author in the case of disagreement. We used standard Cochrane methodological procedures, including assessing the risk of bias of included studies. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were the duration of phototherapy and rate of fall of serum bilirubin at 24 hours. Secondary outcomes included the need for exchange transfusion, number of exchange transfusions, incidence of BIND, and SIDS.

MAIN RESULTS

We included five studies (343 neonates) with an overall high risk of bias in the review. The body position under phototherapy was changed every two hours or every two-and-a-half hours in two studies each, and every three hours in one study. Three of the five studies included healthy term neonates, whilst the other two studies also included preterm neonates (≥ 33 weeks' gestation); however, separate data about review outcomes in preterm neonates were not available. Periodic change in body position may lead to little or no difference in the duration of phototherapy (mean difference (MD) 1.71 hours, 95% confidence interval (CI) -3.17 to 6.59 hours; I² = 58%; 4 studies, 231 participants; low certainty evidence). Only one study reported the rate of fall of serum total bilirubin at 24 hours of starting the phototherapy. Periodic change in body position may lead to little or no difference in the rate of fall of serum total bilirubin at 24 hours (MD 0.02 mg/dL/h, 95% CI -0.02 to 0.06 mg/dL/h; 1 study, 100 participants; low certainty evidence). We downgraded the certainty of evidence to low due to risk of bias and imprecision. None of the included studies reported the need for or number of exchange transfusions, incidence of BIND, or SIDS. Lack of separate data precluded subgroup analysis.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to determine the effects of periodic change of body position compared with no prescribed change of body position under phototherapy. There is low certainty evidence that there may be little or no difference in the duration of phototherapy and rate of fall in bilirubin at 24 hours of starting phototherapy between periodic change in body position and no prescribed change of body position under phototherapy in term and preterm neonates. None of the included studies reported the effect of change of position on the need for or number of exchange transfusions, incidence of BIND, or SIDS. One study is awaiting classification and could not be included in the review. Further studies are needed to evaluate the effect of periodic change in body position under phototherapy, especially in neonates with haemolytic hyperbilirubinaemia and in very preterm neonates. The results of this systematic review apply mainly to neonates born at late-preterm or term gestation receiving phototherapy for non-haemolytic hyperbilirubinaemia.

Validation of published rebound hyperbilirubinemia risk prediction scores during birth hospitalization after initial phototherapy: a retrospective chart review

BACKGROUND

Hyperbilirubinemia commonly affects newborns and may lead to neurotoxicity if untreated. Neonates can experience rebound hyperbilirubinemia (RHB), defined as elevated bilirubin levels requiring re-initiation of treatment. Although studies have formulated risk prediction scores, they lack external validation. In this study, we examine the discrimination and calibration performance of risk prediction scores for RHB, to provide external validation.

METHODS

We reviewed charts of neonates born ≥35 weeks of gestation between January 2015 and December 2019 receiving phototherapy at birth hospitalization. We plotted predicted probabilities against observed outcome proportions to assess model calibration and evaluated discrimination using area under the receiver operating characteristic (AUROC) curves. Odds ratios (ORs) were estimated to evaluate variables associated with RHB.

RESULTS

Of the 271 infants identified, 24% developed RHB. Two- and three-variable prediction scores had lower discrimination in our cohort with AUROC of 0.662 (95% CI 0.590-0.735) and 0.691 (95% CI, 0.619-0.763) compared to 0.876 (95% CI 0.854-0.899) and 0.881 (95% CI 0.859-0.903), respectively, in the published studies. Estimated ORs confirm associations between RHB and variables included in prediction scores.

CONCLUSIONS

Current prediction models for RHB have unclear clinical utility in our patient population. Additional studies are required to further validate these scores.

IMPACT

Describes performance characteristics of two- and three-variable risk prediction scores that lack external validation beyond the initial study cohort. Our findings suggest unclear clinical utility in our clinical population of neonates during birth hospitalization, with lower performance of these prediction scores than observed in the derivation cohort. Odds ratios estimated by logistic regression in our study cohort provide further evidence that variables in published risk prediction scores are associated with rebound hyperbilirubinemia. Further studies are required to externally validate these risk prediction scores and to assess their generalizability.

Smoking influence on early and late fetal growth

OBJECTIVES

Smoking during pregnancy is a leading and modifiable risk factor for fetal growth restriction (FGR) and low birthweight (<10th centile). We studied the effects of smoking in the development of early and late FGR or low birthweight, as well as in uteroplacental and fetoplacental hemodynamics of growth-restricted fetuses.

METHODS

Retrospective cohort study of 5,537 consecutive singleton pregnancies delivered at ≤34 + 0 ("early delivery" group, n=95) and >34 + 0 ("late delivery" group, n=5,442) weeks of gestation. Each group was divided into smokers and non-smokers. Prenatal diagnosis of FGR was based on customized fetal growth standards and fetal Doppler, and postnatal birthweight was assessed using the Olsen newborn chart.

RESULTS

There were 15/95 (15.8%) and 602/5,442 (11.1%) smokers in the early and late delivery groups, respectively. In early deliveries, FGR was diagnosed in 3/15 (20%) of smokers and in 20/80 (25%) of non-smokers (p=0.68). We also found no differences in birthweights and hemodynamics. In late deliveres, FGR was detected in 30/602 (5%) smokers and 64/4,840 (1.3%) non-smokers (p<0.001). Birthweights <3rd centile and <10th centile were more common in smokers vs. non-smokers: 38/602 (6.3%) vs. 87/4,840 (1.8%) and 89/602 (14.8%) vs. 288/4,840 (6%), respectively (all p<0.01). Fetal Doppler of late FGR showed slightly higher umbilical artery resistances in smokers.

CONCLUSIONS

Smoking in pregnancy is associated with FGR, low birthweight and higher umbilical artery Doppler resistances after 34 weeks of gestation, but we could not confirm this association in earlier deliveries.

Current and emerging technologies for the timely screening and diagnosis of neonatal jaundice

Neonatal jaundice is one of the most common clinical conditions affecting newborns. For most newborns, jaundice is harmless, however, a proportion of newborns develops severe neonatal jaundice requiring therapeutic interventions, accentuating the need to have reliable and accurate screening tools for timely recognition across different health settings. The gold standard method in diagnosing jaundice involves a blood test and requires specialized hospital-based laboratory instruments. Despite technological advancements in point-of-care laboratory medicine, there is limited accessibility of the specialized devices and sample stability in geographically remote areas. Lack of suitable testing options leads to delays in timely diagnosis and treatment of clinically significant jaundice in developed and developing countries alike. There has been an ever-increasing need for a low-cost, simple to use screening technology to improve timely diagnosis and management of neonatal jaundice. Consequently, several point-of-care (POC) devices have been developed to address this concern. This paper aims to review the literature, focusing on emerging technologies in the screening and diagnosing of neonatal jaundice. We report on the challenges associated with the existing screening tools, followed by an overview of emerging sensors currently in pre-clinical development and the emerging POC devices in clinical trials to advance the screening of neonatal jaundice. The benefits offered by emerging POC devices include their ease of use, low cost, and the accessibility of rapid response test results. However, further clinical trials are required to overcome the current limitations of the emerging POC's before their implementation in clinical settings. Hence, the need for a simple to use, low-cost POC jaundice detection technology for newborns remains an unsolved challenge globally.

Intensive phototherapy vs. exchange transfusion for the treatment of neonatal hyperbilirubinemia

Background:

Intensive phototherapy (IPT) and exchange transfusion (ET) are the main treatments for extreme hyperbilirubinemia. However, there is no reliable evidence on determining the thresholds for these treatments. This multicenter study compared the effectiveness and complications of IPT and ET in the treatment of extreme hyperbilirubinemia.

Methods:

This retrospective cohort study was conducted in seven centers from January 2015 to January 2018. Patients with extreme hyperbilirubinemia that met the criteria of ET were included. Patients were divided into three subgroups (low-, medium-, and high- risk) according to gestational week and risk factors. Propensity score matching (PSM) was performed to balance the data before treatment. Study outcomes included the development of bilirubin encephalopathy, duration of hospitalization, expenses, and complications. Mortality, auditory complications, seizures, enamel dysplasia, ocular motility disorders, athetosis, motor, and language development were evaluated during follow-up at age of 3 years.

Results:

A total of 1164 patients were included in this study. After PSM, 296 patients in the IPT only group and 296 patients in the IPT plus ET group were further divided into the low-, medium-, and high-risk subgroups with 188, 364, and 40 matched patients, respectively. No significant differences were found between the IPT only and IPT plus ET groups in terms of morbidity, complications, and sequelae. Hospitalization duration and expenses were lower in the low- and medium-risk subgroups in the IPT only group.

Conclusions:

In this study, our results suggest that IPT is a safe and effective treatment for extreme hyperbilirubinemia. The indication of ET for patients with hyperbilirubinemia could be stricter. However, it is necessary to have a contingency plan for emergency ET as soon as IPT is commenced especially for infants with risk factors. If IPT can be guaranteed and proved to be therapeutic, ET should be avoided as much as possible.

The Effect of Breastfeeding and an Intensive Breast Milk Nutritional Support Program on Hospitalization Rates for Hyperbilirubinemia in Term Newborns: An Open Randomized Controlled Trial

OBJECTIVE

The aim of this study was to determine the effect of breastfeeding and intensive breast milk nutritional support program (IBNSP) on hospitalization rates for hyperbilirubinemia in normal term newborns.

METHODS

This study's sample consisted of 68 newborn infants (experimental group: 34; control group: 34) born at a university hospital from October 2020 to April 2021. Five steps of breastfeeding and IBNSP were administered to the experimental group for the first 48 h after birth. This program starts at the postpartum first hour and continues until the 48th hour. It includes face-to-face training, practical support on breastfeeding, and one-to-one demonstration and practice methods. The control group received the standard care recommended by the World Health Organization. Both groups' bilirubin levels were measured 24 and 72 h after birth. Participants in both groups were hospitalized for risky (according to bilirubin values) situations. The groups' bilirubin levels and hospitalization rates for hyperbilirubinemia were compared.

RESULTS

There was no statistically significant difference between the experimental (5.19 ± 1.27) and the control (5.83 ± 1.52) groups' bilirubin levels at 24 h after birth, (t = -1.881, p = 0.064); however, the control group infants (12.03 ± 3.67 mg/dl) had higher bilirubin levels than the infants in the experimental group 72 h after birth (9.55 ± 2.82 mg/dl) (t = -3.122, p = 0.003). The experimental group's hospitalization rate for hyperbilirubinemia (n: 1, 2.9%) was lower than the control group's rate (n: 8, 23.5%), and this difference was statistically significant (X2 = 6.275, p = 0.014).

CONCLUSIONS

Breastfeeding and IBNSP effectively prevent hospitalization for hyperbilirubinemia and reduce newborns' bilirubin levels.

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.

Expert consensus on the clinical practice of neonatal brain magnetic resonance imaging

In recent years, magnetic resonance imaging (MRI) has been widely used in evaluating neonatal brain development, diagnosing neonatal brain injury, and predicting neurodevelopmental prognosis. Based on current research evidence and clinical experience in China and overseas, the Neonatologist Society of Chinese Medical Doctor Association has developed a consensus on the indications and standardized clinical process of neonatal brain MRI. The consensus has the following main points. (1) Brain MRI should be performed for neonates suspected of hypoxic-ischemic encephalopathy, intracranial infection, stroke and unexplained convulsions; brain MRI is not considered a routine in the management of preterm infants, but it should be performed for further evaluation when cranial ultrasound finds evidence of brain injury; as for extremely preterm or extremely low birth weight infants without abnormal ultrasound findings, it is recommended that they should undergo MRI examination at term equivalent age once. (2) Neonates should undergo MRI examination in a non-sedated state if possible. (3) During MRI examination, vital signs should be closely monitored to ensure safety; the necessity of MRI examination should be strictly evaluated for critically ill neonates, and magnetic resonance compatible incubator and ventilator can be used. (4) At present, 1.5 T or 3.0 T equipment can be used for neonatal brain MRI examination, and the special coil for the neonatal head should be used to improve signal-to-noise ratio; routine neonatal brain MRI sequences should at least include axial T1 weighted image (T1WI), axial T2 weighted imaging (T2WI), diffusion-weighted imaging, and sagittal T1WI or T2WI. (5) It is recommended to use a structured and graded reporting system, and reports by at least two reviewers and multi-center collaboration are recommended to increase the reliability of the report.

Clinical Profile and Outcome Following Exchange Transfusion for Neonatal Jaundice in a Tertiary Care Centre

INTRODUCTION

Phototherapy has reduced the need for exchange transfusion (ET) to manage jaundiced neonates. Hence there are concerns about increased risk of complication due to lack of opportunity to sustain skills in performing ET. We studied the complications and treatment outcomes of neonates treated for jaundice with ET.

METHODOLOGY

A retrospective observational study was conducted from June 2013 to June 2020 in a tertiary care hospital in India. All neonates treated with ET for jaundice were included.

RESULTS

Twenty-eight neonates underwent 31 ET during the study period. Their mean gestational age and birth weight were 37 weeks and 3200 g, respectively. Predisposing factor for jaundice observed were Coomb's positive status (11), hepatosplenomegaly suggesting hemolysis (3), cephalhematoma (2) and birth asphyxia (1). Abnormal neurological status before ET was seen in seven neonates. Adverse clinical events that happened during or within 8 h after ET were desaturation (4), tachycardia (3), tachypnea (2), bradycardia (2), shock (2) and temperature instability (2). One neonate developed acute kidney injury after ET and required peritoneal dialysis. Abnormal lab parameters observed during or within 8 h after ET were hypocalcemia (20), anemia (8), hypokalemia (7), hypernatremia (3), thrombocytopenia (3) and hyperkalemia (2). Post ET sepsis was seen in five neonates: two had only blood culture positive sepsis, two had bone and joint infection and one had liver abscess.

CONCLUSION

The neonates undergoing ET are at high risk of developing complications which may be life threatening. Hence careful monitoring during the procedure is needed.

Therapeutic effects of synbiotic on neonates with gestational age over 34 weeks admitted for jaundice

BACKGROUND

Hyperbilirubinemia is a common problem in neonates. The aim of this study was to evaluate the effect of synbiotic in addition to routine phototherapy on the treatment of neonatal jaundice.

METHOD

This double-blind clinical trial, was performed on 194, 3-14 days old neonates. Neonates were divided into intervention and placebo groups. The intervention group received 5 drops of oral synbiotic daily along with phototherapy and the placebo group underwent phototherapy plus a placebo. Gestational age, age, weight, sex, initial and daily bilirubin level, frequency of defecation, mode of delivery, and length of hospitalization were assessed.

RESULTS

The rate of bilirubin reduction on the first day of admission was significantly higher in the intervention group (2.9±1.81 vs. 2.06±1.93, p = 0.002). The mean level of bilirubin on the second (9.8±1.92 vs. 10.88±2.26) and third days (8.06±1.54 vs. 9.86±1.7) was lower in the intervention group (p = 0.001). The proportion of discharged patients in the third and fourth days was higher in the intervention group compared to the control (65% vs. 41%, 99% vs. 86.5%, respectively, p = 0.001). However, the duration of hospitalization was shorter in the intervention group compared to the control (2.36±0.5 vs. 2.74±0.74, p = 0.001).

CONCLUSION

Based on our results, daily treatment with 5 drops of synbiotic along with phototherapy can be a safe and effective modality in faster bilirubin reduction, decreasing the hospitalization period and phototherapy. Therefore, it seems that it can be used as an adjunct therapy for neonates with jaundice.

Development and Validation of a Nomogram for Predicting the Risk of Bell's Stage II/III Necrotizing Enterocolitis in Neonates Compared to Bell's Stage I

BACKGROUND

Patients with Bell's Stage II/III necrotizing enterocolitis (NEC) may have more severe presentations, higher rates of death, and more long-term complications than those with Bell's Stage I NEC, so the purpose of this article was to construct a nomogram model to distinguish Bell's stage II/III NEC early from Bell's Stage I NEC, which is critical in the clinical management of NEC.

PATIENTS AND METHODS

A total of 730 NEC newborns diagnosed from January 2015 to January 2021 were retrospectively studied. They were randomly divided into training and validation groups at the ratio of 7:3. A nomogram model for predicting NEC was developed based on all the independent risk factors by multivariate regression analysis. The model's performance was mainly evaluated through three aspects: the area under the curve (AUC) to verify discrimination, the Hosmer-Lemeshow test and calibration curve to validate the consistency, and decision curve analysis (DCA) to determine the clinical effectiveness.

RESULTS

Predictors included in the prediction model were gestational age (GA), birth weight (BW), asphyxia, septicemia, hypoglycemia, and patent ductus arteriosus (PDA). This nomogram model containing the above-mentioned six risk factors had good discrimination ability in both groups, and the AUCs were 0.853 (95% CI, 0.82-0.89) and 0.846 (95% CI, 0.79-0.90), respectively. The calibration curve and DCA confirmed that the nomogram had good consistency and clinical usefulness.

CONCLUSIONS

This individual prediction nomogram based on GA, BW, asphyxia, septicemia, hypoglycemia, and PDA served as a useful tool to risk-stratify patients with NEC, and can help neonatologists early distinguish Bell's stage II/III NEC early from Bell's Stage I NEC.

Accuracy and Reliability of Whole Blood Bilirubin Measurements Using a Roche Blood Gas Analyzer for Neonatal Hyperbilirubinemia Screening and Risk Stratification

BACKGROUND

Accurate bilirubin measurements are essential for appropriate management of neonatal hyperbilirubinemia. This study aimed to evaluate the accuracy and reliability of whole blood bilirubin measurements obtained using a Roche blood gas analyzer (Roche TBiL), with total serum bilirubin (TSB) measurements determined by the Ortho VITROS 4600 chemistry system (Ortho TSB) serving as a reference.

MATERIALS AND METHODS

Medical records of hospitalized neonates that underwent simultaneous Roche TBiL and Ortho TSB measurements were reviewed for eligibility selection and data collection. The correlations and differences between two sets of results were determined using Passing-Bablok regression analysis and a Bland-Altman plot, respectively. For eligible newborns, the risk of developing severe hyperbilirubinemia was assessed using the Bhutani nomogram. Weighted kappa analysis was used to evaluate the agreement between risk prediction by the two methods.

RESULTS

We obtained 618 paired Roche TBiL and Ortho TSB results from 309 neonates. Roche TBiL and Ortho TSB measurements showed a good correlation (r = 0.923; 95% CI: 0.905-0.938). Passing-Bablok regression analysis yielded the following equation: Roche TBiL = 0.794 × Ortho TSB + 1.255 mg/dL, with a slope of 0.794 (95% CI: 0.763-0.825) and intercept of 1.255 (95% CI: 1.042-1.417). The average difference between the two methods was 0.1 ± 1.448 mg/dL. A total of 207 neonates were eligible for evaluation of the agreement between the risk-grading methods. Although kappa analysis showed good agreement between the methods, with a weighted kappa of 0.681 (95% CI: 0.610-0.751) across all populations, the values for approximately half of the neonates at intermediate and high risk of hyperbilirubinemia (33/72) were underestimated by Roche TBiL.

CONCLUSION

Our results indicate that Roche TBiL and Ortho TSB measurements in the neonatal population are not consistent. As a point-of-care and trace blood assay, Roche blood gas bilirubin measurements can facilitate primary screening of neonatal hyperbilirubinemia, but it seems to lack accuracy regarding risk stratification, particularly for high-risk newborn individuals.

Can serum albumin level affect the transcutaneous bilirubinometry in term neonates?

BACKGROUND

Jaundice is the quite common benign condition in neonates, but due to its potential toxicity, neonates must be monitored. This study was aimed to evaluate the effect of serum albumin level on the transcutaneous bilirubin (TcB) measurements in term neonates with unconjugated hyperbilirubinemia.

METHODS

Serum albumin and total serum bilirubin (TSB) of 252 jaundiced term neonates were estimated and simultaneously TcB was measured over sternum and the effect of serum albumin on TcB measurements was evaluated.

RESULTS

The correlation between TSB and TcB was linear and significant for the entire cohort. When this correlation was studied separately in the groups with different albumin levels, maximum correlation (r = 0.888, R2 linear = 0.789, p < 0.001) was observed in group 1 with hypo-albuminemia followed by in group 2 with normal albumin levels (r = 0.854, R2 linear = 0.729, p < 0.001) and group 3 with higher albumin levels (r = 0.809, R2 linear = 0.689, p < 0.001). Bland-Altman plot analysis of whole study population demonstrate good agreement between TSB and TcB [95% CI = -0.038 to 0.493 mg/dL, 17/252 = 6.75% outside the limits of agreement, Mean difference = 0.227]. This analysis in different groups also show good agreement between TSB and TcB.

CONCLUSIONS

The correlation between the TSB and TcB may affected by serum albumin level. Therefore, transcutaneous bilirubinometry is not able to replace invasive TSB measurement. However, in the absence of TSB it could be an alternative to measure the level of bilirubin in term neonates.

Applicability of the hour of life approach in hyperbilirubinemia among Filipino term infants

BACKGROUND

Hyperbilirubinemia remains a common morbidity among infants. Additional research on bilirubin kinetics and associated risk factors will contribute to providing a more targeted management approach for the Filipino infant.

OBJECTIVE

To develop a Filipino bilirubin nomogram by studying bilirubin patterns during the first 5 days of life.

METHODOLOGY

This prospective study recruited 1,412 stable, full-term infants (≥37 weeks age of gestation) born at the Philippine General Hospital (PGH). Using the Dräger-Minolta JM-103 jaundice meter, transcutaneous bilirubin (TcB) levels were determined at the 3rd, 6th, 12th, 24th, 36th, 48th, 72nd, 96th, and 120th hour of life (HOL). A bilirubin nomogram was created using the averages of 3 TcB forehead and sternal measurements at each time epoch. Simultaneous measurement of TcB and total serum bilirubin (TsB) on a subset of 106 infants was done to determine correlation.

RESULTS

Correlation coefficients were high between TsB and forehead TcB (r² = 0.88), and between TsB and sternal TcB (r² = 0.91). The Filipino bilirubin nomogram reflected a steep rise until the 48th hour, followed by plateauing of values. Inadequate nursing and bilirubin levels at 12th and 48th HOL were risk factors for developing significant hyperbilirubinemia at 72nd HOL.

CONCLUSION

TcB is a reliable, non-invasive bilirubin screening tool. Among healthy, full-term, Filipino infants, their nomogram features a sudden increase in bilirubin values during the first 48 h, followed by a plateau. To aid in identification of infants at risk for significant hyperbilirubinemia, healthcare providers can assess breastfeeding adequacy and perform bilirubin screening at the 24th-48th HOL. Registration No. (RGAO-2016-0686).

Ursodeoxycholic acid as adjuvant treatment to phototherapy for neonatal hyperbilirubinemia: a systematic review and meta-analysis

BACKGROUND

Neonatal hyperbilirubinemia is observed in most newborns, and 5-15% of neonates require phototherapy. Phototherapy is effective but often prolongs hospitalization and has both short-term and potential long-term harms. The aim of this systematic review and meta-analysis was to evaluate the role of ursodeoxycholic acid (UDCA) combined with phototherapy in neonatal hyperbilirubinemia.

METHODS

A literature search was conducted on September 1, 2021; 590 studies were screened, and 17 full texts were assessed by two authors. We included randomized controlled trials with or without placebo intervention. Primary outcomes were changes in total bilirubin levels at 24 hours and phototherapy duration. We calculated mean differences with 95% confidence intervals (CI).

RESULTS

Six studies with 880 neonates were included. Of these studies, only two used a placebo-controlled double-blinded design. The overall risk of bias was high in one and moderate in four of the included studies. The mean decrease in the total bilirubin level during the first 24 hours was 2.06 mg/dL (95% CI 0.82-3.30; six studies) greater in the UDCA treatment group. The phototherapy duration was 19.7 hours (95% CI 10.4-29.1; five studies) shorter in the UDCA treatment group.

CONCLUSIONS

We found low-quality evidence that UDCA as an adjuvant to phototherapy seems to decrease total bilirubin faster and shorten phototherapy duration compared to standard treatment. Further studies are needed to confirm the efficacy, acute and long-term outcomes, and safety before implementing UDCA as an adjuvant to phototherapy in neonatal hyperbilirubinemia.

Effects of spontaneous first breath on placental transfusion in term neonates born by cesarean section: A randomized controlled trial

BACKGROUND

The role of umbilical cord management in placental transfusion in cesarean section (CS) requires clarification. The spontaneous first breath may be more important than the timing of cord clamping for placental transfusion in neonates born by CS.

OBJECTIVE

This study aimed to evaluate the impact of cord clamping after the first spontaneous breath on placental transfusion in neonates born by CS.

METHODS

We recruited women with a live singleton pregnancy at ≥37.0 weeks of gestation admitted for CS. The interventions performed, such as physiologic-based cord clamping (PBCC), intact-umbilical cord milking (I-UCM), 30-s delay in cord clamping (30-s DCC), and 60-s delay in cord clamping (60-s DCC), were noted and placed in a sealed envelope. The sealed envelope was opened immediately before delivery to perform randomization.

RESULTS

A total of 123 infants were eligible for evaluation. Of these, 31, 30, 32, and 30 were assigned to the PBCC, I-UCM, 30-s DCC, and 60-s DCC groups, respectively. The mean hemoglobin (Hb) and mean hematocrit (Hct) were significantly higher in the 60-s DCC group than in the PBCC group (p = 0.028 and 0.019, respectively), but no difference was noted among the I-UCM, 30-s DCC, and PBCC groups at 36 h of age. Further, no significant differences were observed in the mean Hb and mean Hct among the I-UCM, 60-s DCC, and 30-s DCC groups. Peak total serum bilirubin (TSB) levels were higher in the 60-s DCC group than in the I-UCM and PBCC groups (p = 0.017), but there was no difference between the 60-s DCC and 30-s DCC groups during the first week of life. The phototherapy requirement was higher in 60-s DCC than in IUCM and 30-sDCC (p = 0.001).

CONCLUSIONS

Our findings demonstrated that PBCC, 30-s DCC, and I-UCM in neonates born by CS had no significant differences from each other on placental transfusion. The Hb and Hct in the neonates were higher after 60-s DCC than after PBCC.

Transcutaneous bilirubin-based screening reduces the need for blood exchange transfusion in Myanmar newborns: A single-center, retrospective study

BACKGROUND

Neonatal hyperbilirubinemia is a significant health problem in Myanmar. We introduced transcutaneous bilirubin (TcB) measurements in 2017 and developed an hour-specific TcB nomogram for early detection and treatment of hyperbilirubinemia in Myanmar neonates. This study aimed to evaluate whether our screening method for hyperbilirubinemia decreased the requirement of blood exchange therapy (ET).

METHODS

This retrospective cohort study was conducted at the Central Women's Hospital, Yangon. Two groups were included as follows: group 1 (control group; comprising infants born in 2016 and screened on the basis of Kramer's rule), and group 2 (intervention group; comprising infants born in 2019 and screened by TcB measurement using a nomogram). The number of ETs was analyzed based on causes of hyperbilirubinemia and number of days after birth.

RESULTS

Groups 1 and 2 comprised 12,968 and 10,090 infants, respectively. Forty-six and two infants in Groups 1 and 2, respectively, required an ET. The odds ratio for ET was 18.0 (Group 1 to Group 2; 95% confidence interval [CI]: 4.8-67.1; p = 0.000). Serum bilirubin values at the time ET was administered were significantly higher in Group 1 than those in Group 2 (median: 23.0 and 16.8, respectively).

CONCLUSION

The management of hyperbilirubinemia using our screening method (TcB Nomogram) can effectively reduce the need for ET in neonates in Myanmar.

Pilot study of home phototherapy for neonatal jaundice monitored in maternity ward during the enforced Italy-wide COVID-19 national lockdown

In Italy, where neonatal jaundice treatment is required, it is largely carried out in hospitals. However, it is possible to safely administer home phototherapy (HPT). We report our pilot center's experience of HPT and its potential benefits during the COVID-19-enforced national lockdown. This is an observational study performed at the Policlinic Abano Terme, a suburban hospital that covers a large catchment area near the Euganean Hills in Northeast Italy with around 1000 deliveries per year. HPT was started after regular nursery discharge, and the mothers brought the neonates back to the hospital maternity ward each day to check infants' bilirubin levels, weight, and general state of health, until it was deemed safe to stop. The efficacy of HPT in bilirubin reduction, hospital readmission rates, and parental satisfaction were evaluated. Thirty infants received HPT. In 4 of these infants, HPT was associated with total serum bilirubin (TSB) between 75 and 95^th percentile (high-intermediate-risk zone) and in 26 infants HPT was associated with TSB > 95^th percentile (high-risk zone) of the Bhutani nomogram. Among these 30 infants, 27 (90%) completed the HPT with a progressive decrease of TSB levels with 4 neonates requiring a second course and 3 infants requiring a third course of 24-h HPT. Three (10%) neonates failed HPT and were readmitted after one 24-h phototherapy course. No abnormalities of breastfeeding, body weight (defined as > 10% decrease), temperature, nor COVID infections were detected following HPT consultation in the neonatal ward. Home treatment efficacy with varying degrees of parental satisfaction occurred in all but 3 cases that involved difficulties with the equipment and inconsistent lamp manipulation practices.

CONCLUSION

Our pilot study suggests that HPT for neonatal jaundice can be carried out effectively and with parental satisfaction as supported by daily back bilirubin monitoring in the maternity ward during the enforced COVID-19 national lockdown in Italy.

WHAT IS KNOWN

• No high-quality evidence is currently available to support or refute the practice of phototherapy in patients' own homes.

WHAT IS NEW

• Phototherapy can be delivered at home in a select group of infants and could be an ideal option if parents are able to return with their infants to the hospital maternity ward for daily follow-up. • It can be as effective as inpatient phototherapy and potentially helps in delivering family-centered care.

Irradiance footprint of phototherapy devices: a comparative study

BACKGROUND

Phototherapy (PT) is the standard treatment of neonatal unconjugated hyperbilirubinemia. The irradiance footprint, i.e., the illuminated area by the PT device with sufficient spectral irradiance, is essential for PT to be effective. Irradiance footprint measurements are not performed in current clinical practice. We describe a user-friendly method to systematically evaluate the high spectral irradiance (HSI) footprint (illuminated area with spectral irradiance of ≥30 μW cm^-2 nm^-1) of PT devices in clinical practice.

MATERIALS AND METHODS

Six commercially available LED-based overhead PT devices were evaluated in overhead configuration with an incubator. Spectral irradiance (µW cm^-2 nm^-1) and HSI footprint were measured with a radiospectrometer (BiliBlanket Meter II).

RESULTS

The average measured spectral irradiance ranged between 27 and 52 μW cm^-2 nm^-1 and HSI footprint ranged between 67 and 1465 cm², respectively. Three, two, and one PT devices out of six covered the average BSA of an infant born at 22, 26-32, and 40 weeks of gestation, respectively.

CONCLUSION

Spectral irradiance of LED-based overhead PT devices is often lower than manufacturer's specifications, and HSI footprints not always cover the average BSA of a newborn infant. The proposed measurement method will contribute to awareness of the importance of irradiance level as well as footprint measurements in the management of neonatal jaundice.

IMPACT

While a sufficient spectral irradiance footprint is essential for PT to be effective, some PT devices have spectral irradiance footprints that are too small to cover the entire body surface area (BSA) of a newborn infant. This study introduces a user-friendly, accessible method to systematically evaluate the spectral irradiance level and footprint of PT devices. This study supports awareness on the role of the spectral irradiance footprint in the efficacy of PT devices. Irradiance footprint can be easily measured during phototherapy with the proposed method.

Stannsoporfin with phototherapy to treat hyperbilirubinemia in newborn hemolytic disease

OBJECTIVE

To evaluate the efficacy and safety of tin mesoporphyrin (SnMP) in neonates with hyperbilirubinemia (HB) due to hemolysis.

STUDY DESIGN

This multicenter, placebo-controlled phase 2b study (NCT01887327) randomized newborns (35-42 weeks) with hemolysis started on phototherapy (PT) to placebo (Ctrl), SnMP 3.0 mg/kg, or SnMP 4.5 mg/kg given once IM within 30 min of initiation of PT.

RESULTS

In all, 91 patients were randomized (Ctrl: n = 30; 3 mg/kg SnMP: n = 30; 4.5 mg/kg SnMP: n = 31). At 48 h TSB significantly increased in Ctrl by 17.5% (95% CI 5.6-30.7; p = 0.004) and significantly decreased by -13% (95% CI -21.7 to -3.2; p = 0.013) in the 3.0 mg/kg and by -10.5% (95% CI -19.4 to -0.6; p = 0.041) in the 4.5 mg/kg group. Decreases in SnMP groups were significant (p < 0.0001) vs Ctrl.

CONCLUSION

SnMP with PT significantly reduced TSB by 48 h. SnMP may be useful as a treatment for HB in neonates with hemolysis.

Ensemble learning for the early prediction of neonatal jaundice with genetic features

BACKGROUND

Neonatal jaundice may cause severe neurological damage if poorly evaluated and diagnosed when high bilirubin occurs. The study explored how to effectively integrate high-dimensional genetic features into predicting neonatal jaundice.

METHODS

This study recruited 984 neonates from the Suzhou Municipal Central Hospital in China, and applied an ensemble learning approach to enhance the prediction of high-dimensional genetic features and clinical risk factors (CRF) for physiological neonatal jaundice of full-term newborns within 1-week after birth. Further, sigmoid recalibration was applied for validating the reliability of our methods.

RESULTS

The maximum accuracy of prediction reached 79.5% Area Under Curve (AUC) by CRF and could be marginally improved by 3.5% by including genetic variant (GV). Feature importance illustrated that 36 GVs contributed 55.5% in predicting neonatal jaundice in terms of gain from splits. Further analysis revealed that the main contribution of GV was to reduce the false-positive rate, i.e., to increase the specificity in the prediction.

CONCLUSIONS

Our study shed light on the theoretical and practical value of GV in the prediction of neonatal jaundice.

Microfluidic photoreactor to treat neonatal jaundice

While in most cases, jaundice can be effectively treated using phototherapy, severe cases require exchange transfusion, a relatively risky procedure in which the neonate's bilirubin-rich blood is replaced with donor blood. Here, we examine extracorporeal blood treatment in a microfluidic photoreactor as an alternative to exchange transfusion. This new treatment approach relies on the same principle as phototherapy but leverages microfluidics to speed up bilirubin removal. Our results demonstrate that high-intensity light at 470 nm can be used to rapidly reduce bilirubin levels without causing appreciable damage to DNA in blood cells. Light at 470 nm was more effective than light at 505 nm. Studies in Gunn rats show that photoreactor treatment for 4 h significantly reduces bilirubin levels, similar to the bilirubin reduction observed for exchange transfusion and on a similar time scale. Predictions for human neonates demonstrate that this new treatment approach is expected to exceed the performance of exchange transfusion using a low blood flow rate and priming volume, which will facilitate vascular access and improve safety.

Newborn Screening for Biliary Atresia: a Review of Current Methods

PURPOSE OF REVIEW

Biliary atresia is a serious neonatal liver disease due to obstructed bile ducts that has better outcomes when detected and treated in the first 30-45 days of life. This review examines different methods to screen newborns for biliary atresia as well as discusses observations from ongoing screening programs implemented in parts of the United States.

RECENT FINDINGS

Screening strategies for biliary atresia include detecting persistent jaundice, examining stool color, testing fractionated bilirubin levels, or measuring bile acid levels from dried blood spot cards. The stool color card program is the most widely used screening strategy worldwide. An alternative approach under investigation in the United States measures fractionated bilirubin levels, which are abnormal in newborns with biliary atresia. Fractionated bilirubin screening programs require laboratories to derive reference ranges, nurseries to implement universal testing, and healthcare systems to develop infrastructure that identifies and acts upon abnormal results. Biliary atresia meets the disease-specific criteria for newborn screening. Current studies focus on developing a strategy which also meets all test-specific criteria. Such a strategy, if implemented uniformly, has the potential to accelerate treatment and reduce biliary atresia's large liver transplant burden.

Thirty-five males with severe (Class 1) G6PD deficiency (c.637G>T) in a North American family of European ancestry

In North America, jaundiced neonates are not usually tested for G6PD deficiency if the family is of European ancestry. However, we describe such a family where ≥35 males have had severe (Class I) G6PD deficiency. Many of the jaundiced neonates did not have this diagnosis considered, at least three of whom developed bilirubin neurotoxicity. Over seven generations 35 affected males were identified. Three developed signs of kernicterus spectrum disorder; three had exchange transfusions for hyperbilirubinemia; and nine received one or more blood transfusions during childhood.

Perinatal risk factors associated with severity of haemolytic disease of the foetus and newborn due to Rhc maternal-foetal incompatibility: A retrospective cohort study

BACKGROUND AND OBJECTIVES

Anti-c is the third red blood cell antibody responsible for haemolytic disease of the foetus and newborn (HDFN) requiring intrauterine transfusion. We aimed to identify risk factors associated with HDFN and severe HDFN due to Rhc maternal-foetal incompatibility.

MATERIALS AND METHODS

A retrospective cohort study was conducted in Paris and the surrounding area (France), between 2013 and 2015. We included mothers and their children managed by the National Reference Centre in Perinatal Hemobiology for alloimmunization and maternal-foetal incompatibility for the Rhc antigen (N = 121). We conducted bivariate analyses to assess a relationship between perinatal factors (e.g., titre and concentration of anti-c antibodies, direct antiglobulin test) and HDFN, its severity and duration.

RESULTS

The incidence of HDFN was 30% (n = 36), including 11% of severe HDFN (n = 13). Seven percent (n = 9) of neonates received at least one transfusion during the first week and 21% (n = 26) after this period until 3 weeks of life. During pregnancy, a concentration ≥7.5 IU/ml and a titre ≥4 and above were associated with HDFN and severe HDFN (p < 0.05). At birth, the high intensity of the quantitative direct antiglobulin test was associated with HDFN and severe HDFN (p < 0.05). A concentration ≥15 IU/ml is the best factor (area under curve [AUC] = 0.78) in predicting HDFN, followed by a titre ≥8 (AUC = 0.76).

CONCLUSION

Anti-c alloimmunization causes neonatal anaemia, which is often belated. Paediatricians have to be aware of these risk factors and organize prolonged monitoring of neonates.