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Jiménez-Díaz G, Aune A, Elizarrarás-Rivas J, Gierman LM, Keitsch M, Marcuzzi A, Infanti JJ. Neonatal jaundice detection in low-resource Mexican settings: possibilities and barriers for innovation with mobile health. BMC Health Serv Res 2024; 24:671. [PMID: 38807158 PMCID: PMC11134921 DOI: 10.1186/s12913-024-11141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 05/22/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Neonatal jaundice is a common condition that can lead to brain damage and disabilities when severe cases go undetected. Low- and middle-income countries often lack accurate methods for detecting neonatal jaundice and rely on visual assessment, resulting in a higher incidence of adverse consequences. Picterus Jaundice Pro (Picterus JP), an easy-to-use and affordable smartphone-based screening device for the condition, has demonstrated higher accuracy than visual assessment in Norwegian, Philippine and Mexican newborns. This study aimed to identify the barriers and facilitators to implementing Picterus JP in public health services in low-income settings in Mexico by exploring the current process of neonatal jaundice detection and stakeholders' perspectives in that context. METHODS Qualitative data collection techniques, including one focus group, 15 semi-structured interviews and four observations, were employed in urban and rural health facilities in Oaxaca, Mexico. The participants included medical doctors, nurses and health administrators. The data were analysed by thematic analysis guided by the Consolidated Framework for Implementation Research. RESULTS The analysis yielded four main themes: (I) the current state of neonatal care and NNJ detection, (II) the needs and desires for enhancing NNJ detection, (III) the barriers and facilitators to implementing Picterus JP in the health system and (IV) HCWs' expectations of Picterus JP. The findings identify deficiencies in the current neonatal jaundice detection process and the participants' desire for a more accurate method. Picterus JP was perceived as easy to use, useful and compatible with the work routine, but barriers to adoption were identified, including internet deficiencies and costs. CONCLUSIONS The introduction of Picterus JP as a supporting tool to screen for neonatal jaundice is promising but contextual barriers in the setting must be addressed for successful implementation. There is also an opportunity to optimise visual assessment to improve detection of neonatal jaundice.
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Affiliation(s)
- Gabriela Jiménez-Díaz
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
- Picterus AS, Trondheim, Norway.
| | - Anders Aune
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Picterus AS, Trondheim, Norway
- Department of Pediatrics, St Olav's University Hospital, Trondheim, Norway
| | - Jesús Elizarrarás-Rivas
- Health Research Coordination, Mexican Institute of Social Security, IMSS, Oaxaca, Mexico
- Faculty of Medicine and Surgery, Universidad Autónoma Benito Juárez de Oaxaca, Oaxaca City, México
| | | | - Martina Keitsch
- Department of Design, Faculty of Architecture and Design, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anna Marcuzzi
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Physical Medicine and Rehabilitation, St. Olav's University Hospital, Trondheim, Norway
| | - Jennifer J Infanti
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
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Christensen RD, Bahr TM, Wong RJ, Vreman HJ, Bhutani VK, Stevenson DK. A "Gold Standard" Test for Diagnosing and Quantifying Hemolysis in Neonates and Infants. J Perinatol 2023; 43:1541-1547. [PMID: 37468612 DOI: 10.1038/s41372-023-01730-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
Identifying "gold standard" diagnostic tests can promote evidence-based neonatology practice. Hemolysis is a pathological shortening of the erythrocyte lifespan, differing from erythrocyte senescence in responsible mechanisms and clinical implications. Diagnosing hemolysis goes beyond a binary (yes vs. no) determination. It is characterized according to magnitude, and as acute vs. chronic, and genetically based vs. not. For neonates with significant hyperbilirubinemia or anemia, detecting hemolysis and quantifying its magnitude provides diagnostic clarity. The 2022 American Academy of Pediatrics (AAP) Clinical Practice Guideline on management of hyperbilirubinemia in the newborn states that hemolysis is a risk factor for developing significant hyperbilirubinemia and neurotoxicity. The guideline recommends identifying hemolysis from any cause, but specific guidance is not provided. A spectrum of laboratory tests has been endorsed as diagnostic methods for hemolysis. Herein we examine these laboratory tests and recommend one as the "gold standard" for diagnosing and quantifying hemolysis in neonates and infants.
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Affiliation(s)
- Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
- Obstetric and Neonatal Operations, Intermountain Health, Salt Lake City, UT, USA.
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Obstetric and Neonatal Operations, Intermountain Health, Salt Lake City, UT, USA
| | - Ronald J Wong
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Hendrik J Vreman
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Vinod K Bhutani
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David K Stevenson
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Zhan YL, Peng HB, Jin ZC, Su JF, Tan XY, Zhao L, Zhang L. Higher ETCOc predicts longer phototherapy treatment in neonatal hyperbilirubinemia. Front Pediatr 2023; 11:1154350. [PMID: 37114002 PMCID: PMC10126460 DOI: 10.3389/fped.2023.1154350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Objective This study aimed to evaluate the predictive performance of end-tidal carbon monoxide corrected to ambient carbon monoxide (ETCOc) values phototherapy in neonates with significant hyperbilirubinemia. Methods A prospective study was conducted on neonates with significant hyperbilirubinemia who received phototherapy between 3 and 7 days of life. The breath ETCOc and serum total bilirubin of the recruited infants were measured on admission. Results The mean ETCOc at admission in 103 neonates with significant hyperbilirubinemia was 1.70 ppm. The neonates were categorized into two groups: phototherapy duration ≤72 h (n = 87) and >72 h (n = 16) groups. Infants who received phototherapy for >72 h had significantly higher ETCOc (2.45 vs. 1.60, P = 0.001). The cutoff value of ETCOc on admission for predicting longer phototherapy duration was 2.4 ppm, with a sensitivity of 62.5% and specificity of 88.5%, yielding a 50% positive predictive value and a 92.7% negative predictive value. Conclusion ETCOc on admission can help predict the duration of phototherapy in neonates with hyperbilirubinemia, facilitate clinicians to judge disease severity, and make clinical communication easier and more efficient.
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Bao Y, Zhu J, Ma L, Zhang H, Sun L, Xu C, Wu J, He Y, Du L. An End-Tidal Carbon Monoxide Nomogram for Term and Late-Preterm Chinese Newborns. J Pediatr 2022; 250:16-21.e3. [PMID: 35835229 DOI: 10.1016/j.jpeds.2022.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/09/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To establish a reference nomogram for end-tidal CO corrected for ambient CO (ETCOc) levels in term and late-preterm Chinese newborns and then assess its efficacy to identify hemolytic hyperbilirubinemia. STUDY DESIGN We conducted a prospective study by measuring concurrent ETCOc and total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) levels collected postnatally at 12, 24, 48, 72, 96, and 120 hours of age. ETCOc at the 25th, 50th, 75th, and 95th percentiles at each epoch were used to construct the reference nomogram. We then explored the ability of predischarge ETCOc and TSB/TcB metrics to predict the development of hyperbilirubinemia requiring phototherapy in early postnatal period and jaundice readmission in late postnatal period. RESULTS Our nomogram, based on 990 measurements from 455 infants who were not nonhemolytic, displayed a steady line within 3 postnatal days, followed by a subsequent decline. From a cohort of infants with a serial ETCOc measurements (n = 130) and those readmitted (n = 21), we found that ETCOc and TSB/TcB ≥75th percentile can identify most hemolytic hyperbilirubinemia between 12 and 72 hours after birth with an area under the curve (AUC) of 0.741. An ETCOc ≥1.7 ppm alone between 96 and 120 hours after birth can identify most hemolytic hyperbilirubinemia with an AUC of 0.816. In addition, 90.5% of readmitted infants had an ETCOc ≥75th percentile. CONCLUSIONS An ETCOc reference nomogram during the first 5 postnatal days in nonhemolytic term and late-preterm newborns can be used to identify hemolytic hyperbilirubinemia requiring phototherapy in the early postnatal period and readmission in the late postnatal period.
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Affiliation(s)
- Yingying Bao
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Neonatology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiajun Zhu
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lixin Ma
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Zhang
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ling Sun
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuncai Xu
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingyuan Wu
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanyuan He
- Department of Neonatology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lizhong Du
- Department of Neonatology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China; National Clinical Research Center for Child Health, Hangzhou, China
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Reference intervals for end-tidal carbon monoxide of preterm neonates. J Perinatol 2022; 42:116-120. [PMID: 34556800 DOI: 10.1038/s41372-021-01207-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/03/2021] [Accepted: 09/03/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We constructed reference intervals for end-tidal carbon monoxide (ETCOc) levels of neonates 28 0/7 to 34 6/7 weeks gestation in order to assess hemolytic rate. STUDY DESIGN This is a prospective four-NICU study in Bangkok, Thailand, and Utah, USA. RESULTS Of 226 attempted measurements, 92% were successful. Values from day 1 through 28 were charted and upper (>95th percentile) reference interval limits calculated. During the entire 28 days, the ETCOc upper reference intervals from babies in Bangkok were higher than those in Utah (p < 0.01). No differences were found due to sex, or earliest vs. latest gestation at birth (both p > 0.1). Similar to term neonates, preterm neonates in Bangkok and Utah had higher ETCOc values during the first 48 h after birth than thereafter (p < 0.01). CONCLUSIONS Using this methodology, and the reference interval chart, the hemolytic rate of preterm infants ≥28 weeks can be assessed.
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Maisels MJ, Kring EA, Coffey MP. Heme Catabolism and Bilirubin Production in Readmitted Jaundiced Newborns. J Pediatr 2020; 226:285-288. [PMID: 32526232 DOI: 10.1016/j.jpeds.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 11/18/2022]
Abstract
We measured end-tidal CO levels in 50 jaundiced newborns readmitted for phototherapy at age 54-244 hours. The median end-tidal CO level was 1.55 ppm, suggesting that hemolysis is not the primary contributor to the hyperbilirubinemia in many readmitted newborns.
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Affiliation(s)
- M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, MI; Department of Pediatrics, Beaumont Children's Hospital, Royal Oak, MI.
| | - Elizabeth A Kring
- Department of Pediatrics, Beaumont Children's Hospital, Royal Oak, MI
| | - Mary P Coffey
- Department of Biostatistics, Beaumont Health Research Institute, Royal Oak, MI
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Karabulut B, Arcagok BC. A Neglected and Promising Predictor of Severe Hyperbilirubinemia Due to Hemolysis: Carboxyhemoglobin. Fetal Pediatr Pathol 2020; 39:124-131. [PMID: 31322449 DOI: 10.1080/15513815.2019.1641862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: We investigated the relationship between total serum bilirubin (TSB) and carboxyhemoglobin (COHb) in term neonates with detected and treated hemolysis within a particular time frame with the aim of augmenting the case for early diagnosis and prevention of morbidity in hemolysis. Materials and Methods: The study group comprised term newborns who were above the 95th percentile for TSB, underwent intravenous immunoglobulin (IVIG) or applied total exchange transfusion due to hemolysis. Newborns without hemolysis who were above the 95th TSB percentile and required phototherapy comprised the control group. Results: At a cutoff COHb value of 2.2%, 80.8% sensitivity, 95.5% specificity, 18.1 likelihood ratio, positive predictive value of 94.7%, and negative predictive value of 83.2% were identified. Conclusion: We found that COHb is a sensitive and specific method for detecting hemolysis, and it can be used in the early diagnosis of hemolytic diseases causing early and severe hyperbilirubinemia.
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Affiliation(s)
- Birol Karabulut
- Neonatology, Izmir Ataturk Training and Research Hospital, Izmir, Turkey
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Bahr TM, Henry E, Hulse W, Baer VL, Prchal JT, Bhutani VK, Christensen RD. Early Hyperbilirubinemia in Neonates with Down Syndrome. J Pediatr 2020; 219:140-145. [PMID: 32014279 DOI: 10.1016/j.jpeds.2019.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare total serum bilirubin (TSB) levels, phototherapy usage, and hospital readmission for jaundice among neonates with Down syndrome vs controls. STUDY DESIGN A retrospective cohort study using 15 years of multihospital data. We created control reference intervals (5th, median, and 95th percentiles) for initial TSB values hourly during the first days after birth, and determined the proportion of neonates with Down syndrome whose TSB exceeded the 95th percentile control interval. We determined the proportion with an initial TSB exceeding the upper control reference interval, the highest TSB recorded, the percentage of neonates receiving phototherapy, and the rate of hospital readmission for jaundice treatment. RESULTS We compared 357 neonates with Down syndrome with 377 368 controls. Compared with controls, those with Down syndrome had 4.7 times the risk (95% CI, 3.9-5.7; P < .0001) of an initial TSB exceeding the 95th percentile control interval (23.5% vs 5.0%), 8.9 times (95% CI, 8.1-9.8; P < .0001) the phototherapy usage (62.2% vs 7.0%), and 3.6 times (95% CI, 1.6-8.2; P = .0075) the readmission rate for jaundice (17.4 vs 4.8 per 1000 live births). CONCLUSIONS Neonates with Down syndrome have a substantial risk of early hyperbilirubinemia. The American Academy of Pediatrics currently advises obtaining an early screening complete blood count from neonates with Down syndrome. We submit that assessing their TSB is also advisable.
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Affiliation(s)
- Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT.
| | - Erick Henry
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT
| | - Whitley Hulse
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT
| | - Vickie L Baer
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT
| | - Josef T Prchal
- Division of Hematology/Oncology, Department of Internal Medicine, University of Utah Health and Salt Lake City VA Hospital, Salt Lake City, UT
| | - Vinod K Bhutani
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucille Packard Children's Hospital, Stanford, CA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT; Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, UT; Division of Hematology-Oncology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT
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Krzyzanski W, Cook SF, Wilbaux M, Sherwin CMT, Allegaert K, Vermeulen A, van den Anker JN. Population Pharmacokinetic Modeling in the Presence of Missing Time-Dependent Covariates: Impact of Body Weight on Pharmacokinetics of Paracetamol in Neonates. AAPS JOURNAL 2019; 21:68. [PMID: 31140019 DOI: 10.1208/s12248-019-0331-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/06/2019] [Indexed: 11/30/2022]
Abstract
Body weight is the primary covariate in pharmacokinetics of many drugs and dramatically changes during the first weeks of life of neonates. The objective of this study is to determine if missing body weights in preterm and term neonates affect estimates of model parameters and which methods can be used to improve performance of a population pharmacokinetic model of paracetamol. Data for our analysis were obtained from previously published studies on the pharmacokinetics of intravenous paracetamol in neonates. We adopted a population model of body weight change in neonates to implement three previously introduced methods of handling missing covariates based on data imputation, likelihood function modification, and full random effects modeling. All models were implemented in NONMEM 7.4, and population parameters were estimated using the FOCE method. Our major finding was that missing body weights minimally affect population estimates of pharmacokinetic parameters but do affect the covariate relationship parameters, particularly the one describing dependence of clearance on body weight. None of the tested methods changed estimates of between-subject variability nor impacted the predictive performance of the model. Our analysis shows that a modeling approach towards handling missing covariates allows borrowing information gathered in various studies as long as they target the same population. This approach is particularly useful for handling time-dependent missing covariates.
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Affiliation(s)
- Wojciech Krzyzanski
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA.
| | - Sarah F Cook
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Melanie Wilbaux
- Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital (UKBB), Basel, Switzerland
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - An Vermeulen
- Janssen Research & Development, a Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, District of Columbia, USA.,University of Basel Children's Hospital, Basel, Switzerland
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Bhutani VK, Maisels MJ, Schutzman DL, Castillo Cuadrado ME, Aby JL, Bogen DL, Christensen RD, Watchko JF, Wong RJ, Stevenson DK. Identification of risk for neonatal haemolysis. Acta Paediatr 2018. [PMID: 29532503 DOI: 10.1111/apa.14316] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To identify neonates at risk of haemolytic hyperbilirubinaemia through near-concurrent measurements of total serum/plasma bilirubin (TB) or transcutaneous bilirubin (TcB) and end-tidal breath carbon monoxide (CO), corrected for ambient CO (ETCOc), an index of bilirubin production and haemolysis. METHODS Paired TB/TcB (mg/dL) and ETCOc (ppm) measurements were obtained in newborns (n = 283) at 20 to <60 hours of age in five nurseries. TB/TcB values were assigned TB/TcB percentile risk values using the Bhutani hour-specific nomogram. In infants having two serial TB/TcB measurements (n = 76), TB rate of rise (ROR, mg/dL/h) was calculated. RESULTS For the entire cohort (n = 283), 67.1% and 32.9% had TB/TcB<75th and ≥75th percentile, respectively. TB/TcB (5.79 ± 1.84 vs 9.14 ± 2.25 mg/dL) and ETCOc (1.61 ± 0.45 vs 2.02 ± 1.35 ppm, p = 0.0002) were different between the groups. About 36.6% of infants with TB/TcB ≥75th percentile had ETCOc ≥ 2.0 ppm. In the subcohort of infants with serial TB/TcB measurements (n = 76), 44.7% and 55.3% had TB/TcB<75th and ≥75th percentile, respectively. TB/TcB (5.28 ± 1.97 vs 9.53 ± 2.78 mg/dL), ETCOc (1.72 ± 0.48 vs 2.38 ± 1.89 ppm, p = 0.05) and TB ROR (0.011 ± 0.440 vs 0.172 ± 0.471 mg/dL/h) were different between the groups. CONCLUSION The combined use of TB/TcB percentile risk assessments and ETCOc measurements can identify infants with haemolytic hyperbilirubinaemia. The addition of TB ROR can identify those infants with elimination disorders.
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Affiliation(s)
- Vinod K. Bhutani
- Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - M. Jeffrey Maisels
- Department of Pediatrics; Beaumont Children's and Oakland University William Beaumont School of Medicine; Royal Oak MI USA
| | - David L. Schutzman
- Department of Pediatrics; Einstein Medical Center Philadelphia; Philadelphia PA USA
| | | | - Janelle L. Aby
- Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - Debra L. Bogen
- Department of Pediatrics; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Robert D. Christensen
- Department of Pediatrics; University of Utah School of Medicine, and Women and Newborn's Clinical Program; Intermountain Healthcare; Salt Lake City UT USA
| | - Jon F. Watchko
- Department of Pediatrics; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Ronald J. Wong
- Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - David K. Stevenson
- Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
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ABO hemolytic disease of the fetus and newborn: thirteen years of data after implementing a universal bilirubin screening and management program. J Perinatol 2018; 38:517-525. [PMID: 29410540 DOI: 10.1038/s41372-018-0048-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/01/2017] [Accepted: 12/12/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE ABO hemolytic disease occurs among neonates with blood groups A or B delivered to group O women. Extreme neonatal hyperbilirubinemia due to ABO disease has been reported, but its frequency is not well known. We sought to determine the odds of developing severe ABO hemolytic disease in the 13 years since adopting universal bilirubin screening/management in the Intermountain Healthcare system. STUDY DESIGN We conducted a retrospective analysis of neonates born between 2004 and 2016, defining "severe hemolytic disease" as; (1) total serum bilirubin (TSB) >25 mg/dL, or (2) hospital readmission for jaundice, or (3) bilirubin encephalopathy. Neonates born to group O (+) mothers were included and considered either; (1) Controls (not at risk for ABO disease because they were group O), (2) Study subjects (at risk for ABO disease because they were group A or B). RESULTS Of 400,531 live births, 47% were to group O women; 86% of whom were group O (+). Overall, 42,529 (27%) neonates born to group O (+) women had their blood group determined; 29,729 (68%) were O, 10,682 (25%) A, and 3109 (7%) B. Peak TSBs during the first 10 days were higher in group A (11.0 ± 4.2 mg/dL) and B (11.5 ± 4.3) than group O neonates (10.3 ± 4.1). However the relative risks of a TSB ≥25 mg/dL, readmission for jaundice, or kernicterus, were the same in the control vs. study groups. CONCLUSIONS In our health system, severe hemolytic disease in neonates born to group O (+) woman is not more likely in group A or B neonates than in controls (group O). We recognize that in other practices, particularly those who do not have a universal bilirubin screening/management program, ABO hemolytic disease severity might be different than in our system.
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12
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Christensen RD, Agarwal AM, Yaish HM, Reading NS, O'Brien EA, Prchal JT. Three Novel Spectrin Variants in Jaundiced Neonates. Clin Pediatr (Phila) 2018; 57:19-26. [PMID: 28090778 DOI: 10.1177/0009922816687326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Various mutations in the genes encoding alpha spectrin (SPTA1) or beta spectrin (SPTB) are known to cause erythrocyte membrane disorders, sometimes associated with severe neonatal jaundice and anemia. We used a next-generation sequencing panel to evaluate 3 unrelated neonates who had puzzling cases of nonimmune hemolytic jaundice. In each case, we identified novel mutations in either SPTA1 or SPTB. Correlating erythrocyte morphology, clinical course, and computational analysis, we submit that each of the 3 variants is a probable pathogenic cause of the hereditary hemolytic conditions in these patients. We hope other pediatric practitioners caring for neonates with what appears to be idiopathic severe neonatal hyperbilirubinemia will look for spectrin variants as a possible cause, because additional cases with these specific variants along with this clinical phenotype are needed to confirm our postulate that these 3 cases are indeed pathogenic mutations.
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Affiliation(s)
- Robert D Christensen
- 1 University of Utah, Salt Lake City, UT, USA.,2 Intermountain Healthcare, Salt Lake City, UT, USA
| | - Archana M Agarwal
- 1 University of Utah, Salt Lake City, UT, USA.,3 ARUP Laboratories, Salt Lake City, UT, USA
| | | | - N Scott Reading
- 1 University of Utah, Salt Lake City, UT, USA.,3 ARUP Laboratories, Salt Lake City, UT, USA
| | - Elizabeth A O'Brien
- 1 University of Utah, Salt Lake City, UT, USA.,2 Intermountain Healthcare, Salt Lake City, UT, USA
| | - Josef T Prchal
- 1 University of Utah, Salt Lake City, UT, USA.,3 ARUP Laboratories, Salt Lake City, UT, USA.,4 Salt Lake VA Hospital, Salt Lake City, UT, USA
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13
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Bhutani VK, Wong RJ. Risk profiles for haemolytic and nonhaemolytic neonatal jaundice. Acta Paediatr 2016; 105:1387-1388. [PMID: 27870210 DOI: 10.1111/apa.13605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Vinod K. Bhutani
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Lucile Packard Children's Hospital; Stanford Children's Health; Stanford University School of Medicine; Stanford CA USA
| | - Ronald J. Wong
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Lucile Packard Children's Hospital; Stanford Children's Health; Stanford University School of Medicine; Stanford CA USA
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14
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Ahlfors CE. The Bilirubin Binding Panel: A Henderson-Hasselbalch Approach to Neonatal Hyperbilirubinemia. Pediatrics 2016; 138:peds.2015-4378. [PMID: 27609825 DOI: 10.1542/peds.2015-4378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Poor plasma bilirubin binding increases the risk of bilirubin neurotoxicity in newborns with hyperbilirubinemia. New laboratory tests may soon make it possible to obtain a complete bilirubin binding panel when evaluating these babies. The 3 measured components of the panel are the plasma total bilirubin concentration (BTotal), which is currently used to guide clinical care; the bilirubin binding capacity (BBC); and the concentration of non-albumin bound or free bilirubin (BFree). The fourth component is the bilirubin-albumin equilibrium dissociation constant, KD, which is calculated from BTotal, BBC, and BFree The bilirubin binding panel is comparable to the panel of components used in the Henderson-Hasselbalch approach to acid-base assessment. Bilirubin binding population parameters (not prospective studies to determine whether the new bilirubin binding panel components are better predictors of bilirubin neurotoxicity than BTotal) are needed to expedite the clinical use of bilirubin binding. At any BTotal, the BFree and the relative risk of bilirubin neurotoxicity increase as the KD/BBC ratio increases (ie, bilirubin binding worsens). Comparing the KD/BBC ratio of newborns with BTotal of concern with that typical for the population helps determine whether the risk of bilirubin neurotoxicity varies significantly from the inherent risk at that BTotal Furthermore, the bilirubin binding panel individualizes care because it helps to determine how aggressive intervention should be at any BTotal, irrespective of whether it is above or below established BTotal guidelines. The bilirubin binding panel may reduce anxiety, costs, unnecessary treatment, and the likelihood of undetected bilirubin neurotoxicity.
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Affiliation(s)
- Charles E Ahlfors
- Consulting Professor, Stanford University School of Medicine, Stanford, California
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15
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Carroll PD, Christensen RD, Baer VL, Sheffield MJ, Gerday E, Ilstrup SJ. Bilirubin levels and phototherapy use before and after neonatal red blood cell transfusions. Transfusion 2016; 56:2727-2731. [PMID: 27600026 DOI: 10.1111/trf.13761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/13/2016] [Accepted: 07/01/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our previous retrospective study suggested that red blood cell (RBC) transfusion of preterm neonates can be associated with an increase in bilirubin, but this has not been tested prospectively. STUDY DESIGN AND METHODS We studied neonates before and after RBC transfusions, recording serial bilirubin levels and whether they qualified for phototherapy. Because lysed RBCs release plasma-free hemoglobin (Hb), a precursor to bilirubin, we also measured plasma free Hb and bilirubin from the donor blood. RESULTS We studied 50 transfusions given to 39 neonates. Gestation ages of transfused neonates, at birth, were 26 (24-29) weeks (median [interquartile range]); birthweights were 750 (620-1070) g. The study transfusion was given on Day of Life 9.9 (3.4-19.2). In 20% (10/50) phototherapy was being administered at the beginning of and during the transfusion. In these patients neither the 4- to 6- nor the 24- to 36-hour-posttransfusion bilirubin levels were significantly higher than before transfusion. However, in 30% of the others (12/40) phototherapy was started (or restarted) after the transfusion and 15% had a posttransfusion bilirubin increase of at least 2.5 mg/dL. These neonates received donor blood with a higher plasma-free Hb (p < 0.05). CONCLUSIONS Neonates commonly qualify for phototherapy after transfusion. A minority (15% in this series) have a posttransfusion bilirubin increase of at least 2.5 mg/dL. We speculate that neonates qualifying for a RBC transfusion, who are judged to be at high risk for bilirubin-induced neurotoxicity, might benefit from checking their serum bilirubin level after the transfusion and providing donor blood with low plasma-free Hb levels.
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Affiliation(s)
- Patrick D Carroll
- Women and Newborns Program, Dixie Regional Medical Center, St George, Utah.,Neonatology, Dixie Regional Medical Center, St George, Utah
| | - Robert D Christensen
- Women and Newborns Program, Dixie Regional Medical Center, St George, Utah.,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Vickie L Baer
- Women and Newborns Program, Dixie Regional Medical Center, St George, Utah.,Neonatology, McKay Dee Hospital Center, Ogden, Utah
| | - Mark J Sheffield
- Women and Newborns Program, Dixie Regional Medical Center, St George, Utah.,Neonatology, McKay Dee Hospital Center, Ogden, Utah
| | - Erick Gerday
- Women and Newborns Program, Dixie Regional Medical Center, St George, Utah.,Neonatology, Utah Valley Regional Medical Center, Provo, Utah
| | - Sarah J Ilstrup
- Women and Newborns Program, Dixie Regional Medical Center, St George, Utah.,Transfusion Medicine Services, Intermountain Healthcare, Salt Lake City, Utah
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16
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Bhutani VK, Poland R, Meloy LD, Hegyi T, Fanaroff AA, Maisels MJ. Clinical trial of tin mesoporphyrin to prevent neonatal hyperbilirubinemia. J Perinatol 2016; 36:533-9. [PMID: 26938918 DOI: 10.1038/jp.2016.22] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 12/11/2015] [Accepted: 12/22/2015] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To assess the efficacy of the heme oxygenase inhibitor, tin mesoporphyrin (SnMP), to reduce total bilirubin (TB) levels. STUDY DESIGN Masked, SnMP (4.5 mg kg(-1)), placebo-controlled, multicenter trial of single intramuscular injection to newborns ⩾35 weeks gestational age whose predischarge screening transcutaneous bilirubin (TcB) was >75th percentile. RESULTS Two hundred and thirteen newborns (median age 30 h) were randomized to treatment with SnMP (n=87) or 'sham' (n=89). We found that the duration of phototherapy was halved. Within 12 h of SnMP administration, the natural TB trajectory was reversed. At age 3 to 5 days, TB in the SnMP-treated group was +8% but sixfold lower than the 47% increase in the sham-treated group (P<0.001). At age 7 to 10 days, mean TB declined 18% (P<0.001) compared with a 7.1% increase among controls. No short-term adverse events from SnMP treatment were noted other than photoreactivity due to inadvertent exposure to white light phototherapy. CONCLUSION Early, predischarge SnMP administration decreased the duration of phototherapy, reversed TB trajectory and reduced the severity of subsequent hyperbilirubinemia.
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Affiliation(s)
- V K Bhutani
- Division of Neonatal-Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - R Poland
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - L D Meloy
- Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, USA
| | - T Hegyi
- Department of Pediatrics, Robert Wood Johnson Hospital, New Brunswick, NJ, USA
| | - A A Fanaroff
- Department of Pediatrics, Rainbow Babies' and Children's Hospital, Cleveland, OH, USA
| | - M J Maisels
- Department of Pediatrics, William Beaumont Hospital, Royal Oak, MI, USA
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17
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Bhutani VK, Srinivas S, Castillo Cuadrado ME, Aby JL, Wong RJ, Stevenson DK. Identification of neonatal haemolysis: an approach to predischarge management of neonatal hyperbilirubinemia. Acta Paediatr 2016; 105:e189-94. [PMID: 26802319 DOI: 10.1111/apa.13341] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/21/2015] [Accepted: 01/19/2016] [Indexed: 11/28/2022]
Abstract
AIM Relative contributions of increased production [by end-tidal carbon monoxide concentrations (ETCOc)] and decreased elimination of bilirubin to predischarge hour-specific total bilirubin (TB) levels were assessed in healthy late-preterm and term newborns. Secondly, we report predischarge ETCOc ranges to guide clinical management of hyperbilirubinemia. METHODS TB and ETCOc (≤3 timepoints) determinations of newborns aged between six hours and <6 days (n = 79) were stratified by postnatal age epochs. Hyperbilirubinemia risk was assessed by plotting TB values as a function of ETCOc. RESULTS Stratifications of ETCOc (in ppm, mean, median and interquartile ranges) by postnatal age epochs (0-24, 24-48 and 48-72) were as follows: 2.0, 1.9, 1.8-2.2 (n = 11); 1.6, 1.5, 1.1-2.0 (n = 58); and 2.0, 1.8, 1.6-2.3 (n = 9), respectively. Infants with ETCOc ≥ 2.5 were at high risk, between 1.5 and 2.5 at moderate risk and ≤1.5 were at low risk. Risk due to haemolysis alone was not independent (p < 0.01). For infants with TB >75th percentile (n = 31), 23% had ETCO ≤1.5, and 77% had ETCOc > 1.5 (p < 0.00003). CONCLUSION Near-simultaneous ETCOc and TB measurements in infants with TB >75th percentile accurately identify haemolytic hyperbilirubinemia.
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Affiliation(s)
- Vinod K. Bhutani
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - Shanmukha Srinivas
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - Martin E. Castillo Cuadrado
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - Janelle L. Aby
- Division of General Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - Ronald J. Wong
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
| | - David K. Stevenson
- Division of Neonatal and Developmental Medicine; Department of Pediatrics; Stanford University School of Medicine; Stanford CA USA
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