Exchange Transfusion Trends and Risk Factors for Extreme Neonatal Hyperbilirubinemia over 10 Years in Shiraz, Iran

Background

Exchange transfusion (ET) is an effective treatment for acute bilirubin encephalopathy and extreme neonatal hyperbilirubinemia (ENH). It can reduce mortality and morbidity. This study aimed to investigate the trends and risk factors of ENH requiring ET in hospitalized neonates in Iran.

Methods

A retrospective analysis of medical records of neonates who underwent ET due to ENH was conducted from 2011 to 2021, in Shiraz, Iran. Clinical records were used to gather demographic and laboratory data. The quantitative data were expressed as mean±SD, and qualitative data was presented as frequency and percentage. P<0.05 was considered statistically significant.

Results

During the study, 377 ETs were performed for 329 patients. The annual rate of ET decreased by 71.2% during the study period. The most common risk factor of ENH was glucose-6-phosphate dehydrogenase (G6PD) deficiency (35%), followed by prematurity (13.06%), ABO hemolytic disease (7.6%), sepsis (6.4%), Rh hemolytic disease (6.08%), and minor blood group incompatibility (3.34%). In 28.52% of the cases, the cause of ENH was not identified. 17 (5.1%) neonates had acute bilirubin encephalopathy, of whom 6 (35.29%) had G6PD deficiency, 6 (35.29%) had ABO incompatibility, and 2 (11.76%) had Rh incompatibility.

Conclusion

Although the rate of ET occurrence has decreased, it seems necessary to consider different risk factors and appropriate guidelines for early identification and management of neonates at risk of ENH should be developed. The findings of the study highlighted the important risk factors of ENH in southern Iran, allowing for the development of appropriate prevention strategies.

Hyperbilirubinemia screening and treatment in neonates born prior to 35 weeks of gestation

BACKGROUND

Guidelines on when to screen for neonatal hyperbilirubinemia apply to infants born at 35 weeks or later of gestation. It is unknown whether infants born earlier would benefit from similar guidelines. Our objective was to examine hyperbilirubinemia screening and phototherapy prescription among early preterm infants during the first 6 days of life.

METHODS

We reviewed the charts of 193 infants born prior to 35 weeks of gestation who were admitted to a tertiary care NICU in Southeastern Ontario in 2018-2019. Information on total serum bilirubin (TSB) measurements over each 12-hour interval during the first six days of life and the treatment decision (no treatment, initiate, continue, or stop phototherapy) was extracted. We also examined what proportion of infants were prescribed phototherapy during each 12-hour interval.

RESULTS

Of 1006 TSB measurements performed over the first 6 days of life, 605 were done to determine whether phototherapy should be initiated. Treatment was prescribed in 275 instances (45%). A higher proportion of infants born prior to 28 weeks of gestation required phototherapy in the first 12 hours of life (37%) compared to those born at 28-32 weeks (20%) and 33-34 weeks (5.7%).

CONCLUSIONS

Our results suggest that TSB measurements are often poorly timed to detect treatment need in infants born prior to 35 weeks of gestation. This unnecessarily increases the risk of complications from phlebotomy and is an ineffective use of health care resources. There is a need to develop guidelines to optimize hyperbilirubinemia screening among early preterm infants.

Intravenous immunoglobulin G therapy for neonatal hyperbilirubinemia

BACKGROUND

Neonatal hyperbilirubinemia (NHb) results from increased total serum bilirubin and is a common reason for admission and readmission amongst newborn infants born in North America. The use of intravenous immunoglobulin (IVIG) therapy for treating NHb has been widely debated, and the current incidence of NHb and its therapies remain unknown.

METHODS

Using national and provincial databases, a population-based retrospective cohort study of infants born in Ontario from April 2014 to March 2018 was conducted.

RESULTS

Of the 533,084 infants born in Ontario at ≥35 weeks gestation, 29,756 (5.6%) presented with NHb. Among these infants, 80.1-88.2% received phototherapy, 1.1-2.0% received IVIG therapy and 0.1-0.2% received exchange transfusion (ET) over the study period. Although phototherapy was administered (83.0%) for NHb, its use decreased from 2014 to 2018 (88.2-80.1%) (P < 0.01). Similarly, the incidence of IVIG therapy increased from 71 to 156 infants (1.1-2.0%) (P < 0.01) and a small change in the incidence of ET (0.2-0.1%) was noted.

CONCLUSION

IVIG therapy is increasingly being used in Ontario despite limited studies evaluating its use. The results of this study could inform treatment and management protocols for NHb.

IMPACTS

Clinically significant neonatal hyperbilirubinemia still occurs in Ontario, with an increasing number of infants receiving Intravenous Immunoglobulin G (IVIG) therapy. IVIG continues to be used at increasing rates despite inconclusive evidence to recommend its use. This study highlights the necessity of a future prospective study to better determine the effectiveness of IVIG use in treating neonatal hyperbilirubinemia, especially given the recent shortage in IVIG supply in Ontario. The results of this study could inform treatment and management protocols for neonatal hyperbilirubinemia.

Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns

BACKGROUND

Jaundice is a very common condition in newborns, affecting up to 60% of term newborns and 80% of preterm newborns in the first week of life. Jaundice is caused by increased bilirubin in the blood from the breakdown of red blood cells. The gold standard for measuring bilirubin levels is obtaining a blood sample and processing it in a laboratory. However, noninvasive transcutaneous bilirubin (TcB) measurement devices are widely available and used in many settings to estimate total serum bilirubin (TSB) levels.

OBJECTIVES

To determine the diagnostic accuracy of transcutaneous bilirubin measurement for detecting hyperbilirubinaemia in newborns.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries up to 18 August 2022. We also checked the reference lists of all included studies and relevant systematic reviews for other potentially eligible studies.

SELECTION CRITERIA

We included cross-sectional and prospective cohort studies that evaluated the accuracy of any TcB device compared to TSB measurement in term or preterm newborn infants (0 to 28 days postnatal age). All included studies provided sufficient data and information to create a 2 × 2 table for the calculation of measures of diagnostic accuracy, including sensitivities and specificities. We excluded studies that only reported correlation coefficients.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the eligibility criteria to all citations from the search and extracted data from the included studies using a standard data extraction form. We summarised the available results narratively and, where possible, we combined study data in a meta-analysis.

MAIN RESULTS

We included 23 studies, involving 5058 participants. All studies had low risk of bias as measured by the QUADAS 2 tool. The studies were conducted in different countries and settings, included newborns of different gestational and postnatal ages, compared various TcB devices (including the JM 101, JM 102, JM 103, BiliChek, Bilitest and JH20-1C) and used different cutoff values for a positive result. In most studies, the TcB measurement was taken from the forehead, sternum, or both. The sensitivity of various TcB cutoff values to detect significant hyperbilirubinaemia ranged from 74% to 100%, and specificity ranged from 18% to 89%.

AUTHORS' CONCLUSIONS

The high sensitivity of TcB to detect hyperbilirubinaemia suggests that TcB devices are reliable screening tests for ruling out hyperbilirubinaemia in newborn infants. Positive test results would require confirmation through serum bilirubin measurement.

Deep Learning Network with Spatial Attention Module for Detecting Acute Bilirubin Encephalopathy in Newborns Based on Multimodal MRI

BACKGROUND

Acute bilirubin encephalopathy (ABE) is a significant cause of neonatal mortality and disability. Early detection and treatment of ABE can prevent the further development of ABE and its long-term complications. Due to the limited classification ability of single-modal magnetic resonance imaging (MRI), this study aimed to validate the classification performance of a new deep learning model based on multimodal MRI images. Additionally, the study evaluated the effect of a spatial attention module (SAM) on improving the model's diagnostic performance in distinguishing ABE.

METHODS

This study enrolled a total of 97 neonates diagnosed with ABE and 80 neonates diagnosed with hyperbilirubinemia (HB, non-ABE). Each patient underwent three types of multimodal imaging, which included T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and an apparent diffusion coefficient (ADC) map. A multimodal MRI classification model based on the ResNet18 network with spatial attention modules was built to distinguish ABE from non-ABE. All combinations of the three types of images were used as inputs to test the model's classification performance, and we also analyzed the prediction performance of models with SAMs through comparative experiments.

RESULTS

The results indicated that the diagnostic performance of the multimodal image combination was better than any single-modal image, and the combination of T1WI and T2WI achieved the best classification performance (accuracy = 0.808 ± 0.069, area under the curve = 0.808 ± 0.057). The ADC images performed the worst among the three modalities' images. Adding spatial attention modules significantly improved the model's classification performance.

CONCLUSION

Our experiment showed that a multimodal image classification network with spatial attention modules significantly improved the accuracy of ABE classification.

Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.

[Interpretation of "International guidelines regarding the role of IVIG in the management of Rh- and ABO-mediated haemolytic disease of the newborn"]

International guidelines regarding the role of intravenous immunoglobulin (IVIG) in the management of Rh- and ABO-mediated haemolytic disease of the newborn was drafted by an international panel of experts in the fields of hematology, neonatology, and blood transfusion and was published in British Journal of Haematology on March 16, 2022. The guidelines summarize the evidence-based practice of IVIG in Rh- and ABO-mediated haemolytic disease of the newborn and propose related recommendations. The guidelines recommend that IVIG should not be applied as a routine treatment regimen for Rh- and ABO-mediated haemolytic disease of the newborn in order to reduce exchange transfusion (ET), and the best time to apply IVIG remains unclear in the situations where hyperbilirubinaemia is severe (approaching or exceeding the ET threshold) or ET cannot be implemented. These guidelines are formulated with rigorous methods, but with the lower quality of evidence.

Hemolytic Disease of the Newborn: A Community Hospitalist Perspective

Hemolytic disease of the newborn is commonly diagnosed and managed by pediatric and newborn hospitalists. Severe cases, however, pose unique challenges for community hospitals without higher level neonatal intensive care units. This case highlights the challenges faced by pediatric hospitalists in the community and suggests a focused approach to management.

International guidelines regarding the role of IVIG in the management of Rh- and ABO-mediated haemolytic disease of the newborn

Haemolytic disease of the newborn (HDN) can be associated with significant morbidity. Prompt treatment with intensive phototherapy (PT) and exchange transfusions (ETs) can dramatically improve outcomes. ET is invasive and associated with risks. Intravenous immunoglobulin (IVIG) may be an alternative therapy to prevent use of ET. An international panel of experts was convened to develop evidence-based recommendations regarding the effectiveness and safety of IVIG to reduce the need for ETs, improve neurocognitive outcomes, reduce bilirubin level, reduce the frequency of red blood cell (RBC) transfusions and severity of anaemia, and/or reduce duration of hospitalization for neonates with Rh or ABO-mediated HDN. We used a systematic approach to search and review the literature and then develop recommendations from published data. These recommendations conclude that IVIG should not be routinely used to treat Rh or ABO antibody-mediated HDN. In situations where hyperbilirubinaemia is severe (and ET is imminent), or when ET is not readily available, the role of IVIG is unclear. High-quality studies are urgently needed to assess the optimal use of IVIG in patients with HDN.

Neurological Surveillance in Moderate-Late Preterm Infants-Results from a Dutch-Canadian Survey

Preterm birth remains an important cause of abnormal neurodevelopment. While the majority of preterm infants are born moderate-late preterm (MLPT; 32-36 weeks), international and national recommendations on neurological surveillance in this population are lacking. We conducted an observational quantitative survey among Dutch and Canadian neonatal level I-III centres (June 2020-August 2021) to gain insight into local clinical practices on neurological surveillance in MLPT infants. All centres caring for MLPT infants designated one paediatrician/neonatologist to complete the survey. A total of 85 out of 174 (49%) qualifying neonatal centres completed the survey (60 level I-II and 25 level III centres). Admission of MLPT infants was based on infant-related criteria in 78/85 (92%) centres. Cranial ultrasonography to screen the infant's brain for abnormalities was routinely performed in 16/85 (19%) centres, while only on indication in 39/85 (46%). In 57/85 (67%) centres, neurological examination was performed at least once during admission. Of 85 centres, 51 (60%) followed the infants' development post-discharge, with follow-up duration ranging from 1-52 months of age. The survey showed a wide variety in neurological surveillance in MLPT infants among Dutch and Canadian neonatal centres. Given the risk for short-term morbidity and long-term neurodevelopmental disabilities, future studies are required to investigate best practices for in-hospital care and follow-up of MLPT infants.

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.

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.

Assessment and Management of Pain in Preterm Infants: A Practice Update

Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant.

Treatment practices and implementation of guidelines for hyperbilirubinemia and rebound hyperbilirubinemia

BACKGROUND

Hyperbilirubinemia (HB), defined as elevated total serum bilirubin (TSB) levels, commonly affects neonates and requires prompt treatment to prevent neurological complications. Up to 10%of neonates experience rebound hyperbilirubinemia (RHB), requiring re-initiation of treatment. Unfortunately, treatment guidelines lack practical recommendations surrounding subthreshold phototherapy, treatment termination, and RHB investigations. We examined local management practices for HB and RHB treatment in a well newborn nursery. As a secondary aim, we investigated the association between treatment practices and RHB rates.

METHODS

Retrospective chart review identified neonates treated for hyperbilirubinemia between January 2015 and December 2019 during their birth hospitalization at a tertiary care centre. Standardized data collection sheets were used to record treatment parameters.

RESULTS

Over the 5-year period, there were 9683 births and 305 (3.15%) neonates received phototherapy. Of the treated cases, 20-25%were subthreshold to practice guideline values. Upon treatment termination 25-55%of cases had TSB levels within 3 mg/dL, which may increase the risk of RHB. In our cohort, 20.3%of treated cases experienced one episode of RHB and 3.9%experienced two episodes of RHB. Although clinicians evaluated neonates for RHB 0-12 hours following treatment termination prior to discharge, many cases were identified in outpatient settings and required re-admission for phototherapy.

CONCLUSION

When managing HB and RHB, treatment practices such as when to terminate treatment in relation to threshold values, and timing of RHB investigations, are largely inconsistent amongst clinicians. Future studies are required to better understand the landscape of hyperbilirubinemia treatment beyond initiation of phototherapy.

Improving quality of transcutaneous bilirubin measurements: Value of in-house developed quality control

OBJECTIVES

Quality assurance (QA) plays an integral role in Point of Care Testing (POCT) programs. Quality control (QC) is an important QA program component to ensure high quality results and enhanced patient care. The measurement of transcutaneous bilirubin (TcB) in the POCT setting is an essential part of newborn care in Alberta, Canada. However, there is currently no available commercial QC material for TcB meters. An in-house developed QC material has been in use within a single TcB POCT program within Alberta. The objective of this study was to determine the performance of this QC material by other POCT staff and clinical end-users to assess whether its use could be expanded.

DESIGN AND METHODS

Two levels of QC material were measured by POCT staff and clinical end-users across 12 different sites using the Dräger Jaundice Meter JM-103® and JM-105® meters.

RESULTS

The performance of the QC material was acceptable when tested by POCT staff, was stable and reliable over time, and had an acceptable CV (≤8%). However, the data does not support use of the QC material by clinical end-users.

CONCLUSIONS

The use of the QC material could be expanded into other TcB settings for use by POCT staff. Additional training and experience with the QC material by end-users is needed to facilitate QC use in the clinical setting.

BIND score: A system to triage infants readmitted for extreme hyperbilirubinemia

Extreme hyperbilirubinemia [EHB, total serum bilirubin (TB) >25 mg/dL]) can lead to death, acute bilirubin encephalopathy (ABE), exchange transfusion, and/or bilirubin-induced neurologic dysfunction (BIND). In specific low- to middle-income countries, an "epidemic" exists, therefore, a simplified triage management system is needed. Here, we studied a cohort of 72 infants readmitted for EHB (TB: 28.1 ± 2.5; range: 25-42 mg/dL). Of these, 15/72 (20.8%) newborns had BIND scores ≥4. Eleven (15.3%) infants with BIND scores of 4 to 6 developed moderate ABE, with 6/11 (54.5%) with TB of 28.1 ± 4.8 mg/dL having post-icteric sequelae. Eight infants (TB of 32.1 ± 3.5 mg/dL) had BIND scores >6 and developed adverse outcomes. One infant, who had Rh disease and a BIND score of 8 died. We report that the key determinants for adverse outcomes were TB >30 mg/dL and a BIND score ≥4 and may be useful for a systems approach to triage infants readmitted for EHB.

Assessing knowledge and skills of maternity care professionals regarding neonatal hyperbilirubinaemia: a nationwide survey

BACKGROUND

Neonatal hyperbilirubinaemia is a physiologic phenomenon, but, when severe, may cause lifelong disability. Maternity care assistants (MCAs) play an important role in timely recognition of severe neonatal jaundice. We assessed knowledge and skills of MCAs regarding neonatal hyperbilirubinaemia.

METHODS

All Dutch MCAs (n = 9065) were invited to fill out a questionnaire assessing knowledge, expertise, and handling of neonatal jaundice. Additionally, we developed an e-learning and provided training sessions to a subgroup of MCAs (n = 99), and assessed their knowledge on neonatal hyperbilirubinaemia before and after the training.

RESULTS

One thousand four hundred sixty-five unique online questionnaires were completed (response 16.2%). The median number of correctly answered knowledge questions was 5 (out of six; IQR 1). Knowledge was significantly better when respondents had had in-service training on neonatal hyperbilirubinaemia in the previous year (p = 0.024). Although 82% of respondents felt highly skilled or skilled to assess jaundice, accuracy of estimation of total serum bilirubin levels by assessing skin colour was generally poor and prone to underestimation. Among participants attending a training session, those who completed the e-learning beforehand had higher pre-training scores (5 (IQR 1) vs. 4 (IQR 2); p < 0.001). The median post-training score was higher than pre-training (6 (IQR 1) vs. 5 (IQR 2); p < 0.001).

CONCLUSIONS

Background knowledge of MCAs regarding neonatal hyperbilirubinaemia was adequate, but can be improved by further training. Estimation of total serum bilirubin levels based on skin colour was often inadequate. Approaches to improve timely recognition of jaundiced neonates are needed.

Going home with baby: innovative and comprehensive support for new mothers

Shorter length of stay for postpartum mothers and their newborns necessitates careful community follow-up after hospital discharge. The vast amount of information given during the initial postpartum period can be overwhelming. New parents often need considerable support to understand the nuances of newborn care including newborn feeding. Primary health care and community services need to ensure there is a seamless continuum of care to support, empower, and educate new mothers and their families to prevent unnecessary hospital readmission and other negative health outcomes. The Healthy & Home postpartum community nursing program provides clinical communication and supports to bridge the gap between acute hospital and community follow-up care through home visits, a primary health care clinic, a breastfeeding center, a breastfeeding café, a postpartum anxiety and depression support group, bereavement support, and involvement in a Baby-Friendly Initiative™ coalition. Nurses working in the program have the acute care skills and resources to complete required health care assessments and screening tests. They are also international board-certified lactation consultants able to provide expert breastfeeding and lactation care. This paper describes how the Healthy & Home program has evolved over the past 25 years and offers suggestions to other organizations wanting to develop a postpartum program to meet the physical and mental health needs of postpartum families to promote maternal and infant wellbeing.

Facilitating discharge from hospital of the healthy term infant

This statement provides guidance for health care providers to ensure the safe discharge of healthy term infants who are born in hospital and who are ≥37 weeks' gestational age. Hospital care for mothers and infants should be family-centred, with healthy mothers and infants remaining together and going home at the same time. The specific length of stay for newborn infants depends on the health of their mother, infant health and stability, the mother's ability to care for her infant, support at home, and access to follow-up care. Many mother-infant dyads are ready to go home 24 h after birth. Parent or guardian education and assessment of discharge readiness are important components of discharge planning. Each infant must have an appropriate discharge plan, including identification of the infant's primary health care provider and assessment by a health care provider 24 h to 72 h after discharge.

Diagnostic Performance Analysis of the Point-of-Care Bilistick System in Identifying Severe Neonatal Hyperbilirubinemia by a Multi-Country Approach

IMPORTANCE

The real prevalence and clinical burden of severe neonatal jaundice are undefined due to difficulties in measuring total serum bilirubin (TSB) outside secondary and tertiary clinical centers.

OBJECTIVE

To assess the diagnostic performance of the point-of care Bilistick System (BS) in identifying neonatal jaundice patients requiring treatment.

DESIGN

Between April 2015 and November 2016, 1911 neonates, were recruited to participate in the study. Blood samples were simultaneously collected for the TSB determination by BS and by hospital laboratory (Lab). Data were collected and sent to the Bilimetrix headquarter in Trieste where statistical analysis was performed. Newborns with neonatal jaundice were treated with phototherapy according to each center's guidelines.

SETTING

17 hospitals from Nigeria, Egypt, Indonesia, and Viet Nam.

PARTICIPANTS

1911 newborns were included, of which 1458 (76·3%) fulfilled the inclusion criteria.

RESULTS

TSB level measured by BS agreed (p < .0001) with the lab result in all four countries. The diagnostic performance of BS showed a positive predictive value (PPV) of 92·5% and a negative predictive value (NPV) of 92·8%.

CONCLUSIONS AND RELEVANCE

BS is a reliable system to detect neonatal jaundice over a wide range of bilirubin levels. Since Bilistick is a point-of-care test, its use may provide appropriate and timely identification of jaundiced newborns requiring treatment.

Effectiveness of universal hyperbilirubinemia screening on newborn health: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to assess the effectiveness of the universal hyperbilirubinemia screening program on common newborn health outcomes.Specifically, the review will assess: the incidence of severe hyperbilirubinemia/kernicterus/exchange transfusion, rate of readmission due to jaundice, length of hospital stay on birth admission, rate and utilization of phototherapy during birth hospitalization, and jaundice related emergency visits.

[G6PD deficiency in females with neonatal revelation. Report of four cases]

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common human erythrocyte enzyme defect, estimated to affect approximately 4 million people worldwide. It is associated with severe neonatal hyperbilirubinemia, which may lead to bilirubin encephalopathy and kernicterus, and with hemolytic crisis. G6PD deficiency is an X-linked enzymopathy affecting hemizygous males, homozygous females, and also a subset of heterozygous females via chromosome X inactivation. We report four cases of female newborns with neonatal hyperbilirubinemia related to a G6PD deficiency and followed by the Centre national de référence en hémobiologie périnatale (CNRHP) from November 2013 to July 2014. Clinical and biological characteristics suggested G6PD deficiency (jaundice observed within the first 24h, severe hyperbilirubinemia, associated with regenerative hemolytic anemia, low response to phototherapy, ethnic origin of the parents from high-incident geographical regions). The family investigations revealed a deficit in G6PD in one of the parents who was unaware of this deficit until then. This article aims to make neonatologists and pediatricians aware of the need to search for an etiology for any severe hyperbilirubinemia and to raise G6PD deficiency in male and female newborns in case of hyperbilirubinemia with hemolysis.

Reliability of transcutaneous bilirubinometry from shielded skin in neonates receiving phototherapy: a prospective cohort study

OBJECTIVE

To determine the agreement between transcutaneous bilirubin (TcB) measured from shielded skin and serum total bilirubin (STB) in infants (34 to 41 weeks of gestation) with hyperbilirubinemia receiving phototherapy (PT).

STUDY DESIGN

In this prospective cohort study, we shielded a small area of skin on sternum using a commercial photo-opaque patch (BilEclipseTM, Philips Respironics, Murrysville, PA, USA). The TcB from the shielded skin (TcBs) and STB were measured at four time points-before initiation, 12 and 24 h during and once after (12 h) cessation of PT. TcB was measured using multiwavelength transcutaneous bilirubinometer (BiliChek, Philips Children's Medical Ventures, Monroeville, PA, USA). The STB was measured in triplicate by spectrophotometry (Apel BR 5100, APEL, Japan). Bland and Altman plots were drawn to determine agreement between the TcBs and STB.

RESULTS

The gestation and birth weight of enrolled neonates were 37.0 (1.0) weeks and 2750 (458) g, respectively. The age at initiation and duration of PT were 75 (27 to 312) and 25.3 (4.4) h, respectively. Bland and Altman plot showed poor agreement between TcBs and STB at all time points. The gradient (median, range) between TcBs and STB at 0, 12, 24 h and 12 h after cessation of PT were -0.2 (-4.9 to 3.5), 1.4 (-4.7 to 4.0), 1.5 (-3.8 to 9.4) and 2 (-2.9 to 5.8) mg dl^-1. The proportions of TcBs values outside ±1.5 mg dl^-1 of STB ranged from 47 to 64% at four time points.

CONCLUSION

TcBs does not appear to be reliable for estimating serum bilirubin in late preterm and term neonates receiving PT.

[Management of jaundice in the newborn≥35 GW: From screening to follow-up after discharge. Guidelines for clinical practice]

Jaundice due to unconjugated bilirubin is an everyday condition in the neonatal period because it results from the adaptation of bilirubin metabolism at this time of life. Hyperbilirubinemia has a potential neurotoxicity and although it most often resolves spontaneously, it can lead to acute and sometimes chronic encephalopathy. The latter condition is called kernicterus and induces severe and irreversible neurological sequelae. This rare complication is still reported in all countries throughout the world even if severe hyperbilirubinemia can be prevented and critical points points of failure in jaundice management are identified. Jaundice management are identified, jaundice is the most frequent symptom during the first days of life and after discharge from the maternity ward but also the major cause of readmission in the 15 first days of life. Therefore in the past 20 years, numerous countries have written national practical guidelines for the management of neonatal jaundice using various methodologies. Most of the time, the guidelines resulted from expert consensus more than from an evidence-based argument. The Société française de néonatologie created a working group to provide the first French clinical guidelines for the management of jaundice in the near-term newborn (35 weeks and more). They were written following a physiopathological argument and taking into account both clinical risk factors for severe hyperbilirubinemia and interindividual variability in vulnerability to bilirubin neurotoxicity. Practical tools were also developed to facilitate implementation of the guidelines and are also included.

Use of intravenous immunoglobulin in neonates at a tertiary academic hospital: a retrospective 11-year study

BACKGROUND

Intravenous immunoglobulin (IVIG) is used to treat a variety of diseases in the neonatal intensive care unit (NICU). Although audits have reported on the spectrum of IVIG use in adults, the indications and utilization in neonates has not been investigated. The objectives of this study were to describe the usage pattern of and indications for IVIG in a tertiary care NICU.

STUDY DESIGN AND METHODS

A retrospective chart review was performed of all neonates who received IVIG in the NICU from January 2003 to December 2013. Data collected included patient demographic features, antenatal maternal details, neonatal laboratory results, treatment details, adverse events, and patient outcome.

RESULTS

Thirty-seven neonates received IVIG over the 11-year period. Twenty-three (67%) were treated for hemolytic disease of the newborn (HDN); 13 treatments were ABO related, six were anti-D related, and four were for clinically significant antibodies. Fourteen (33%) were treated for non-HDN causes, including eight for septic neonates, two for neonates with necrotizing enterocolitis, two for neonates with a clinically significant antibody but without evidence of hemolysis, and two for neonates with glucose 6-phosphate dehydrogenase deficiency. A complete hemolytic workup was not performed consistently before the receipt of IVIG.

CONCLUSIONS

This novel assessment of IVIG use in the NICU revealed the spectrum of disease for which IVIG is ordered. This study also found that key diagnostic tests needed to confirm an immune etiology for idiopathic jaundice are not performed routinely before IVIG receipt. Neonatal transfusion-related databases are needed to carry out pragmatic clinical trials to establish better evidence-based guidelines for IVIG therapy in the NICU.

Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy

OBJECTIVE

To test whether the combined use of total plasma/serum bilirubin (TSB) levels and clinical risk factors more accurately identifies infants who receive phototherapy than does the use of either method alone.

STUDY DESIGN

We recruited healthy infants of ≥35 weeks' gestation at 6 centers that practiced universal predischarge TSB screening. Transcutaneous bilirubin (TcB) was measured at 24 hours, with TSB at 24-60 hours and at 3- to 5- and 7- to 14-day follow-up visits. Clinical risk factors were identified systematically.

RESULTS

Of 1157 infants, 1060 (92%) completed follow-up, and 982 (85%) had complete datasets for analysis. Infant characteristics included 25% were nonwhite and 55% were Hispanic/Latino; >90% were breastfed. During the first week, jaundice was documented in 84% of subjects. Predischarge TSB identified the 41 (4.2%) and 34 (3.5%) infants who received phototherapy before and after discharge, respectively. Prediction of postdischarge phototherapy was similar for combined clinical risk factors (earlier gestational age [GA], bruising, positive direct antiglobulin test, Asian race, exclusive breastfeeding, blood type incompatibility, jaundice extent) and age-adjusted TSB (area under the curve [AUC] = .86 vs .87), but combined screening was better (AUC = .95). TcB/TSB combined with GA alone was equally predictive (AUC = .95; 95% CI .93-.97).

CONCLUSIONS

Jaundice is present in 4 of 5 (84%) healthy newborns. Predischarge TcB/TSB (adjusted for postnatal age) combined with specific clinical factors (especially GA) best predicts subsequent phototherapy use. Universal implementation of this strategy in the US should improve outcomes of healthy newborns discharged early.

Cost-effectiveness analysis of a system-based approach for managing neonatal jaundice and preventing kernicterus in Ontario

OBJECTIVE

To evaluate the incremental cost-effectiveness of a system-based approach for the management of neonatal jaundice and the prevention of kernicterus in term and late-preterm (≥35 weeks) infants, compared with the traditional practice based on visual inspection and selected bilirubin testing.

STUDY DESIGN

Two hypothetical cohorts of 150,000 term and late-preterm neonates were used to compare the costs and outcomes associated with the use of a system-based or traditional practice approach. Data for the evaluation were obtained from the case costing centre at a large teaching hospital in Ontario, supplemented by data from the literature.

RESULTS

The per child cost for the system-based approach cohort was $176, compared with $173 in the traditional practice cohort. The higher cost associated with the system-based cohort reflects increased costs for predischarge screening and treatment and increased postdischarge follow-up visits. These costs are partially offset by reduced costs from fewer emergency room visits, hospital readmissions and kernicterus cases. Compared with the traditional approach, the cost to prevent one kernicterus case using the system-based approach was $570,496, the cost per life year gained was $26,279, and the cost per quality-adjusted life year gained was $65,698.

CONCLUSION

The cost to prevent one kernicterus case using the system-based approach is much lower than previously reported in the literature.

Screening and early postnatal management strategies to prevent hazardous hyperbilirubinemia in newborns of 35 or more weeks of gestation

Although kernicterus is a rare condition, it is still being reported in North America and Western Europe in addition to less developed parts of the world. The majority of affected infants are term and late-preterm newborns who have been discharged from the nursery as 'healthy newborns' yet have subsequently developed extreme hyperbilirubinemia and the classic neurodevelopmental findings associated with kernicterus. Published guidelines provide the basic tools for preventing hazardous hyperbilirubinemia and the two most important of these are a systematic assessment, prior to discharge, of each infant, for the risk of severe hyperbilirubinemia, and appropriate follow-up based on the time of discharge and the risk assessment. The most recent recommendations call for a predischarge measurement of the serum or transcutaneous bilirubin in all infants. When combined with the gestational age and other risk factors for hyperbilirubinemia, this provides the best estimate of the risk, or lack of risk, for subsequent hyperbilirubinemia, and determines the timing of follow-up and the need for further evaluation and treatment. The application of these principles to the management of the jaundiced newborn might not eliminate every case of kernicterus, but should contribute to a reduction in its occurrence.

Glucose-6-phosphate dehydrogenase deficiency and severe neonatal hyperbilirubinemia: a complexity of interactions between genes and environment

Glucose-6-phosphate dehydrogenase deficiency is a commonly occurring genetic condition, likely to be encountered today in virtually any corner of the globe. Sudden episodes of hemolysis associated with the condition may result in exponential increases in serum total bilirubin concentrations to levels at which bilirubin-induced neurologic damage may occur. The hyperbilirubinemia is the result of complex interactions between genes and environment. Neonatal screening programs coupled with parental and medical caretaker education may be successful in limiting the severity of disease.

Neonatal hyperbilirubinemia and kernicterus - not gone but sometimes forgotten

The introduction of exchange transfusion made it possible to prevent severe hyperbilirubinemia and kernicterus, but kernicterus has never completely disappeared and it is still occurring in North America and, more frequently in Western Europe and the developing world. I discuss the epidemiology and major causes of severe hyperbilirubinemia and the potential root causes and system failures associated with the development of extreme hyperbilirubinemia and, subsequently, kernicterus. In the Western world, kernicterus remains a rare cause of cerebral palsy but, in contrast to the other causes of cerebral palsy, kernicterus should almost always be preventable. The key elements in preventing kernicterus are risk assessment and appropriate follow-up for the newborn infant and these are presented in a recently developed algorithm. Implementation of this approach might contribute to the prevention of severe hyperbilirubinemia and bilirubin encephalopathy.

Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: US Preventive Services Task Force recommendation statement

DESCRIPTION

Recommendation on screening newborn infants, based on a recent supplemental review of a 2003 Agency for Healthcare Research and Quality evidence report on the effectiveness of various screening strategies for preventing the development of chronic bilirubin encephalopathy, performed at the request of the US Preventive Services Task Force (USPSTF). This topic has not been previously considered by the USPSTF.

METHODS

The USPSTF reviewed experimental and observational studies that included comparison groups. For harms associated with phototherapy, case reports or case series were also included.

CONCLUSION

The evidence is insufficient to assess the balance of benefits and harms of screening for hyperbilirubinemia to prevent chronic bilirubin encephalopathy (I statement).