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Gopal SH, Zebda R, Mohan A, Borovsky K, Takwoingi Y, Scandrett K, Pammi M. Population-based screening strategies for biliary atresia in the newborn: A systematic review and meta-analysis. PLoS One 2024; 19:e0307837. [PMID: 39197055 PMCID: PMC11357077 DOI: 10.1371/journal.pone.0307837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 07/11/2024] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND Newborn screening for biliary atresia (BA) may facilitate earlier diagnosis and intervention for improved clinical outcomes. METHODS We systematically reviewed the accuracy of population-based screening strategies for BA in the newborn using PRISMA-DTA guidelines. We included cohort or cross-sectional studies. The screening (index) tests included stool color card (SCC) and direct/conjugated bilirubin (DB/CB) and the reference standard was intraoperative cholangiogram. Meta-analysis was performed using random-effects logistic regression models. RESULTS We included 15 studies (1,816,722 participants) that assessed 5 different population-based screening strategies. QUADAS-2 assessment revealed high risk of bias for patient selection in one study and uncertain risks for reference standard in multiple studies. High certainty evidence suggests that DB/CB assessed after birth had a summary sensitivity of 100% (95% CI 100,100) and specificity of 98.8% (98.8,98.9) (5 studies, 662141 participants). Moderate certainty evidence suggests that SCC screening at a month of age had summary sensitivity of 79.6% (95% CI 70.6, 86.4) and specificity of 99.9% (95% CI 99.9, 99.9) (7 studies, 996262 participants). CONCLUSIONS DB/CB in the first few days of life has the best diagnostic accuracy for population screening for biliary atresia in the newborn. Future research should focus on cost-effectiveness and combinations of screening strategies.
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Affiliation(s)
- Srirupa Hari Gopal
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Rema Zebda
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Arvind Mohan
- University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kristin Borovsky
- Division of Pediatric Gastroenterology, Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Yemisi Takwoingi
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Katie Scandrett
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mohan Pammi
- Division of Neonatal-Perinatal Medicine, Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
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Tam PKH, Wells RG, Tang CSM, Lui VCH, Hukkinen M, Luque CD, De Coppi P, Mack CL, Pakarinen M, Davenport M. Biliary atresia. Nat Rev Dis Primers 2024; 10:47. [PMID: 38992031 DOI: 10.1038/s41572-024-00533-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 07/13/2024]
Abstract
Biliary atresia (BA) is a progressive inflammatory fibrosclerosing disease of the biliary system and a major cause of neonatal cholestasis. It affects 1:5,000-20,000 live births, with the highest incidence in Asia. The pathogenesis is still unknown, but emerging research suggests a role for ciliary dysfunction, redox stress and hypoxia. The study of the underlying mechanisms can be conceptualized along the likely prenatal timing of an initial insult and the distinction between the injury and prenatal and postnatal responses to injury. Although still speculative, these emerging concepts, new diagnostic tools and early diagnosis might enable neoadjuvant therapy (possibly aimed at oxidative stress) before a Kasai portoenterostomy (KPE). This is particularly important, as timely KPE restores bile flow in only 50-75% of patients of whom many subsequently develop cholangitis, portal hypertension and progressive fibrosis; 60-75% of patients require liver transplantation by the age of 18 years. Early diagnosis, multidisciplinary management, centralization of surgery and optimized interventions for complications after KPE lead to better survival. Postoperative corticosteroid use has shown benefits, whereas the role of other adjuvant therapies remains to be evaluated. Continued research to better understand disease mechanisms is necessary to develop innovative treatments, including adjuvant therapies targeting the immune response, regenerative medicine approaches and new clinical tests to improve patient outcomes.
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Affiliation(s)
- Paul K H Tam
- Medical Sciences Division, Macau University of Science and Technology, Macau, China.
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Rebecca G Wells
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Clara S M Tang
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong, Hong Kong SAR, China
| | - Vincent C H Lui
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong, Hong Kong SAR, China
| | - Maria Hukkinen
- Section of Paediatric Surgery, Paediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carlos D Luque
- Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Paolo De Coppi
- NIHR Biomedical Research Centre, Great Ormond Street Hospital for Children NHS Foundation Trust and Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Cara L Mack
- Department of Paediatrics, Division of Paediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Mikko Pakarinen
- Section of Paediatric Surgery, Paediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
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Eiamkulbutr S, Tubjareon C, Sanpavat A, Phewplung T, Srisan N, Sintusek P. Diseases of bile duct in children. World J Gastroenterol 2024; 30:1043-1072. [PMID: 38577180 PMCID: PMC10989494 DOI: 10.3748/wjg.v30.i9.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/26/2023] [Accepted: 02/04/2024] [Indexed: 03/06/2024] Open
Abstract
Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases.
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Affiliation(s)
- Sutha Eiamkulbutr
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Chomchanat Tubjareon
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Anapat Sanpavat
- Department of Pathology, Chulalongkorn University, Bangkok 10330, Thailand
| | - Teerasak Phewplung
- Department of Radiology, Chulalongkorn University, Bangkok 10330, Thailand
| | - Nimmita Srisan
- Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Palittiya Sintusek
- Center of Excellence in Thai Pediatric Gastroenterology, Hepatology and Immunology, Division of Gastroenterology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
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Arshad A, Gardiner J, Ho C, Rees P, Chadda K, Baker A, Sutcliffe AG. Population-based screening methods in biliary atresia: a systematic review and meta-analysis. Arch Dis Child 2023; 108:468-473. [PMID: 36797045 DOI: 10.1136/archdischild-2022-324946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE The aim of this study was to investigate tested methods of population-based biliary atresia (BA) screening. DESIGN We searched 11 databases between 1 January 1975 and 12 September 2022. Data extraction was independently done by two investigators. MAIN OUTCOME MEASURES Our primary outcomes were: sensitivity and specificity of screening method in BA detection, age at Kasai, BA associated morbidity and mortality, cost-effectiveness of screening. RESULTS Six methods of BA screening were evaluated: stool colour charts (SCCs), conjugated bilirubin measurements, stool colour saturations (SCSs), measurements of urinary sulfated bile acids (USBAs), assessments of blood spot bile acids and blood carnitine measurements.In a meta-analysis, USBA was the most sensitive and specific, with a pooled sensitivity and specificity of 100.0% (95% CI 2.5% to 100.0%) and 99.5% (95% CI 98.9% to 99.8%) (based on one study). This was followed by conjugated bilirubin measurements: 100.0% (95% CI 0.0% to 100.0%) and 99.3% (95% CI 91.9% to 99.9%), SCS: 100.0% (95% CI 0.00% to 100.0%) and 92.4% (95% CI 83.4% to 96.7%), and SCC: 87.9% (95% CI 80.4% to 92.8%) and 99.9% (95% CI 99.9% to 99.9%).SCC reduced the age of Kasai to ~60 days, compared with 36 days for conjugated bilirubin. Both SCC and conjugated bilirubin improved overall and transplant-free survival. The use of SCC was considerably more cost-effective than conjugated bilirubin measurements. CONCLUSION Conjugated bilirubin measurements and SCC are the most researched and demonstrate improved sensitivity and specificity in detecting BA. However, their use is expensive. Further research into conjugated bilirubin measurements, as well as alternative methods of population-based BA screening, is required. PROSPERO REGISTRATION NUMBER CRD42021235133.
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Affiliation(s)
- Adam Arshad
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Julian Gardiner
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Carmen Ho
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Philippa Rees
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Karan Chadda
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, London, UK
| | - Alastair Baker
- Department of Paediatric Hepatology, Kings College Hospital, London, UK
| | - Alastair G Sutcliffe
- Population, Policy & Practice Department, UCL GOS Institute of Child Health, Institute of Child Health, London, UK
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Hoshino E, Moriwaki K, Morimoto K, Sakai K, Shimohata N, Konomura K, Urayama KY, Suzuki M, Shimozuma K. Cost-Effectiveness Analysis of Universal Screening for Biliary Atresia in Japan. J Pediatr 2023; 253:101-106.e2. [PMID: 36179888 DOI: 10.1016/j.jpeds.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of universal newborn screening using stool color card or direct bilirubin (DB) testing when comparing with no screening for biliary atresia in Japanese setting. STUDY DESIGN A decision analytic Markov microsimulation model was developed to evaluate the universal screening for biliary atresia. Our screening strategies included stool color card, DB, or no screening. The outcomes of all newborns undergoing 3 strategies were simulated to analyze event-free life-years defined as liver transplant-free survival, costs, and incremental cost-effectiveness ratio (ICER) over a 25-year period with an annual discount rate of 2% applied for both costs and outcomes. A 1-way sensitivity analysis was performed to assess the uncertainty. RESULTS There were 941 000 newborn infants in our cohort and 114 cases of biliary atresia. The base case analysis showed that the stool color card strategy was $14 927 337 higher than no screening with an increase in 44 more event-free life-years gained, resulting in an ICER of $339 258 per event-free life-year gained. The DB screening strategy compared with stool color card was $138 994 060 higher with an increase in 271 more event-free life-years gained and an ICER of $512 893 per event-free life-year gained. The DB screening strategy compared with no screening resulted in an ICER of $488 639 per event-free life-year gained. The DB screening resulted in 16 fewer liver transplants than stool color card and stool color card had 2 fewer liver transplants than no screening. CONCLUSIONS Universal screening for biliary atresia could be cost-effective depending on the willingness to pay thresholds for health benefits.
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Affiliation(s)
- Eri Hoshino
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan; Graduate School of Public Health, St. Luke's International University, Kyoto, Japan.
| | - Kensuke Moriwaki
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | | | - Kotomi Sakai
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | - Nobuyuki Shimohata
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | - Keiko Konomura
- Center for Outcomes Research and Economic Evaluation for Health (C2H), National Institute of Public Health, Kyoto, Japan
| | - Kevin Y Urayama
- Graduate School of Public Health, St. Luke's International University, Kyoto, Japan; Department of Social Medicine, National Center for Child Health and Development, Kyoto, Japan
| | - Mitsuyoshi Suzuki
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Kyoto, Japan
| | - Kojiro Shimozuma
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
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Islek A, Tumgor G. Biliary atresia and congenital disorders of the extrahepatic bile ducts. World J Gastrointest Pharmacol Ther 2022; 13:33-46. [PMID: 36051179 PMCID: PMC9297290 DOI: 10.4292/wjgpt.v13.i4.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/10/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
Biliary atresia (BA) and choledochal cysts are diseases of the intrahepatic and extrahepatic biliary tree. While their exact etiopathogeneses are not known, they should be treated promptly due to the potential for irreversible parenchymal liver disease. A diagnosis of BA may be easy or complicated, but should not be delayed. BA is always treated surgically, and performing the surgery before the age of 2 mo greatly increases its effectiveness and extends the time until the need for liver transplantation arises. While the more common types of choledochal cysts require surgical treatment, some can be treated with endoscopic retrograde cholangiopancreatography. Choledochal cysts may cause recurrent cholangitis and the potential for malignancy should not be ignored.
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Affiliation(s)
- Ali Islek
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
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7
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Liao FM, Chang KC, Wu JF, Chen HL, Ni YH, Chang MH. Direct Bilirubin and Risk of Biliary Atresia. Pediatrics 2022; 149:186994. [PMID: 35506333 DOI: 10.1542/peds.2021-053073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Early detection of biliary atresia (BA) is important for optimal treatment. Direct bilirubin (D-bil) levels are used for BA screening. In this study, we aimed to determine the sensitivity and specificity of elevated D-bil and the direct-to-total bilirubin (D/T) ratio for BA detection in high-risk infants. METHODS This retrospective, cross-sectional study was conducted in a tertiary medical center in Taiwan. Infants indicated for total bilirubin and D-bil measurements before age 60 days were included. The first bilirubin assessment was considered the test point. BA diagnosis was based on International Classification of Diseases, Ninth and Tenth Revision, codes 751.61 and Q44.0 to Q44.3, respectively. RESULTS Between January 2009 and December 2016, 4468 infants were enrolled, including 38 with BA. Among infants aged 3 to 60 days, a sensitivity of 100% (95% confidence interval, 90.3-100.0) was found for D-bil ≥1.0 mg/dL and either D-bil ≥1.0 mg/dL or D/T ratio ≥20%. However, D-bil ≥1.0 mg/dL had higher specificity (77.3% [76.0-78.5] vs 68.3% [66.8-69.7], respectively). In newborns aged <3 days, D-bil ≥0.5 mg/dL was considered a positive result, with a sensitivity of 50%. D-bil >0.45 mg/dL was a better cutoff point in receiver operating characteristic analysis, with a sensitivity and specificity of 100% (95% CI: 15.8-100) and 15.4% (95% CI, 11.8-19.7), respectively. CONCLUSIONS D-bil ≥1.0 mg/dL was better for BA detection than the D/T ratio in infants aged 3 to 60 days. For newborns aged <3 days, a more definitive cutoff point is required.
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Affiliation(s)
- Fang-Min Liao
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Pediatrics, Saint Paul's Hospital, Taoyuan, Taiwan
| | - Kai-Chi Chang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
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Schreiber RA, Harpavat S, Hulscher JBF, Wildhaber BE. Biliary Atresia in 2021: Epidemiology, Screening and Public Policy. J Clin Med 2022; 11:jcm11040999. [PMID: 35207269 PMCID: PMC8876662 DOI: 10.3390/jcm11040999] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 12/12/2022] Open
Abstract
Biliary atresia (BA) is a rare newborn liver disease with significant morbidity and mortality, especially if not recognized and treated early in life. It is the most common cause of liver-related death in children and the leading indication for liver transplantation in the pediatric population. Timely intervention with a Kasai portoenterostomy (KPE) can significantly improve prognosis. Delayed disease recognition, late patient referral, and untimely surgery remains a worldwide problem. This article will focus on biliary atresia from a global public health perspective, including disease epidemiology, current national screening programs, and their impact on outcome, as well as new and novel BA screening initiatives. Policy challenges for the implementation of BA screening programs will also be discussed, highlighting examples from the North American, European, and Asian experience.
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Affiliation(s)
- Richard A. Schreiber
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Correspondence: ; Tel.: +1-604-875-2332 (ext. 1); Fax: +1-604-875-3244
| | - Sanjiv Harpavat
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX 77030, USA;
| | - Jan B. F. Hulscher
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Barbara E. Wildhaber
- Swiss Pediatric Liver Center, Division of Pediatric Surgery, Department of Pediatrics, Gynecology, and Obstetrics, University of Geneva, 1205 Geneva, Switzerland;
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Biliary Atresia Screening in India-Strategies and Challenges in Implementation. Indian J Pediatr 2022; 89:133-140. [PMID: 34453683 DOI: 10.1007/s12098-021-03862-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 05/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the utilization of SCC implemented in southern India and the effect on SCC utilization of face-to-face verbal education versus video-based content delivery. METHODS The study included newborns with postnatal age of less than 2 wk at discharge. Mothers were administered SCCs and provided standardized verbal or video health education based on the time-period of enrollment. Home based monitoring of stool color and return of SCC on postnatal day 21 was advised. Telephone surveys were conducted to identify SCC use among families that did not return the SCC by post. RESULTS Of the 2254 newborns enrolled, 1130 were in the verbal-counseling group and 1124 in the video-counseling group. No newborns with pale stools and biliary atresia were identified. SCC return rates were 3.8% and 2.8%. Comparing the verbal and video-counseling groups, there were no differences in the conservative (81.8% vs. 81.5%) and optimistic estimates (97.1% vs. 97.3%) of SCC utilization rates. Mothers with better educational status had higher optimistic estimates of SCC utilization. CONCLUSIONS The use of a validated SCC in Tamil with standardized information delivery leads to good utilization rates in southern India, with video content delivery being as effective as face-to-face verbal content delivery. SCC return by post is not a feasible mode of identification of card use. TRIAL REGISTRATION The study is registered under Clinical Trials Registry - India (CTRI/2018/01/011285).
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Rabbani T, Guthery SL, Himes R, Shneider BL, Harpavat S. Newborn Screening for Biliary Atresia: a Review of Current Methods. Curr Gastroenterol Rep 2021; 23:28. [PMID: 34817690 DOI: 10.1007/s11894-021-00825-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Tebyan Rabbani
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Stephen L Guthery
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Utah and Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Ryan Himes
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Ochsner Health, New Orleans, LA, USA
| | - Benjamin L Shneider
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA.
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11
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Neonatale Cholestase. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-020-01042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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12
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Fernando M, Rajindrajith S. Neonatal and infantile cholestasis: An overlooked health burden with unmet needs. Indian J Gastroenterol 2020; 39:531-538. [PMID: 33475928 DOI: 10.1007/s12664-020-01137-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/09/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Meranthi Fernando
- Department of Pediatrics, Faculty of Medicine, University of Kelaniya, Talagolla Road, Ragama, 11010, Sri Lanka.
| | - Shaman Rajindrajith
- Department of Pediatrics, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Colombo, 00800, Sri Lanka
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Angelico R, Liccardo D, Paoletti M, Pietrobattista A, Basso MS, Mosca A, Safarikia S, Grimaldi C, Saffioti MC, Candusso M, Maggiore G, Spada M. A novel mobile phone application for infant stool color recognition: An easy and effective tool to identify acholic stools in newborns. J Med Screen 2020; 28:230-237. [PMID: 33241758 DOI: 10.1177/0969141320974413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Early diagnosis of biliary atresia is essential to improve long-term outcomes. Newborn screening with an infant stool color card allows early recognition of biliary atresia patients. Our aim was to develop and validate a mobile phone application (PopòApp) able to identify acholic stools. METHODS An intuitive app was developed for iOS and Android smartphones. A learning machine process was used to generate an algorithm for stools color recognition based on the seven colors of the infant stool color card, which were considered as the gold standard. Consecutive images of stools were taken by the PopòApp, directly into the diapers of children aged ≤6 months. The PopòApp classified the photographs as "normal", "acholic" or "uncertain". To validate the PopòApp, four doctors independently classified all images, and only those for which all doctors agreed were included. The sensitivity, specificity, positive/negative predictive values, and accuracy of the PopòApp were evaluated. RESULTS Of 165 images collected, 160 were included in the study. All acholic stools were recognized by the PopòApp. The PopòApp sensitivity was 100% (95% CI:93.9%-100%) with no false negatives, regardless of the brand of phone. The specificity was 99.0% (95% CI:94.6%-99.9%). The accurancy of the PopòApp was 99.4% (95% CI:96.6%-99.9%), with a positive predictive value of 98.4% (95% CI:89.8%-99.8%). CONCLUSION The current study proved, in a large cohort, that the PopòApp is an accurate and easy tool for recognition of acholic stools. The mobile App may represent an effective strategy for the early referral of children with acholic stools, and potentially could improve the outcomes of biliary atresia.
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Affiliation(s)
- Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.,Department of Surgical Science, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Daniela Liccardo
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Monica Paoletti
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Andrea Pietrobattista
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria S Basso
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Antonella Mosca
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Samira Safarikia
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria C Saffioti
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Manila Candusso
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giuseppe Maggiore
- Division of Gastroenterology, Hepatology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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Gong Z, Wu Y, Zheng L, Chen L, Lv Z. Can Free Carnitine or Bilirubin in Blood Be Used in Neonatal Screening for Biliary Atresia? Eur J Pediatr Surg 2020; 30:459-464. [PMID: 31600802 DOI: 10.1055/s-0039-1698764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the efficiency of free carnitine, unconjugated bilirubin (UBIL), bilirubin monoglucuronide (BMG), and bilirubin diglucuronide (BDG) in dry blood spots (DBSs) measured using tandem mass spectrometry (MS/MS) for screening biliary atresia (BA). MATERIALS AND METHODS All the patients with BA, residing in Shanghai, were collected from four different children's hospitals in Shanghai from January 1, 2015, to June 30, 2017. UBILMS, BMG, BDG, and free carnitine were measured in the DBS samples of 48 patients with BA, 10,008 pediatric patients, and 52,862 newborns using MS/MS. Conjugated bilirubin was measured by MS/MS (CBMS) = BMG + BDG, and total bilirubin was measured by MS/MS (TBMS) = UBILMS + CBMS. Four hundred pediatric patients' direct bilirubin (DB) and total bilirubin (TB), measured by the clinical laboratory and MS/MS, were used as a control. RESULTS The total number of births at the registered permanent residences in Shanghai was 233,000; among them, the occurrence of BA was in 33 patients in 2 years. Therefore, the incidence of BA in Shanghai was 1:7,060. The ratio of DB/TB and CBMS/TBMS of most patients with BA was elevated gradually in the neonatal period and higher than the normal range after 1 month after birth. The area under the receiver operating characteristic curve of DB, DB/TB, CBMS/TBMS, CBMS, and free carnitine for predicting BA was 0.98, 0.95, 0.73, 0.57, and 0.92, respectively. Using the 95% percentile as a cutoff, the sensitivity of DB and free carnitine to predict BA was 100 and 85%, respectively, and the specificity was 52 and 85%, respectively. CONCLUSION In free carnitine, DB, and CBMS/TBMS tests, blood concentrations are elevated in all infants with BA. However, they may not be elevated while they are newborns. These tests will result in high false negatives or positives. Thus, they should not be used as newborn screening tests for BA due to their lower sensitivity and specificity.
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Affiliation(s)
- Zhenhua Gong
- Department of Pediatric Surgery, Children's Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Yibo Wu
- Department of Pediatric Surgery, Children's Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Lulu Zheng
- Department of Pediatric Surgery, Children's Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Licai Chen
- Department of Pediatric Surgery, Children's Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Zhibzo Lv
- Department of Pediatric Surgery, Children's Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
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McKiernan PJ. Prompt diagnosis of biliary atresia: education has not succeeded, time to move to universal screening. Arch Dis Child 2020; 105:709-710. [PMID: 32586929 DOI: 10.1136/archdischild-2020-319351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Patrick James McKiernan
- Division of Dastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
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Cifuentes Y, Arteaga C. Dysmorphic features in a newborn with neurological, liver and kidney involvement by defective peroxisomal biogenesis. Case report. CASE REPORTS 2020. [DOI: 10.15446/cr.v6n1.78747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Inborn errors of metabolism have significant morbidity and mortality rates in the neonatal period. One of these disorders is defective peroxisomal biogenesis, which causes complex and severe clinical pictures because peroxisomes are present in all nucleated cells of mammals.Case presentation: This is the case of a newborn with dysmorphic features who had seizures at birth and presented with neurological, liver, kidney and heart involvement during her 20 days of life. Necropsy confirmed liver and kidney involvement, which, together with family history of death of a sibling and a cousin, led to suspect a peroxisomal disease that was confirmed by the biochemical alterations observed.Discussion: Dysmorphism and seizures at birth may be an expression of a metabolic disease. The findings of the physical examination and the demonstration of liver, kidney and heart involvement are consistent with the initial description of Zellweger syndrome; the biochemical alterations are conclusive.Conclusions: It is necessary to define if dysmorphism is an isolated finding or if there is involvement of other organ(s) or system(s) to establish a suitable diagnosis of peroxisome biogenesis. Inborn errors of metabolism should be included in the diagnosis of dysmorphic newborns when several organs are involved, since their identification enables genetic counseling.
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Expression of vascular endothelial growth factor A in liver tissues of infants with biliary atresia. Clin Exp Hepatol 2019; 5:308-316. [PMID: 31893243 PMCID: PMC6935852 DOI: 10.5114/ceh.2019.89476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/01/2019] [Indexed: 12/22/2022] Open
Abstract
Aim of the study Assessment of hepatic expression of vascular endothelial growth factor A (VEGF-A) in liver tissues of infants with biliary atresia (BA). Material and methods This retrospective study included 35 infants with BA (BA group), and 38 infants with cholestasis due to causes other than BA (non-BA group). All patients had undergone full history taking, through clinical examination, routine investigations and immunostaining of liver tissue for VEGF-A and cytokeratin 7 (CK7). The diagnosis of BA was confirmed by intraoperative cholangiography. In the non-BA group, other specific laboratory tests according to the expected etiology were done. Results Most of the BA group showed positive VEGF-A expression with variable degrees in both bile ducts (BDs; 80%), and arterial walls (AWs; 77.2%), while most of the non-BA group showed negative staining of VEGF in both BDs and AWs (89.5% and 86.8% respectively) (p < 0.0001). Positive VEGF expression in the portal structures in both BDs and AWs had 84.9% and 82.19% accuracy; respectively. The majority of BA group showed either grade II of positive cytokeratin-7 expression in liver tissues (45.7%) or grade III (34.3%), while most of the non-BA group showed grade I (71.1%) (p < 0.0001). Positive CK7 expression in > 25% of the liver tissues had 80.8% accuracy in discriminating between BA and non-BA. Conclusions VEGF-A expression in the portal structures in liver tissues in both BDs and AWs had very good accuracy in discriminating between BA and non-BA patients.
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Harpavat S, Lupo PJ, Liwanag L, Hollier J, Brandt ML, Finegold MJ, Shneider BL. Factors Influencing Time-to-diagnosis of Biliary Atresia. J Pediatr Gastroenterol Nutr 2018; 66:850-856. [PMID: 29315162 PMCID: PMC5963977 DOI: 10.1097/mpg.0000000000001887] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Diagnosing biliary atresia (BA) quickly is critical, because earlier treatment correlates with delayed or reduced need for liver transplantation. However, diagnosing BA quickly is also difficult, with infants usually treated after 60 days of life. In this study, we aim to accelerate BA diagnosis and treatment, by better understanding factors influencing the diagnostic timeline. METHODS Infants born between 2007 and 2014 and diagnosed with BA at our institution were included (n = 65). Two periods were examined retrospectively: P1, the time from birth to specialist referral, and P2, the time from specialist referral to treatment. How sociodemographic factors associate with P1 and P2 were analyzed with Kaplan-Meier curves and Cox proportional hazard models. In addition, to better characterize P2, laboratory results and early tissue histology were studied. RESULTS P1 associated with race/ethnicity, with shorter times in non-Hispanic white infants compared to non-Hispanic black and Hispanic infants (P = 0.007 and P = 0.004, respectively). P2 associated with referral age, with shorter times in infants referred after 30, 45, or 60 days of life (P < 0.001, P < 0.001, and P = 0.001, respectively). One potential reason for longer P2 in infants referred ≤30 days is that aminotransferase levels were normal or near-normal. However, despite reassuring laboratory values, tissue histology in early cases showed key features of BA. CONCLUSIONS Our findings suggest 2 opportunities to accelerate BA diagnosis and treatment. First, to achieve prompt referrals for all races/ethnicities, universal screening strategies should be considered. Second, to ensure efficient evaluations independent of age, algorithms designed to detect early features of BA can be developed.
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Affiliation(s)
- Sanjiv Harpavat
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | - Philip J. Lupo
- Department of Pediatrics, Division of Hematology and Oncology
| | - Loriel Liwanag
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | - John Hollier
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | | | - Milton J. Finegold
- Department of Pathology, Baylor College of Medicine and Texas
Children’s Hospital
| | - Benjamin L. Shneider
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
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Hodgson JM, van Someren VH, Smith C, Goyale A. Direct bilirubin levels observed in prolonged neonatal jaundice: a retrospective cohort study. BMJ Paediatr Open 2018; 2:e000202. [PMID: 29637188 PMCID: PMC5843007 DOI: 10.1136/bmjpo-2017-000202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Prolonged neonatal jaundice is common and usually benign; however, assessment of bilirubin fractions is recommended to determine the need for further assessment for congenital liver disease, particularly biliary atresia. The direct (conjugated) bilirubin thresholds currently used are variable and poorly evidenced. Hence, we aimed to delineate direct bilirubin levels in disease-free neonates with prolonged jaundice. METHODS We performed a retrospective cohort analysis of split bilirubin levels, and subsequent follow-up, for all neonates initially assessed in our prolonged neonatal jaundice clinic over 2 years. We plotted centile charts for total, direct and direct-total bilirubin ratio levels against age at sampling. The association was assessed using linear regression analysis. RESULTS Data were collected for 420 neonates (501 blood samples) across an age range of 10-70 days. No significant liver disease was found. For each day of older age, total bilirubin fell by 3.72 µmol/L (95% CI 2.46 to 5.00) and direct bilirubin fell by 0.39 µmol/L (0.18 to 0.59). The ratio between the two did not change significantly (-0.0006 to +0.0034). The 95th centile for direct bilirubin was stable at ~25 µmol/L. Direct-total bilirubin ratio was very variable with some 95th centiles >30%. CONCLUSIONS In a clinically relevant population of disease-free neonates with prolonged jaundice both the total and the direct bilirubin decreased with age. The absolute direct bilirubin is more useful clinically than the direct-total bilirubin ratio. Our results support National Institute for Health and Care Excellence guidance that conjugated bilirubin >25 µmol/L, or even more stringent criteria, constitutes an appropriate threshold for further investigation for neonatal liver disease.
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Affiliation(s)
- Joshua Mark Hodgson
- Paediatrics and Child Health, Royal Free London NHS Foundation Trust, London, UK
| | | | - Colette Smith
- Research Department of Infection and Population Health, University College London, London, UK
| | - Atul Goyale
- Clinical Biochemistry, Royal Free London NHS Foundation Trust, London, UK
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Shen Z, Zheng S, Dong R, Chen G. Objectification of facial color inspection to differentiate obstructive/nonobstructive jaundice in neonates by spectrophotometer. J Pediatr Surg 2017; 52:1981-1983. [PMID: 28958715 DOI: 10.1016/j.jpedsurg.2017.08.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/28/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to study whether color difference in facial color truly exists between neonates with obstructive and nonobstructive jaundice, and whether the color difference could be objectified by spectrophotometer. METHODS Twelve biliary atresia patients were enrolled in an obstructive jaundice group and 15 neonates admitted for non-conjugated hyperbilirubinemia in a nonobstructive group. Nine patients with syphilis (n=6) and sacrococcygeal teratoma (n=3) were studied as control. Transcutaneous total bilirubin (TB) and hemoglobin were recorded. Face color was measured by spectrophotometer. Spectral reflection curve and L*a*b* model parameters were studied. RESULTS Facial color of jaundiced neonates were characteristic in waveform that reflectivity at wavelength of 550nm was significantly decreased compared with control by 16.4±3.4%, while not significantly different between obstructive and nonobstructive jaundice (p=0.124). At 650nm, reflection in nonobstructive jaundice was decreased by 8.4±2.3% (p<0.01), and reflection in obstructive jaundice was (9.6±3.2) % lower compared with nonobstructive jaundice (p<0.01). In L*a*b* model, mean color difference between obstructive and nonobstructive jaundice was 9.60. L* was significantly different: control (71.84±3.75%)>obstructive jaundice (58.09±1.25%)>nonobstructive jaundice (54.25±7.27%). Value b* was higher in jaundiced patients compared to normal control (11.88±2.16, p<0.001), but not significantly different in obstructive and nonobstructive jaundice (20.12±2.17vs18.25±4.58). Value a* was not significantly different between normal control (5.57±2.38) and obstructive jaundice (5.25±1.19), but was lower than nonobstructive jaundice (14.03±3.29, p<0.001). TB was significantly correlated with b* (R=0.526, p=0.014), while hemoglobin was correlated with a* (R=0.791, p<.001) and L* (R=-0.707, p<.001). CONCLUSIONS Obstructive and nonobstructive jaundice could be objectively differentiated through facial color inspection by spectrophotometer. TYPE OF STUDY Study of Diagnostic Test. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Zhen Shen
- Department of Surgery, Children's Hospital of Fudan University, Shanghai, PR China
| | - Shan Zheng
- Department of Surgery, Children's Hospital of Fudan University, Shanghai, PR China.
| | - Rui Dong
- Department of Surgery, Children's Hospital of Fudan University, Shanghai, PR China
| | - Gong Chen
- Department of Surgery, Children's Hospital of Fudan University, Shanghai, PR China
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Abstract
Early diagnosis followed by proper KP is essential for the improvement of long-term prognosis for patients with BA. It is increasingly accepted that KP at ≤ 30 days of age significantly improves native liver survival rate. Published analyses in English and Japanese indicate that screening by SCC and DB/CB is potentially feasible. Screening with SCC has been implemented in Tochigi Prefecture, Japan, since 1994. The concept of SCC was introduced from Japan to Taiwan and resulted in nationwide screening with SCC for the first time in Taiwan in 2004, followed by Japan in 2012. Home-based screening using SCC is easy and cost-effective; however, it may cause some difficulties for families in case of stools with intermediate colors. Laboratory-based screening using DB/CB may detect the suspected cases earlier, resulting in an increase in the number of patients with BA who undergo KP at ≤ 30 days of age; however, the recall rate is 1% and may be beyond an acceptable range. Further studies are needed to assess the feasibility and cost-effectiveness of both home-based (SCC) and laboratory-based (DB/CB) screening for BA.
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Affiliation(s)
- Akira Matsui
- Graduate School of Nursing Science, St. Luke's International University, 3-8-5 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Sánchez-Redondo Sánchez-Gabriel MD, Leante Castellanos JL, Benavente Fernández I, Pérez Muñuzuri A, Rite Gracia S, Ruiz Campillo CW, Sanz López E, Sánchez Luna M. Guidelines for prevention, detection and management of hyperbilirubinaemia in newborns of 35 or more weeks of gestation. An Pediatr (Barc) 2017. [DOI: 10.1016/j.anpede.2017.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Chiou FK, Ong C, Phua KB, Chedid F, Kader A. Conjugated hyperbilirubinemia presenting in first fourteen days in term neonates. World J Hepatol 2017; 9:1108-1114. [PMID: 28989567 PMCID: PMC5612842 DOI: 10.4254/wjh.v9.i26.1108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/06/2017] [Accepted: 09/07/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the etiology and characteristics of early-onset conjugated hyperbilirubinemia (ECHB) presenting within 14 d of life in term neonates.
METHODS Retrospective review was performed of term infants up to 28-d-old who presented with conjugated hyperbilirubinemia (CHB) at a tertiary center over a 5-year period from January 2010 to December 2014. CHB is defined as conjugated bilirubin (CB) fraction greater than 15% of total bilirubin and CB greater or equal to 25 μmol/L. ECHB is defined as CHB detected within 14 d of life. “Late-onset” CHB (LCHB) is detected at 15-28 d of life and served as the comparison group.
RESULTS Total of 117 patients were recruited: 65 had ECHB, 52 had LCHB. Neonates with ECHB were more likely to be clinically unwell (80.0% vs 42.3%, P < 0.001) and associated with non-hepatic causes (73.8% vs 44.2%, P = 0.001) compared to LCHB. Multifactorial liver injury (75.0%) and sepsis (17.3%) were the most common causes of ECHB in clinically unwell infants, majority (87.5%) had resolution of CHB with no progression to chronic liver disease. Inborn errors of metabolism were rare (5.8%) but associated with high mortality (100%) in our series. In the subgroup of clinically well infants (n = 13) with ECHB, biliary atresia (BA) was the most common diagnosis (61.5%), all presented initially with normal stools and decline in total bilirubin but with persistent CHB.
CONCLUSION Secondary hepatic injury is the most common reason for ECHB. BA presents with ECHB in well infants without classical symptoms of pale stools and deep jaundice.
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Affiliation(s)
- Fang Kuan Chiou
- Gastroenterology Service, Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Christina Ong
- Gastroenterology Service, Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Kong Boo Phua
- Gastroenterology Service, Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Fares Chedid
- Neonatal Medicine, Al Jalila Children’s Specialty Hospital, Dubai, United Arab Emirates
| | - Ajmal Kader
- Pediatric Gastroenterology, Dubai Hospital, Dubai, United Arab Emirates
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[Guidelines for prevention, detection and management of hyperbilirubinaemia in newborns of 35 or more weeks of gestation]. An Pediatr (Barc) 2017; 87:294.e1-294.e8. [PMID: 28526241 DOI: 10.1016/j.anpedi.2017.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/13/2017] [Indexed: 11/22/2022] Open
Abstract
Hyperbilirubinaemia is one of the most frequent causes of hospital readmission during the first week of life. Its detection is still a big challenge, mainly due to the early discharge from the hospital that can be associated with a delay of the diagnosis. The identification of those newborns at risk of developing significant hyperbilirubinaemia is one of the main priorities in the public health care system. An approach to the management of newborn jaundice is presented in this article, following the recommendations based on the medical evidence and on the opinion of the Standards Committee of the Spanish Society of Neonatology.
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Sloane AJ, Nawab US, Carola D, Aghai ZH. Utility of measuring direct bilirubin at first 72 h of age in neonates admitted to the neonatal intensive care unit. J Perinatol 2017; 37:536-540. [PMID: 28125097 PMCID: PMC5646268 DOI: 10.1038/jp.2016.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 11/21/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the utility of measuring direct bilirubin (DB) during the first 72 h of life in infants admitted to the neonatal intensive care unit (NICU). STUDY DESIGN Infants born between May 2006 and June 2013, and admitted to the NICU were included. Abnormal DB was defined as: DB level⩾1 mg dl-1 with a corresponding TB of ⩽5 mg dl-1 or DB level >20% of the corresponding TB>5 mg dl-1. RESULTS The DB levels were measured in 3715 infants during the first 72 h of life. Sixty-three infants (1.7%) had abnormal DB. In a number of infants with potentially treatable diseases (biliary atresia and choledochal cyst), the only abnormal finding was a mildly elevated DB (1 to 2 mg dl-1) during the first 3 days of life. In 22 infants (35%), the cause for high DB was unknown (16%) or not investigated (19%). CONCLUSIONS Routine measurement of DB in neonates admitted to NICU may be helpful in identifying potentially treatable causes of cholestasis.
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Lam L, Musaad S, Kyle C, Mouat S. Utilization of Reflex Testing for Direct Bilirubin in the Early Recognition of Biliary Atresia. Clin Chem 2017; 63:973-979. [DOI: 10.1373/clinchem.2016.268532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/11/2017] [Indexed: 01/21/2023]
Abstract
Abstract
BACKGROUND
Delayed diagnosis of biliary atresia is an important cause of pediatric end-stage liver failure and liver transplantation. We sought to determine whether direct bilirubin is underutilized by retrospectively reviewing patients with biliary atresia. Further, we aimed to determine the role of reflex testing for direct bilirubin in patients suspected for jaundice.
METHODS
The time intervals between total bilirubin and direct bilirubin measurements were retrospectively reviewed in patients with biliary atresia. We also audited the results of two major laboratories that had implemented reflex testing for direct bilirubin. We evaluated the clinical impact and cost of reflex testing in infants with increased direct bilirubin (>1.5 mg/dL; >25 μmol/L).
RESULTS
In patients with known biliary atresia, an isolated total bilirubin measurement preceded direct bilirubin measurement in 46% (40/87) of patients; with a median delay of 19 days (interquartile range 3–44 days). In the community setting, direct bilirubin had a higher clinical specificity for biliary atresia than in the hospital setting. Reporting direct bilirubin results in 1591 infants younger than 2 weeks of age in the community was associated with three admissions to the hospital, one of whom was diagnosed with biliary atresia. The cost for the two laboratories for direct-bilirubin testing was estimated at US$3200 (NZ$4600) for each newly diagnosed case of biliary atresia.
CONCLUSIONS
We identified underutilization of direct bilirubin as a cause of delay in the recognition of biliary atresia and show that reflex testing for direct bilirubin in jaundiced infants is a cost-effective solution.
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Affiliation(s)
- Leo Lam
- Department of Chemical Pathology, Labplus, Auckland City Hospital, Auckland, New Zealand
| | | | - Campbell Kyle
- Department of Chemical Pathology, Labplus, Auckland City Hospital, Auckland, New Zealand
- Department of Biochemistry, Labtests, Auckland, New Zealand
| | - Stephen Mouat
- Department of Paediatric Gastroenterology, Starship Hospital, Auckland, New Zealand
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Newborn Direct or Conjugated Bilirubin Measurements As a Potential Screen for Biliary Atresia. J Pediatr Gastroenterol Nutr 2016; 62:799-803. [PMID: 26720765 DOI: 10.1097/mpg.0000000000001097] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although screening for biliary atresia (BA) is associated with improved outcomes, no screening program currently exists in the United States. In this study, we explore the possibility of a screening strategy based on newborn direct or conjugated bilirubin (DB or CB) measurements. Our objective is to estimate testing's sensitivity and specificity for BA. METHODS Two groups were examined retrospectively. For sensitivity calculations, a BA group consisting of infants born between January 2011 and December 2014, diagnosed with BA, and cared for at a pediatric gastroenterology referral center was examined. For specificity calculations, a non-BA group that comprised of infants born between June 2009 and August 2011 in a hospital with a policy of checking newborn bilirubin concentrations was studied. RESULTS All 35 infants with newborn DB or CB measurements in the BA group had elevated concentrations, translating to a sensitivity of 100% (95% CI 87.7-100). In the non-BA group, 8936 of 9102 infants had DB concentrations within the laboratory's reference interval, translating to a specificity of 98.2% (95% CI 97.9-98.4). Three methods-calculating direct:total bilirubin ratios, using 99% reference intervals, and repeat testing-changed specificity to different degrees. CONCLUSIONS Newborn DB or CB measurements may have a high sensitivity and specificity for BA. Specificity can be further improved by using 99% reference intervals and/or repeat testing. Our findings can serve as the foundation for larger prospective studies, to determine whether newborn DB or CB measurements can be an effective screening strategy for BA.
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Biliary atresia: Clinical advances and perspectives. Clin Res Hepatol Gastroenterol 2016; 40:281-287. [PMID: 26775892 DOI: 10.1016/j.clinre.2015.11.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 11/03/2015] [Accepted: 11/16/2015] [Indexed: 02/04/2023]
Abstract
Biliary atresia (BA) is a rare and severe inflammatory and obliterative cholangiopathy that affects both extra- and intrahepatic bile ducts. BA symptoms occur shortly after birth with jaundice, pale stools and dark urines. The prognosis of BA has dramatically changed in the last decades: before the Kasai operation most BA patients died, while nowadays with the sequential treatment with Kasai operation±liver transplantation BA patient survival is close to 90%. Early diagnosis is very important since the chances of success of the Kasai procedure decrease with time. The causes of BA remain actually unknown but several mechanisms including genetic and immune dysregulation may probably lead to the obliterative cholangiopathy. Current research focuses on the identification of blood or liver factors linked to the pathogenesis of BA that could become therapeutic targets and avoid the need for liver transplantation. No similar disease leading to total obstruction of the biliary tree exists in older children or adults. But understanding the physiopathology of BA may highlight the mechanisms of other destructive cholangiopathies, such as sclerosing cholangitis.
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Abstract
Biliary atresia is the most common cause of pediatric end-stage liver disease and the leading indication for pediatric liver transplantation. Affected infants exhibit evidence of biliary obstruction within the first few weeks after birth. Early diagnosis and successful surgical drainage of bile are associated with greater survival with the child's native liver. Unfortunately, because noncholestatic jaundice is extremely common in early infancy, it is difficult to identify the rare infant with cholestatic jaundice who has biliary atresia. Hence, the need for timely diagnosis of this disease warrants a discussion of the feasibility of screening for biliary atresia to improve outcomes. Herein, newborn screening for biliary atresia in the United States is assessed by using criteria established by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Published analyses indicate that newborn screening for biliary atresia by using serum bilirubin concentrations or stool color cards is potentially life-saving and cost-effective. Further studies are necessary to evaluate the feasibility, effectiveness, and costs of potential screening strategies for early identification of biliary atresia in the United States.
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Effects of age at Kasai portoenterostomy on the surgical outcome: a review of the literature. Surg Today 2014; 45:813-8. [PMID: 25212566 DOI: 10.1007/s00595-014-1024-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 08/12/2014] [Indexed: 01/16/2023]
Abstract
The efficacy of early Kasai portoenterostomy has been repeatedly reported. However, the optimal age for performing this procedure remains controversial. This article reviews the literature on the age of patients at the time of Kasai portoenterostomy and its utility as a prognostic indicator. The age at the time of surgery is a known predictor of outcome; however, its exact predictive value in this context is unclear. Multicenter studies involving large volumes of data have tended to show advantages of early Kasai portoenterostomy, and there is no clear evidence to recommend any delay in the timing of surgery. At present, a reasonable strategy would be to perform a Kasai portoenterostomy as early as possible. The stool color card system has recently been implemented in Japan as part of a nationwide screening program, and it is expected to work well based on the early reports. However, efforts to identify an optimal screening system for ensuring the earliest diagnosis of biliary atresia should continue. An early diagnosis of biliary atresia is difficult, and global efforts are required to improve the early diagnosis rates.
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Schreiber RA, Masucci L, Kaczorowski J, Collet JP, Lutley P, Espinosa V, Bryan S. Home-based screening for biliary atresia using infant stool colour cards: a large-scale prospective cohort study and cost-effectiveness analysis. J Med Screen 2014; 21:126-32. [PMID: 25009198 DOI: 10.1177/0969141314542115] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Biliary atresia (BA), a leading cause of paediatric liver failure and liver transplantation, manifests by three weeks of life as jaundice with acholic stools. Poor outcomes due to delayed diagnosis remain a problem worldwide. We evaluated and assessed the cost-effectiveness of methods of introducing a BA Infant Stool Colour Card (ISCC) screening programme in Canada. SETTING AND METHODS A prospective study at BC Women's Hospital recruited consecutive healthy newborns through six incrementally more intensive screening approaches. Under the baseline "passive" strategy, families received ISCCs at maternity, with instructions to monitor infant stool colour daily and return the ISCC by mail at age 30 days. Additional strategies were: ISCC mailed to family physician; reminder letters or telephone calls to families or physicians. Random telephone surveys of ISCC non-returners assessed total card utilization. Primary outcome was ISCC utilization rate expressed as a composite outcome of the ISCC return rate and non-returned ISCC use. Markov modelling was used to predict incremental costs and life years gained from screening (passive and reminder), compared with no screening, over a 10-year time horizon. RESULTS 6,187 families were enrolled. Card utilization rates in the passive screening strategy were estimated at 60-94%. For a Canadian population, the increase in cost for passive screening, compared with no screening, is $213,584 and the gain in life years is 9.7 ($22,000 per life-year gained). CONCLUSIONS A BA ISCC screening programme targeting families of newborns is feasible in Canada. Passive distribution of ISCC at maternity is potentially effective and highly cost-effective.
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Affiliation(s)
- Richard A Schreiber
- Division of Pediatric Gastroenterology, Hepatology and Nutrition Department of Pediatrics, University of British Columbia, Vancouver, Canada Child and Family Research Institute, Vancouver, Canada
| | - Lisa Masucci
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Institute, BC, Canada
| | - Janusz Kaczorowski
- Dept of Family and Emergency Medicine, Université de Montréal and CRCHUM, Canada
| | - J P Collet
- Department of Pediatrics, University of British Columbia, Vancouver, Canada Child and Family Research Institute, Vancouver, Canada
| | - Pamela Lutley
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - Stirling Bryan
- School of Population & Public Health, University of British Columbia, Vancouver, Canada Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Institute, BC, Canada
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Zhou K, Lin N, Xiao Y, Wang Y, Wen J, Zou GM, Gu X, Cai W. Elevated bile acids in newborns with Biliary Atresia (BA). PLoS One 2012; 7:e49270. [PMID: 23166626 PMCID: PMC3498146 DOI: 10.1371/journal.pone.0049270] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 10/04/2012] [Indexed: 01/09/2023] Open
Abstract
Biliary Atresia (BA), a result from inflammatory destruction of the intrahepatic and extrahepatic bile ducts, is a severe hepatobiliary disorder unique to infancy. Early diagnosis and Kasai operation greatly improve the outcome of BA patients, which encourages the development of early screening methods. Using HPLC coupled tandem mass spectrometry, we detected primary bile acids content in dried blood spots obtained from 8 BA infants, 17 neonatal jaundice and 292 comparison infants at 3–4 days of life. Taurocholate (TC) was significantly elevated in biliary atresia infants (0.98±0.62 µmol/L) compared to neonatal jaundice (0.47±0.30 µmol/L) and comparison infants (0.43±0.40 µmol/L), with p = 0.0231 and p = 0.0016 respectively. The area under receiver operating characteristic (ROC) curve for TC to discriminate BA and comparison infants was 0.82 (95% confidence interval: 0.72–0.92). A cutoff of 0.63 µmol/L produced a sensitivity of 79.1% and specificity of 62.5%. The concentrations of total bile acids were also raised significantly in BA compared to comparison infants (6.62±3.89 µmol/L vs 3.81±3.06 µmol/L, p = 0.0162), with the area under ROC curve of 0.75 (95% confidence interval: 0.61–0.89). No significant difference was found between the bile acids of neonatal jaundice and that of comparison infants. The early increase of bile acids indicates the presentation of BA in the immediate newborn period and the possibility of TC as newborn screening marker.
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Affiliation(s)
- Kejun Zhou
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Shanghai Institute of Pediatric Research, Shanghai, China
| | - Na Lin
- Shanghai Institute of Pediatric Research, Shanghai, China
- Department of Pediatrics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yongtao Xiao
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Shanghai Institute of Pediatric Research, Shanghai, China
| | - Yang Wang
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Shanghai Institute of Pediatric Research, Shanghai, China
| | - Jie Wen
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Shanghai Institute of Pediatric Research, Shanghai, China
| | - Gang-Ming Zou
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Shanghai Institute of Pediatric Research, Shanghai, China
| | - XueFan Gu
- Shanghai Institute of Pediatric Research, Shanghai, China
- Department of Pediatrics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Cai
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
- Shanghai Institute of Pediatric Research, Shanghai, China
- * E-mail:
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Palermo JJ, Joerger S, Turmelle Y, Putnam P, Garbutt J. Neonatal cholestasis: opportunities to increase early detection. Acad Pediatr 2012; 12:283-7. [PMID: 22634076 PMCID: PMC3398230 DOI: 10.1016/j.acap.2012.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 03/23/2012] [Accepted: 03/28/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe primary care management of early and prolonged jaundice in otherwise-healthy term infants to identify opportunities to increase early diagnosis of cholestasis. METHODS Community-based pediatricians in St Louis, Missouri completed a mailed, anonymous, 29-item survey to assess practice demographics, timing of routine newborn office visits, and the management of early and prolonged neonatal jaundice. RESULTS A total of 108 of 230 (47%) of eligible physicians responded (mean years in practice, 15.3, SD, 9.4). More respondents were very familiar with national guidelines for management of early (49%) than prolonged (16%) neonatal jaundice. Eighty-six percent reported all newborns were checked with transcutaneous bilirubin before hospital discharge. For transcutaneous bilirubin results at 48 hours of 7, 10, 12 and 15 mg/dL, 1%, 26%, 70%, and 74% of respondents, respectively, would order a fractionated bilirubin. Although the first routine visit usually occurred in the first week after discharge, 25% of physicians reported the 2nd visit was routinely scheduled after 4 weeks of age. Ninety-four percent reported they would obtain a fractionated bilirubin for infants jaundiced beyond 4 weeks of age. If cholestasis was identified at 6 weeks of age, 32% would obtain additional testing without referral to a subspecialist. CONCLUSIONS Management of early and prolonged neonatal jaundice is variable. Current practices appear to miss opportunities for early diagnosis of cholestasis and referral that are unlikely to be addressed without redesigning systems of care.
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Affiliation(s)
- Joseph J. Palermo
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Shannon Joerger
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Yumirle Turmelle
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Peter Putnam
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Jane Garbutt
- Department of Pediatrics, Washington University, St. Louis, MO, United States
- Department of Medicine, Washington University, St. Louis, MO, United States
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Harpavat S, Finegold MJ, Karpen SJ. Patients with biliary atresia have elevated direct/conjugated bilirubin levels shortly after birth. Pediatrics 2011; 128:e1428-33. [PMID: 22106076 PMCID: PMC3387898 DOI: 10.1542/peds.2011-1869] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Healthy infants are thought to acquire biliary atresia (BA) in the first weeks of life. Because those diagnosed earlier have better outcomes, we were interested in determining the earliest time BA could be detected. We started by examining the immediate postnatal period, hypothesizing that newborns would not yet have acquired disease and still have normal direct/conjugated bilirubin (DB/CB) levels. PATIENTS AND METHODS Newborn DB/CB levels were obtained retrospectively from birth hospitals. Subjects with BA were born between 2007 and 2010 and cared for at Texas Children's Hospital. Those with BA splenic malformation syndrome or born prematurely were excluded. Control subjects were term newborns who later never developed neonatal liver disease. RESULTS Of the 61 subjects with BA, 56% had newborn DB/CB levels measured. All DB/CB levels exceeded laboratory norms and rose over time. At 24 to 48 hours of life, subjects with BA had mean DB levels significantly higher than those of controls (1.4 ± 0.43 vs. 0.19 ± 0.075 mg/dL, P < .0001), even while their mean total bilirubin (TB) levels remained below phototherapy limits. Finally, despite the elevated DB/CB levels, the majority of patients (79%) had normal DB:TB ratios ≤ 0.2. CONCLUSIONS Patients with BA have elevated DB/CB levels shortly after birth. To detect affected infants earlier and improve outcomes, the results suggest two possibilities: (1) screen all newborns for elevated DB/CB levels, rather than just those who appear jaundiced; and then (2) follow all newborns with elevated DB/CB levels, rather than just those with DB:TB ratios >0.2.
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Affiliation(s)
- Sanjiv Harpavat
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and
| | - Milton J. Finegold
- Department of Pathology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Saul J. Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and
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Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks' gestation) - Summary. Paediatr Child Health 2011; 12:401-18. [PMID: 19030400 DOI: 10.1093/pch/12.5.401] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hyperbilirubinemia is very common and usually benign in the term newborn infant and the late preterm infant at 35 and 36 completed weeks' gestation. Critical hyperbilirubinemia is uncommon but has the potential for causing long-term neurological impairment. Early discharge of the healthy newborn infant, particularly those in whom breastfeeding may not be fully established, may be associated with delayed diagnosis of significant hyperbilirubinemia. Guidelines for the prediction, prevention, identification, monitoring and treatment of severe hyperbilirubinemia are presented.
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Wadhwani SI, Turmelle YP, Nagy R, Lowell J, Dillon P, Shepherd RW. Prolonged neonatal jaundice and the diagnosis of biliary atresia: a single-center analysis of trends in age at diagnosis and outcomes. Pediatrics 2008; 121:e1438-40. [PMID: 18443020 DOI: 10.1542/peds.2007-2709] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Age at diagnosis is a modifiable risk factor in outcomes after hepatoportoenterostomy in biliary atresia; however, distinguishing biliary atresia from other more common causes of prolonged neonatal jaundice can be difficult. To focus attention on diagnosis of biliary atresia, we analyzed secular trends in the age at diagnosis, and other factors that might influence outcome. We performed a retrospective analysis of 55 consecutive infants with biliary atresia presenting to a single academic pediatric center over 15-year period from 1990 to 2004. The median age at diagnosis was 60 days (range: 21-152). In recent era (2000-2004), the median age was 69.0 days, compared with 48.5 days (1990-1994) and 59.5 days (1995-1999), respectively. Consistent with previous studies, the median age at diagnosis of those with poor outcomes (death or liver transplant) exceeded those with good outcomes after the hepatoportoenterostomy (72 vs 52 days, P < .001). The lack of improvement, or a concerning trends toward an increase in the age at diagnosis of biliary atresia, is perhaps attributable to neonatal follow-up practices. Efforts to make an earlier diagnose of this important condition deserve wider application and study.
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Affiliation(s)
- Sharad I Wadhwani
- Division of Gastroenterology, St Louis Children's Hospital, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri 63110, USA
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Abstract
Extra-hepatic biliary atresia occurs in approximately 1:15,000 live births leading to about 50 new cases/year in the UK. Presentation is with prolonged jaundice, usually in a term baby who develops signs of obstructive jaundice. Management has been improved by public and professional education to encourage early referral and diagnosis to facilitate initial surgery before 8 weeks of age. Surgical management is complementary and includes an attempt to restore biliary flow (the Kasai portoenterostomy) and liver transplantation if necessary. Medical management consists of antibiotics, ursodeoxycholic acid to encourage bile flow, fat soluble vitamin supplementation and nutritional support. Centralising surgery to specialised centres has improved survival of this potentially fatal disease to over 90% in the UK. Over half of infants undergoing portoenterostomy will clear the jaundice and have a greater than 80% chance of a good quality of life, reaching adolescence without transplantation. For those children developing intractable complications of cirrhosis and portal hypertension, liver transplantation provides a 90% chance of achieving normal life.
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Affiliation(s)
- Deirdre A Kelly
- The Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, UK.
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Sokol RJ, Shepherd RW, Superina R, Bezerra JA, Robuck P, Hoofnagle JH. Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop. Hepatology 2007; 46:566-81. [PMID: 17661405 PMCID: PMC3888317 DOI: 10.1002/hep.21790] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary atresia is the most common cause of end-stage liver disease in the infant and is the leading pediatric indication for liver transplantation in the United States. Earlier diagnosis (<30-45 days of life) is associated with improved outcomes following the Kasai portoenterostomy and longer survival with the native liver. However, establishing this diagnosis is problematic because of its rarity, the much more common indirect hyperbilirubinemia that occurs in the newborn period, and the schedule for routine infant health care visits in the United States. The pathogenesis of biliary atresia appears to involve immune-mediated fibro-obliteration of the extrahepatic and intrahepatic biliary tree in most patients and defective morphogenesis of the biliary system in the remainder. The determinants of the outcome of portoenterostomy include the age at surgery, the center's experience, the presence of associated congenital anomalies, and the postoperative occurrence of cholangitis. A number of screening strategies in infants have been studied. The most promising are early measurements of serum conjugated bilirubin and a stool color card given to new parents that alerts them and their primary care provider to alcholic stools. This report summarizes a National Institutes of Health workshop held on September 12 and 13, 2006, in Bethesda, MD, that addressed the issues of outcomes, screening, and pathogenesis of biliary atresia.
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Affiliation(s)
- Ronald J Sokol
- Department of Pediatrics, University of Colorado School of Medicine, The Children's Hospital, Denver, CO, USA.
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Barrington KJ, Sankaran K. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants. Paediatr Child Health 2007. [DOI: 10.1093/pch/12.suppl_b.1b] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lignes directrices pour la détection, la prise en charge et la prévention de l'hyperbilirubinémie chez les nouveau-nés à terme et peu prématurés (35 semaines d'âge gestationnel ou plus) – Résumé. Paediatr Child Health 2007. [DOI: 10.1093/pch/12.5.411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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