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Fanello C, Lee SJ, Bancone G, Kayembe D, Ndjowo P, Badjanga B, Gornsawun G, Chotthanawathit P, Waithira N, White NJ, Onyamboko M. Prevalence and Risk Factors of Neonatal Hyperbilirubinemia in a Semi-Rural Area of the Democratic Republic of Congo: A Cohort Study. Am J Trop Med Hyg 2023; 109:965-974. [PMID: 37669757 PMCID: PMC10551084 DOI: 10.4269/ajtmh.23-0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/13/2023] [Indexed: 09/07/2023] Open
Abstract
Neonatal hyperbilirubinemia (NH) is a frequent condition that, if left untreated, can lead to neurological disability and death. We assessed the prevalence of NH and associated neonatal and maternal risk factors in 362 mothers and 365 newborns in a semi-rural area of the Democratic Republic of Congo. In addition, we explored the knowledge and practices of mothers regarding this condition. We collected demographic data, anthropometric data, and obstetric and medical anamneses. We examined newborns at birth and at 24, 48, and 72 hours and measured bilirubin at birth in umbilical cord and capillary blood and thereafter in capillary blood. Hemoglobin, hematocrit, ABO group, Rhesus factor, glucose-6-phosphate dehydrogenase (G6PD) deficiency, Hemoglobin S (HbS), and malaria were assessed in mothers and newborns. Among 296 newborns (all time points available), 5.7% developed NH (95% CI: 3.4-9.0) between 24 and 72 hours according to National Institute for Health and Care Excellence (NICE) UK guidelines. There was a significantly higher risk in newborns with G6PD deficiency (homo- and hemizygous adjusted Odd Ratio [aOR]: 21.0, 95% CI: 4.1-105.9), preterm births (aOR: 6.1, 95% CI: 1.4-26.9), newborns with excessive birth weight loss (aOR: 5.8, 95% CI: 1.4-23.2), and hyperbilirubinemia at birth (aOR: 14.8, 95% CI: 2.7-79.6). Newborns with feto-maternal ABO incompatibility and G6PD deficiency had significantly higher bilirubin at birth than others. More than 60% of mothers had adequate knowledge of NH, but compliance with phototherapy in the absence of symptoms was low. Although risk factors for NH are common in this area, prevalence was not high, suggesting a need for better case definition. Implementation of point-of-care devices for diagnosis and awareness programs on risk prevention could help reduce neonatal morbidity and mortality associated with hyperbilirubinemia in these areas.
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Affiliation(s)
- Caterina Fanello
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Kinshasa-Oxford Medical Research Unit, Kinshasa, Democratic Republic of Congo
| | - Sue Jean Lee
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Germana Bancone
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Daddy Kayembe
- Kinshasa-Oxford Medical Research Unit, Kinshasa, Democratic Republic of Congo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pauline Ndjowo
- Kinshasa-Oxford Medical Research Unit, Kinshasa, Democratic Republic of Congo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Benjamen Badjanga
- Kinshasa-Oxford Medical Research Unit, Kinshasa, Democratic Republic of Congo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Gornpan Gornsawun
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Paphapisa Chotthanawathit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Naomi Waithira
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas John White
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marie Onyamboko
- Kinshasa-Oxford Medical Research Unit, Kinshasa, Democratic Republic of Congo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
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Anne RP, Rahiman EA, Dudeja S, Kumar A. Diagnostic Accuracy of Cord Bilirubin to Predict the Need for Phototherapy in Healthy Neonates >35-Week Gestational Age: A Systematic Review and Meta-Analysis. J Clin Exp Hepatol 2023; 13:666-681. [PMID: 37440934 PMCID: PMC10333952 DOI: 10.1016/j.jceh.2022.11.011] [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: 09/17/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022] Open
Abstract
Objective Early discharge puts neonates at risk of delayed detection of jaundice and resulting neurological injury. In these neonates, we can use cord bilirubin to make predictions. In this meta-analysis, we assessed the diagnostic accuracy of cord bilirubin in predicting the need for phototherapy (AAP-2004 or NICE-2010 charts). Methods We searched the databases of PubMed, Embase, Cochrane Library, Google Scholar, and Index Medicus for Southeast Asian Region. We included all observational studies that assessed the diagnostic accuracy of cord bilirubin. A bivariate model was used to pool the data in prespecified range of cord bilirubin levels (<1.5 mg/dl, 1.5-2.0 mg/dl, 2.0-2.5 mg/dl, 2.5-3.0 mg/dl, and >3.0 mg/dl). Data were pooled separately for studies including all neonates (no risk stratification), high-risk neonates (Rh and/or ABO incompatibility only), and low-risk neonates (excluded Rh and ABO incompatibility). Results Of the 1990 unique records, we studied 153 full texts and included 54 studies in the meta-analysis. For all the three groups of studies, the highest diagnostic odds ratio was noted for a cord bilirubin cut-off of 2.5-3.0 mg/dl (all neonates: 22.5, 95% CI: 21.1, 22.9; high-risk neonates: 75.5, 95% CI: 63, 85.7; low-risk neonates: 91.9; 95% CI: 64, 134.14). Using the same cut-off, the studies including all neonates without risk stratification had a pooled sensitivity of 0.31 (95% CI: 0.18, 0.47) and a pooled specificity of 0.98 (0.96, 0.99) in predicting the need for phototherapy. In studies on high-risk neonates, the pooled sensitivity was 0.8 (0.39, 0.96) and pooled specificity was 0.95 (0.78, 0.99). In studies on low-risk neonates, the pooled sensitivity was 0.74 (0.39, 0.93) and pooled specificity of 0.97 (0.91, 0.99). We noted significant heterogeneity and a high risk of bias in the index test's conduct. Conclusion A cord bilirubin cut-off of 2.5-3 mg/dl has good diagnostic accuracy in predicting the need for phototherapy in neonates. Registration number CRD42020196216.
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Affiliation(s)
| | - Emine A. Rahiman
- All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India
| | - Sankalp Dudeja
- Sita Ram Bhartia Institute of Science and Research, New Delhi, India
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Şahan H, Gülaşı S, Mert MK, Çekinmez EK. The predictive significance of umbilical cord bilirubin and bilirubin/albumin ratio for neonatal jaundice in healthy term newborns. Turk J Med Sci 2023; 53:511-517. [PMID: 37476881 PMCID: PMC10387865 DOI: 10.55730/1300-0144.5611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/03/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND The aim of this study is to determine the value of the questions asked in routine follow-up, the cord blood bilirubin (CBB) and bilirubin/albumin (B/A) ratio in estimating the risk of developing hyperbilirubinemia. METHODS Term and healthy 217 newborns whose CBB and albumin could be obtained and whose needed to be measured bilirubin level at the 24thand 72nd hours of life were included. Nutrition, sex and nationality, consanguinity between parents, jaundice in the sibling (s), mother's medications were questioned. CBB and albumin, serum total bilirubin (STB), serum albumin and transcutaneous bilirubin (TcB) at the 24th and 72nd hours of life, were recorded. RESULTS CBB and cord B/A ratio, STB and serum B/A ratio, and TcB at the 24th and 72nd hours were found to be higher in the babies who received the phototherapy (p < 0.001 for all). The moderate positive correlation (correlation coefficient 0.383) at the 24th hour and strong positive correlation (correlation coefficient 0.759) at the 72nd hour between STB and TcB measurements was detected. In estimating the need for phototherapy the sensitivity and specificity of CBB were 74.2% and 56.5%, the sensitivity and specifity of cord B/A was 74.2%, and 61.8%. The cut-off value of CBB in estimating the need for phototherapy is 1.8, and the cut-off value of the cord B/A ratio is 0.56. When the cut-off value is 1.8 for the CCB and the cord B/A ratio is 0.56, the positive predictive values are low, but the negative predictive values are significantly high (92.9% and 93.5%, respectively) in determining the need for phototherapy. DISCUSSION CBB and B/A ratio are important in predicting the possibility of indirect hyperbilirubinemia (IHB) development. Babies should be followed closely in terms of IHB development when their CBB value is 1.8 mg/dL and above, and the cord blood B/A ratio is 0.56 and above.
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Affiliation(s)
- Handan Şahan
- Department of Pediatrics, Faculty of Medicine, Health Sciences University, Adana City Training and Research Hospital, Adana, Turkey
| | - Selvi Gülaşı
- Department of Pediatrics, Faculty of Medicine, Health Sciences University, Adana City Training and Research Hospital, Adana, Turkey
| | - Mustafa Kurthan Mert
- Department of Pediatrics, Faculty of Medicine, Health Sciences University, Adana City Training and Research Hospital, Adana, Turkey
| | - Eren Kale Çekinmez
- Department of Pediatrics, Faculty of Medicine, Health Sciences University, Adana City Training and Research Hospital, Adana, Turkey
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Hajjaj OI, Clarke G, Lieberman L. Immunohematology testing using umbilical cord blood: review of the literature, survey of practice and guidance development. Transfusion 2022; 62:871-886. [PMID: 35322408 DOI: 10.1111/trf.16834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Omar I Hajjaj
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Gwen Clarke
- Canadian Blood Services, Laboratory Services, Ottawa, Ontario, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Kardum D, Serdarušić I, Biljan B, Šantić K, Živković V, Kos M. Cord blood bilirubin and prediction of neonatal hyperbilirubinemia and perinatal infection in newborns at risk of hemolysis. J Pediatr (Rio J) 2021; 97:440-444. [PMID: 33049218 PMCID: PMC9432075 DOI: 10.1016/j.jped.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To assess the accuracy of umbilical cord bilirubin values to predict jaundice in the first 48h of life and neonatal infection. METHOD Newborn infants treated at a regional well-baby nursery born at ≥36 weeks of gestation were included in this retrospective cohort study. All infants born in a 3-year period from mothers with O blood type and/or Rh-negative were included and had the umbilical cord bilirubin levels measured. Hyperbilirubinemia in the first 48h was defined as bilirubin levels above the phototherapy threshold. Neonatal infection was defined as any antibiotic treatment before discharge. RESULTS A total of 1360 newborn infants were included. Two hundred and three (14.9%) newborn infants developed hyperbilirubinemia in the first 48h of life. Hyperbilirubinemic infants had smaller birth weight, higher levels of umbilical cord bilirubin, a higher rate of infection and were more often direct antiglobulin test positive. Umbilical cord bilirubin had a sensitivity of 76.85% and a specificity of 69.58% in detecting hyperbilirubinemia in the first 48h, with the cut-off value at 34μmol/L. The area under the receiver operating characteristic curve was 0.80 (95% CI: 0.78-0.82). Umbilical cord bilirubin had a sensitivity of 27.03% and specificity of 91.31% in detecting perinatal infection. The area under the receiver operating characteristic (ROC) curve was 0.59 (95% CI: 0.57-0.63). CONCLUSIONS A positive correlation was found between umbilical cord bilirubin and hyperbilirubinemia in the first 48h of life. Umbilical cord bilirubin is a poor marker for predicting neonatal infection.
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Affiliation(s)
- Darjan Kardum
- University Hospital Osijek, Department of Pediatrics, Osijek, Croatia; J. J. Strossmayer University of Osijek, School of Medicine, Osijek, Croatia.
| | - Ivana Serdarušić
- University Hospital Osijek, Department of Pediatrics, Osijek, Croatia; J. J. Strossmayer University of Osijek, School of Medicine, Osijek, Croatia
| | - Borna Biljan
- University Hospital Osijek, Department of Pediatrics, Osijek, Croatia; J. J. Strossmayer University of Osijek, School of Medicine, Osijek, Croatia
| | - Krešimir Šantić
- University Hospital Osijek, Department of Pediatrics, Osijek, Croatia; J. J. Strossmayer University of Osijek, School of Medicine, Osijek, Croatia
| | - Vinko Živković
- University Hospital Osijek, Department of Pediatrics, Osijek, Croatia
| | - Martina Kos
- University Hospital Osijek, Department of Pediatrics, Osijek, Croatia; J. J. Strossmayer University of Osijek, School of Medicine, Osijek, Croatia
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Birhanu MY, Workineh AA, Molla Y, Abebaw E, Arora A, Bazezew Y. Rate and Predictors of Neonatal Jaundice in Northwest Ethiopia: Prospective Cohort Study. J Multidiscip Healthc 2021; 14:447-457. [PMID: 33654404 PMCID: PMC7910087 DOI: 10.2147/jmdh.s298034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/04/2021] [Indexed: 12/26/2022] Open
Abstract
Background Neonatal jaundice is one of the most common clinical disorders occurred worldwide. About 1.1 million neonates develop jaundice per year globally and the vast majority of them found in sub-Saharan Africa and South Asia. There is a paucity of evidence on the incidence rate and predictors of neonatal jaundice in Ethiopia. Therefore, this study was aimed at determining the rate and predictors of neonatal jaundice in the northwest, Ethiopia. Methods A prospective cohort study design was conducted at Debre Markos comprehensive, specialized Hospitals using 334 neonates from October 1, 2019, to June 30, 2020. Using a systematic random sampling technique, the study subjects were drawn. Data were entered into the Epi-DataTM Version 4.2 and analyzed using STATATM Version 14.0. The Kaplan-Meier survival curve was used to estimate the survival time. A generalized Log rank test was used to compare the survival curves of different categorical variables. Finally, both bi-variable and multivariable Cox-proportional hazards regression models were used to identify the predictors of neonatal jaundice. The Results The overall incidence rate of jaundice among neonates was 4.5 per 100 person-hours. Long duration of labor [ARR = 3.5; 95% confidence interval (CI), (2.8–8.7)], being male neonates [ARR= 5.2; 95% CI (3.5–7.3)], “O” blood group mothers [ARR = 4.5; 95% CI (3.4–10.3)], and having neonatal sepsis 3.4 [ARR=3.4; 95% CI: (2.5–6.1)] were predictors. Conclusion The incidence rate of jaundice was higher in this study than the finding of the previous one. Being male, prolonged duration of labor, “O” blood group mothers and sepsis were the significant predictors. Hence, an effort has to be made to decrease the incidence rate of neonatal jaundice through improving newborn care and timely intervention for neonates with sepsis and delivered at a long duration of time as well as the neonates born from “o” blood type mothers are our recommendation.
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Affiliation(s)
- Molla Yigzaw Birhanu
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Aytenew Atnaf Workineh
- Department of Medical Laboratory Sciences, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Yalew Molla
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Ermias Abebaw
- Department of Pediatrics, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Amit Arora
- School of Health Sciences, Western Sydney University, Penrith, NSW, 2751, Australia
| | - Yibelu Bazezew
- Department of Midwifery, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Fei F, Marques MB, Staley EM, Williams LA. An Automated Method for Direct Antiglobulin Testing and the Resulting Amount of Phototherapy Used at a Large Academic Medical Center. Lab Med 2020; 51:50-55. [PMID: 31150549 DOI: 10.1093/labmed/lmz029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate how clinical practice was affected by the change in direct antiglobulin testing (DAT) methodologies and subsequent stronger reported DAT results at our large academic medical center. METHOD We retrospectively reviewed DAT results of umbilical cord blood from infants with blood type A or B born to mothers with antibody-negative type O blood, based on records kept at the University of Alabama at Birmingham (UAB) Hospital, a 1400-bed academic medical center. RESULTS We randomly chose 50 neonates with positive DAT results who had been tested using the tube method and 50 whose testing had used the gel method. Although 86% of results with the tube method were positive microscopically, 52% and 40% of the DAT results with the gel method were 1+ and 2+ positive, respectively. Further, we observed an increase in the number of neonates treated with phototherapy who had been tested using the gel method. CONCLUSION We report that DATs performed using the gel method had increased DAT strength compared with tube testing, which led to increased use of phototherapy by our clinical colleagues.
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Affiliation(s)
- Fei Fei
- Department of Pathology, University of Alabama at Birmingham
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Zanardo V, Simbi AK, Parotto M, Guerrini P, Severino L, Ferro S, Straface G. Umbilical cord bilirubin level and pre-discharge hyperbilirubinemia risk. J Matern Fetal Neonatal Med 2019; 34:1120-1126. [PMID: 31195862 DOI: 10.1080/14767058.2019.1627318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To assess whether arterial umbilical cord bilirubin (aUCB) level at delivery predicts predischarge neonatal hyperbilirubinemia, facilitating a safe discharge from the hospital. METHODS Prospective analysis of hospital biochemistry records identified near term and term infants with recorded aUCB and predischarge, at 36 h of life, capillary heal bilirubin (cHB), to identify those with a cutoff of bilirubin levels >9 mg/ml, >75th percentile on the nomogram of Bhutani et al. RESULTS Of 616 study neonates, median (IQR) aUCB and cHB levels were 1.5 mg % (IQR 0.7-2.2) and 7.7 mg % (IQR 6.6-8.9), respectively. The values resulted statistically correlated (Pearson correlation coefficient 0.26, p < .0001) and an increment of 1 mg/dl in aUCB was associated with an increment (Regression coefficient, 95% confidence interval) of mean cHB 0.49 (0.33-0.65, p < .0001). Among these, 143 (23.2%) neonates developed bilirubin levels >9 mg/ml at 36 h of life and multivariable analysis confirmed that cHB levels (OR 1.49, 95% CI 1.22-1.82; p < .0001) and vaginal delivery (OR 2.34, 95% CI 1.33-4.36; p = .005) were significantly associated with bilirubin levels >9 mg/ml. CONCLUSIONS These data suggest that aUCB should be added to the list of major risk factors for neonatal hyperbilirubinemia.
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Affiliation(s)
- Vincenzo Zanardo
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
| | - Alphonse K Simbi
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
| | - Matteo Parotto
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Pietro Guerrini
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
| | - Lorenzo Severino
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
| | - Sergio Ferro
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
| | - Gianluca Straface
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
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