Rationalized assessment of prolonged jaundice is safe and cost-effective

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of a standardized protocol for the Management of Prolonged Neonatal Jaundice in a regional setting: an interventional quasi-experimental study

Background

Prolonged neonatal jaundice (PNNJ) is often caused by breast milk jaundice, but it could also point to other serious conditions (biliary atresia, congenital hypothyroidism). When babies with PNNJ receive a routine set of laboratory investigations to detect serious but uncommon conditions, there is always a tendency to over-investigate a large number of well, breastfed babies. A local unpublished survey in Perak state of Malaysia revealed that the diagnostic criteria and initial management of PNNJ were not standardized. This study aims to evaluate and improve the current management of PNNJ in the administrative region of Perak.

Methods

A 3-phase quasi-experimental community study was conducted from April 2012 to June 2013. Phase l was a cross-sectional study to review the current practice of PNNJ management. Phase ll was an interventional phase involving the implementation of a new protocol. Phase lll was a 6 months post-interventional audit. A registry of PNNJ was implemented to record the incidence rate. A self-reporting surveillance system was put in place to receive any reports of biliary atresia, urinary tract infection, or congenital hypothyroidism cases.

Results

In Phase I, 12 hospitals responded, and 199 case notes were reviewed. In Phase II, a new protocol was developed and implemented in all government health facilities in Perak. In Phase III, the 6-month post-intervention audit showed that there were significant improvements when comparing mean scores of pre- and post-intervention: history taking scores (p < 0.001), family history details (p < 0.05), physical examination documentation (p < 0.001), and total investigations done per patient (from 9.01 to 5.81, p < 0.001). The total number of patient visits reduced from 2.46 to 2.2 per patient. The incidence of PNNJ was found to be high (incidence rate of 158 per 1000 live births).

Conclusions

The new protocol standardized and improved the quality of care with better clinical assessment and a reduction in unnecessary laboratory investigations.

Trial registration

Research registration number: NMRR-12-105-11288.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1550-3) contains supplementary material, which is available to authorized users.

Transcutaneous Bilirubin Levels during the First Month of Life in Term and Late-preterm Newborns

OBJECTIVE

We aimed to develop a transcutaneous bilirubin (TcB) nomogram for assessment of the risk of significant hyperbilirubinemia and prolonged jaundice during the first month of life in term and late-preterm Turkish newborns.

METHODS

On the basis of the daily (3rd, 7th, 15th and 30th days) TcB measurements, 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentiles, and 5 percentile tracks were obtained. TcB measurements were made by a transcutaneous bilirubinometer (JaundiceDetector JH20-1C).

RESULTS

We screened 729 healthy term and late-preterm Turkish infants 3-30 days old and developed a nomogram of TcB levels. TcB level was ≥5 mg/dl in 41.98% and 25.9% of infants at age 15.0  ±  2.1 days and 30.9  ±  2.6 days, respectively. The TcB measurement-based nomogram values of the 97th percentiles (cutoff values) at age 15.0  ±  2.1 and 30.9  ±  2.6 days were 11.4 (10.82-12.13) mg/dl and 10.0 (9.40-10.70) mg/dl, respectively.

CONCLUSION

This nomogram can be used to determine the risk status of Turkish newborns regarding significant hyperbilirubinemia and prolonged jaundice on the basis of TcB measurement in the first month of life.

Is screening for urine infection in well infants with prolonged jaundice required? Local review and meta-analysis of existing data

BACKGROUND

The National Institute for Health and Care Excellence (NICE) neonatal jaundice guidance recommends a urine culture for investigation of babies with prolonged jaundice. However, the evidence cited for this guidance is limited. We aimed to review local data and the existing literature to identify evidence to either support or refute this guidance.

METHOD

We retrospectively reviewed 3 years of urine cultures from our outpatient prolonged jaundice clinic. We then conducted literature review with meta-analysis of studies presenting original data on urine tract infection (UTI) rates in jaundiced and prolonged jaundiced babies.

RESULTS

From our local data, none of the 279 patients met our unit clinical criteria for UTI. Literature review revealed considerable differences worldwide in UTI rates in both jaundiced and prolonged jaundiced cases. Using pooled data from our literature review and our local population, the incidence of UTI in prolonged jaundiced babies is 0.21% (95% CI 0.0% to 0.73%) in the UK. This is significantly lower than the figure indicated from the data from elsewhere in the world, 8.21% (95% CI 4.36% to 13.0%).

CONCLUSIONS

The findings both from our local data and the current literature do not support the practice of routine screening for urine infection in well babies with prolonged jaundice. In view of the above, we no longer include urine culture in screening of well infants with prolonged jaundice. We hope that NICE will re-examine the evidence and recommend changes to their guidance on the role of routine screening for urine infection in babies with prolonged jaundice.