Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns

Bilirubin measurements in neonates: uniform neonatal treatment can only be achieved by improved standardization

Measurement of total bilirubin (TBil) concentration in serum is the gold standard approach for diagnosing neonatal unconjugated hyperbilirubinemia. It is of utmost importance that the measured TBil concentration is sufficiently accurate to prevent under treatment, unnecessary escalation of care, or overtreatment. However, it is widely recognized that TBil measurements urgently require improvement in neonatal clinical chemistry. External quality assessment (EQA) programs for TBil assess for differences between laboratories and provide supporting evidence of significant differences between various methods, manufacturers and measurement platforms. At the same time, many countries have adopted or only slightly adapted the neonatal hyperbilirubinemia management guidelines from the USA or UK, often without addressing differences in the methodology of TBil measurements. In this report, we provide an overview of the components of bilirubin that are measured by laboratory platforms, the availability of current reference measurement procedures and reference materials, and the role of EQA surveys in this context. Furthermore, the current status of agreement in neonatal bilirubin against clinical decision thresholds is reviewed. We advocate for enhancements in accuracy and comparability of neonatal TBil measurements, propose a path forward to accomplish this, and reflect on the position of the International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Working Group Neonatal Bilirubin (WG-NB) in this matter.

Signal Quality in Continuous Transcutaneous Bilirubinometry

Bilirubin is a product of the metabolism of hemoglobin from red blood cells. Higher levels of bilirubin are a sign that either there is an unusual breaking down rate of red blood cells or the liver is not able to eliminate bilirubin, through bile, into the gastrointestinal tract. For adults, bilirubin is occasionally monitored through urine or invasive blood sampling, whilst all newborns are routinely monitored visually, or non-invasively with transcutaneous measurements (TcBs), due to their biological immaturity to conjugate bilirubin. Neonatal jaundice is a common condition, with higher levels of unconjugated bilirubin concentration having neurotoxic effects. Actual devices used in TcBs are focused on newborn populations, are hand-held, and, in some cases, operate in only two wavelengths, which does not necessarily guarantee reliable results over all skin tones. The same occurs with visual inspections. Based on that, a continuous bilirubin monitoring device for newborns is being developed to overcome visual inspection errors and to reduce invasive procedures. This device, operating optically with a mini-spectrometer in the visible range, is susceptible to patient movements and, consequently, to situations with a lower signal quality for reliable bilirubin concentration estimates on different types of skin. Therefore, as an intermediate development step and, based on skin spectra measurements from adults, this work addresses the device's placement status prediction as a signal quality indication index. This was implemented by using machine learning (ML), with the best performances being achieved by support vector machine (SVM) models, based on the spectra acquired on the arm and forehead areas.

Clinical Decision Support Tool to Promote Adoption of New Neonatal Hyperbilirubinemia Guidelines

OBJECTIVE

 This study aimed to increase the adoption of revised newborn hyperbilirubinemia guidelines by building a clinical decision support (CDS) tool into templated notes.

METHODS

 We created a rule-based CDS tool that correctly populates the phototherapy threshold from more than 2,700 possible values directly into the note and guides clinicians to an appropriate follow-up plan consistent with the new recommendations. We manually reviewed notes before and after CDS tool implementation to evaluate new guidelines adherence, and surveys were used to assess clinicians' perceptions.

RESULTS

 Postintervention documentation showed a decrease in old risk stratification methods (48 to 0.4%, p < 0.01) and an increase in new phototherapy threshold usage (39 to 95%, p < 0.01) and inclusion of follow-up guidance (28 to 79%, p < 0.01). Survey responses on workflow efficiency and satisfaction did not significantly change after CDS tool implementation.

CONCLUSION

 Our study details an innovative CDS tool that contributed to increased adoption of newly revised guidelines after the addition of this tool to templated notes.

Newborn Weight Loss Tool and Readmission for Hyperbilirubinemia

OBJECTIVE

The aim of this study was to determine if the Newborn Weight Loss Tool (NEWT) can predict hospital readmission due to hyperbilirubinemia.

STUDY DESIGN

This is a case-control study of 93 newborns and 186 controls ≥35 weeks' gestation. All were discharged from the Mother-Baby unit of an urban academic center and subsequently readmitted for hyperbilirubinemia. Controls were matched for date of birth, gestational age, and Bhutani risk zone. All infants were screened for hyperbilirubinemia prior to discharge and managed according to American Academy of Pediatrics guidelines in place at the time. Chi-square, Fisher's exact test, and multivariate analysis were utilized as appropriate.

RESULTS

There was no significant difference between the groups for a NEWT < 50% at discharge. More cases than controls breastfed. A significantly greater percentage of cases had NEWT > 50% at readmission than discharge. NEWT > 90% was moderately associated with readmission for hyperbilirubinemia (p = 0.081).

CONCLUSION

NEWT provides a more nuanced assessment of weight loss following birth and can aid in highlighting newborns at risk for readmission due to hyperbilirubinemia.

KEY POINTS

· Weight loss is a risk factor for readmission after birth.. · NEWT is a more nuanced assessment of weight loss.. · NEWT > 90% is associated with readmission for jaundice..

Evaluation of Myocardial Injury Using Serum Cardiac Troponin-I in Asphyxiated Neonates at Enugu State University Teaching Hospital, Enugu, South-East Nigeria

BACKGROUND

The burden of perinatal asphyxia remains high in our environment and when asphyxia is severe, vital organs are affected, with resultant multiorgan hypoxic-iscahemic injury to the heart, the brain, adrenals and other organs.

STUDY AIM

To evaluate for myocardial injury in asphyxiated term neonates with hypoxic ischaemic encephalopathy using serum cardiac troponin-I (cTnI).

METHODS

The study was a hospital-based descriptive cross-sectional study involving sixty term asphyxiated neonates and sixty gestational age-and sex-matched controls. The subjects were term neonates with five-minute Apgar score ≤ 6 and HIE while the controls were healthy term neonates with five-minute Apgar score > 6. Five-minute Apgar score was utilized to classify asphyxia into mild, moderate and severe asphyxia. The degree of encephalopathy was determined by modified Sarnat and Sarnat criteria. The serum cTnI was measured in subjects and controls at 12-24 hours of life using Enzyme-linked immunosorbent assay technique. The serum bilirubin levels were also measured in participants to exclude hyperbilirubinemia.

RESULTS

The median serum cTnI levels was significantly higher in the subjects (0.56ng/mL; 0.25-0.94ng/mL) than in the controls (0.50ng/mL; 0.00-0.67ng/mL), respectively; p=0.001. Similarly, the median serum cTnI level in HIE stage II (0.56ng/mL; 0.38-0.72ng/mL) or III (0.56ng/ml; 0.50-0.94ng/mL) was also significantly higher than the median value in HIE stage I (0.38ng/mL;0.25-0.72ng/mL) or in controls (0.50ng/mL; 0.00-0.67ng/mL); p<0.001. There was significant positive correlation between serum cTnI levels and severity of HIE in asphyxiated neonates (rs = 0.505, p < 0.001).

CONCLUSION

serum cTnI levels were elevated in severely asphyxiated neonates with HIE. The concentration of serum cTnI demonstrated significant positive correlation with HIE severity. Hence, the presence of HIE in asphyxiated neonates should prompt an evaluation for myocardial injury using serum cTnI. Any derangement noted should warrant instituting cardiovascular support in order to improve outcome and reduce asphyxia-related mortality.

Effect of HHFNC therapy on organ oxygenation and brain metabolism in neonates receiving exchange transfusion

Background

Exchange transfusion therapy is a complex and invasive procedure with a high risk coefficient. This method involves replacing the entire blood of a child with fresh blood with double circulating blood volume in a short period, typically in 1-2 h. This procedure can cause the body's internal environment to be unstable, which can put newborns under a lot of stress. This stress can lead to many, including abnormal laboratory biochemical examination, low or high blood pressure, and apnea. There is also the possibility of secondary infection and, in severe cases, cardiac arrest. This study investigated the effects of Humidified high-flow nasal cannula (HHFNC) ventilation on hemodynamic stability and oxygenation during exchange transfusion in neonates. Furthermore, the effects on brain metabolism and salivary cortisol during exchange transfusion were also analyzed.

Methods

In this study, the control group consisted of 45 cases of children who underwent simple blood exchange between 1 May 2017, and 31 December 2019 control group. The observation group consisted of 33 cases of children who underwent blood exchange under HHFNC support between 1 January 2020, and 30 April 2022. The study compared various physiological parameters between the control and the observation group. These included blood gas analysis, pulmonary artery pressure, ejection fraction, invasive mean arterial pressure, heart rate, cerebral oxygenation, intestinal oxygenation, renal oxygenation, and duration of blood exchange. Furthermore, the study also compared the changes in brain metabolic and salivary cortisol indicators between the two groups of children.

Results

The results did not reveal any significant difference in PH, PaO2, and duration of blood exchange between the control and the observation group. However, the observation group's invasive mean arterial pressure, ejection fraction, cerebral oxygenation, intestinal oxygenation, and renal oxygenation were higher than those of the control group. Furthermore, compared with the control group, the pulmonary artery pressure, heart rate, and PaCO2 were lower in the observation group. There was a statistically significant difference between the two groups of children in the relevant clinical indicators (total bilirubin, hemoglobin, SPO2, etc.) after exchange transfusion. After 1 h of blood exchange and after blood exchange, the salivary cortisol levels of the observation group were lower than the control group. The difference was statistically significant. The NAA/Cho and Cho/Cr values of the two groups of children were also significantly different.

Conclusion

During blood exchange, unstable hemodynamics substantially impact organ oxygenation. The results of this study suggest that HHFNC and specific ventilation pressure support can improve the respiratory rate and help maintain blood flow stability and organ oxygenation. This technique can also reduce adverse reactions caused by blood exchange, minimizing patient stress and reducing the impact on brain metabolism.

Transcutaneous bilirubinometry for detecting jaundice in term or late preterm neonates

BACKGROUND

The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and this has become the standard practice in both countries. However, the US Preventive Task Force has found no strong evidence to suggest that this practice of universal screening for bilirubin reduces the occurrence of significant outcomes such as bilirubin-induced neurologic dysfunction or kernicterus.

OBJECTIVES

To evaluate the effectiveness of transcutaneous screening compared to visual inspection for hyperbilirubinemia to prevent the readmission of newborns (infants greater than 35 weeks' gestation) for phototherapy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, ICTRP, and ISRCTN in June 2023. We also searched conference proceedings, and the reference lists of included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, or prospective cohort studies with control arm that evaluated the use of transcutaneous bilirubin (TcB) screening for hyperbilirubinemia in newborns before hospital discharge.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) and 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to evaluate the certainty of evidence.

MAIN RESULTS

We identified one RCT that met our inclusion criteria. The study included 1858 African newborns at 35 weeks' gestation or greater who were receiving routine care at a well-baby nursery, and were randomly recruited prior to discharge to undergo TcB screening. The study had good methodologic quality. TcB screening versus visual assessment of hyperbilirubinemia in newborns: - probably reduces readmission to the hospital for hyperbilirubinemia (RR 0.25, 95% CI 0.14 to 0.46; P < 0.0001; moderate-certainty evidence); - may have little or no effect on the rate of exchange transfusion (RR 0.20, 95% CI 0.01 to 14.16; low-certainty evidence); - probably increases the number of newborns who require phototherapy prior to discharge (RR 2.67, 95% CI 1.56 to 4.55; moderate-certainty evidence). - may have little or no effect on the rate of acute bilirubin encephalopathy (RR 0.33, 95% CI 0.01 to 8.18; low-certainty evidence). The study did not evaluate or report cost of care.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that TcB screening probably reduces hospital readmission for hyperbilirubinemia compared to visual inspection. Low-certainty evidence also suggests that TcB screening may have little or no effect on the rate of exchange transfusion compared to visual inspection. However, moderate-certainty evidence suggests that TcB screening probably increases the number of newborns that require phototherapy before discharge compared to visual inspection. Low-certainty evidence suggests that TcB screening may have little or no effect on the rate of acute bilirubin encephalopathy compared to visual inspection. Given that we have only identified one RCT, further studies are necessary to determine whether TcB screening can help to reduce readmission and complications related to neonatal hyperbilirubinemia. In settings with limited newborn follow-up after hospital discharge, identifying newborns at risk of severe hyperbilirubinemia before hospital discharge will be important to plan targeted follow-up of these infants.

National Needs Assessment of Utilization of Common Newborn Clinical Decision Support Tools

OBJECTIVE

Clinical decision support tools (CDSTs) are common in neonatology, but utilization is rarely examined. We examined the utilization of four CDSTs in newborn care.

STUDY DESIGN

A 72-field needs assessment was developed. It was distributed to listservs encompassing trainees, nurse practitioners, hospitalists, and attendings. At the conclusion of data collection, responses were downloaded and analyzed.

RESULTS

We received 339 fully completed questionnaires. BiliTool and the Early-Onset Sepsis (EOS) tool were used by > 90% of respondents, the Bronchopulmonary Dysplasia tool by 39%, and the Extremely Preterm Birth tool by 72%. Common reasons CDSTs did not impact clinical care included lack of electronic health record integration, lack of confidence in prediction accuracy, and unhelpful predictions.

CONCLUSION

From a national sample of neonatal care providers, there is frequent but variable use of four CDSTs. Understanding the factors that contribute to tool utility is vital prior to development and implementation.

KEY POINTS

· Clinical decision support tools are common in medicine.. · There is a varied use of neonatal CDST.. · Understanding the use of CDST is vital for future development..

Application of machine learning algorithms for accurate determination of bilirubin level on in vitro engineered tissue phantom images

Neonatal Jaundice is a common occurrence in neonates. High excess bilirubin would lead to hyperbilirubinemia, leading to irreversible adverse damage such as kernicterus. Therefore, it is necessary and important to monitor neonates' bilirubin levels in real-time for immediate intervention. However, current screening protocols have their inherent limitations, necessitating more convenient measurements. In this proof-of-concept study, we evaluated the feasibility of using machine learning for the screening of hyperbilirubinemia in neonates from smartphone-acquired photographs. Different machine learning models were compared and evaluated to gain a better understanding of feature selection and model performance in bilirubin determination. An in vitro study was conducted with a bilirubin-containing tissue phantom to identify potential biological and environmental confounding factors. The findings of this study present a systematic characterization of the confounding effect of various factors through separate parametric tests. These tests uncover potential techniques in image pre-processing, highlighting important biological features (light scattering property and skin thickness) and external features (ISO, lighting conditions and white balance), which together contribute to robust model approaches for accurately determining bilirubin concentrations. By obtaining an accuracy of 0.848 in classification and 0.812 in regression, these findings indicate strong potential in aiding in the design of clinical studies using patient-derived images.

Positive Direct Antiglobulin Test: Is It a Risk Factor for Significant Hyperbilirubinemia in Neonates with ABO Incompatibility?

OBJECTIVE

ABO blood group (ABO) incompatibility is a common cause of neonatal indirect hyperbilirubinemia. The direct antiglobulin test (DAT) can identify infants developing hemolytic disease. This study aims to evaluate the significance of DAT positivity among neonates with ABO incompatibility.

STUDY DESIGN

This retrospective study included 820 neonates with blood group A or B who were born to blood group O mothers. The study group consisted of neonates (n = 79) who had positive DAT, and the control group consisted of infants (n = 741) who had negative DAT. Demographic and clinical data of the neonates regarding jaundice were collected and compared statistically.

RESULTS

The bilirubin level at 24 hours of life (study group: 8 ± 2.6 mg/dL, control group: 6 ± 2.2 mg/dL, p < 0.001) and the highest bilirubin level (study group: 12.7 ± 3.6 mg/dL, control group: 10.4 ± 4.2 mg/dL, p < 0.001) were higher in infants with positive DAT. A total of 37 (46.8%) infants in the study group and 83 (11.2%) infants in the control group received phototherapy (PT) in the nursery (p < 0.001). In neonates with positive DAT, direct bilirubin level, duration of hospitalization, and PT in the nursery were higher (p = 0.002, <0.001, and <0.001, respectively), whereas hemoglobin level was lower (p < 0.001).

CONCLUSION

In neonates with ABO incompatibility, a positive DAT is a risk factor for developing significant hyperbilirubinemia. Close follow-up of newborn infants with ABO incompatibility is crucial for early detection and treatment of neonatal jaundice to avoid early and late complications.

KEY POINTS

· The clinical spectrum of ABO incompatibility varies widely.. · The ABO incompatibility with positive DAT are at greater risk for high bilirubin levels.. · Infants with blood group incompatibilities must be monitored closely..

Novel Two-Infusion Pump Technique for Exchange Transfusion in a Hyperbilirubinemic Neonate

Neonatal hyperbilirubinemia is a common concern in newborns, with ABO blood group incompatibility serving as a significant risk factor for severe jaundice. This case report outlines the successful management of a 2.5 kg female infant born to a primigravida mother with ABO incompatibility-induced hyperbilirubinemia. The neonate, born at 38.4 weeks via lower segment cesarean section, exhibited signs of jaundice at 91 hours of life, prompting screening and subsequent confirmation of serum bilirubin levels 26.4. The decision was made using the American Academy of Pediatrics (AAP) and categorized the child under high risk according to age and bilirubin level to implement a complete exchange transfusion using a novel approach with two infusion pumps. The unique aspect of this case lies in introducing a two-infusion pump technique, one to infuse and one to extract blood by inserting the IV set in opposite directions in the infusion pump to perform the exchange transfusion, aiming to minimize complications associated with traditional methods. Careful handling of umbilical venous and arterial lines, coupled with aseptic precautions, sought to mitigate the risk of sepsis. The procedure, conducted over two hours, demonstrated stability in vital signs and was monitored with a transcutaneous bilirubinometer. Post-transfusion, repeat serum bilirubin tests showed a decrease in bilirubin of 10.1, indicating the success of the novel exchange transfusion method. The infant was discharged after a five-day hospital stay, showcasing this innovative approach's potential efficacy and safety. This case contributes to the evolving strategies in neonatal care and emphasizes the importance of tailored interventions in managing hyperbilirubinemia associated with ABO incompatibility.

A Significant Increase in the Incidence of Neonatal Hyperbilirubinemia and Phototherapy Treatment Due to a Routine Change in Laboratory Equipment

CONTEXT.—

Total serum bilirubin (TSB) analysis is pivotal for diagnosing neonatal hyperbilirubinemia. Because of a routine change in laboratory equipment, our TSB assay changed from a diazo to a vanadate oxidase method. Upon implementation, TSB results were substantially higher in newborns than expected based on the validation.

OBJECTIVE.—

To investigate the application of TSB and intermethod differences in neonates and their impact on phototherapy treatment.

DESIGN.—

The diazo and vanadate methods were compared directly using neonatal and adult samples. Anonymized external quality control data were analyzed to explore interlaboratory differences among 8 commercial TSB assays. Clinical patient data were extracted from the medical records to investigate the number of newborns receiving phototherapy.

RESULTS.—

The mean bias of the vanadate versus the diazo TSB method was +17.4% and +3.7% in neonatal and adult samples, respectively. External quality control data showed that the bias of commercial TSB methods compared with the reference method varied from -3.6% to +20.2%. Within-method variation ranged from 5.2% to 16.0%. After implementation of the vanadate TSB method, the number of neonates treated with phototherapy increased approximately threefold.

CONCLUSIONS.—

Currently available TSB assays lack harmonization for the diagnosis of neonatal hyperbilirubinemia. Between-methods differences are substantially higher in neonatal compared with adult samples, highlighting the importance of including neonatal samples during assay validation. Close collaboration between laboratory specialists and clinicians is essential to prevent overtreatment or undertreatment upon the implementation of novel analyzers or assays. Also, harmonization of TSB assays, with an emphasis on neonatal application, is warranted.

Neonatal hyperbilirubinemia and repercussions on neurodevelopment: A systematic review

BACKGROUND

Accumulation of bilirubin above normal levels is considered a neurological risk factor for both premature and full-term newborns. This systematic review aimed to determine the effect of neonatal hyperbilirubinemia on neurodevelopment in preterm and full-term newborns.

METHODS

PubMed, EMBASE, Cochrane Library, CINAHL, PsycINFO, Scopus and Lilacs databases were searched for articles published until 1 June 2022. The quality of cohort and case-control studies was assessed with the Newcastle-Ottawa Scale, and the MINCir scale was used to evaluate the methodological quality of therapy studies or the therapeutic procedures. Premature neonates without neurological conditions and those born at term with hyperbilirubinemia as the sole risk factor were included. Studies reporting one or more neurodevelopmental outcomes were included with an inter-group comparison of a hyperbilirubinemia group versus a non-hyperbilirubinemia or non-pathological hyperbilirubinemia group. The main outcomes were auditory function, visual function, cognitive function, motor function, behavior, global development and neurological risk.

RESULTS

The search identified 951 studies, 19 of which (n = 2210 newborns) were finally included. Fifteen of the cohort and case-control studies presented low risk of bias, and six studies showed high methodological quality. Within the preterm population, hyperbilirubinemia as the sole risk factor was not shown to affect neurodevelopment. Auditory, neurological and motor development alterations were found in the population of full-term newborns with hyperbilirubinemia, which were more evident during the first year of life.

CONCLUSIONS

Elevated bilirubin levels may be a trigger for the onset of neurodevelopmental disorders in full-term infants during the first year of life. More studies are warranted in the preterm population with hyperbilirubinemia to draw conclusions about its impact on their neurodevelopment.

Updated Clinical Practice Guidelines for Management of Hyperbilirubinemia in Infants Born at 35 Weeks or More Gestation

Given the prevalence of jaundice in newborns, and the consequences of untreated hyperbilirubinemia, the long-awaited revised clinical practice guidelines for hyperbilirubinemia were finally released in August 2022 by the American Academy of Pediatrics as an update to the 2004 guidelines on the same topic. As new evidence and data become available, it is important for pediatricians and neonatologists to re-assess their clinical decision-making over time to ensure that patients are receiving the best care possible. With improvements in medical equipment and medical technology, and growing concerns about the overtreatment of hyperbilirubinemia, the newest clinical practice guidelines attempt to tackle the prevention, risk assessment, monitoring, and treatment of hyperbilirubinemia with these things in mind. [Pediatr Ann. 2023;52(12):e436-e439.].

Intrapartum Maternal Prophylactic Antimicrobial Treatment and Neonatal Jaundice

Intrapartum antibiotics are widely used and may potentially affect bilirubin levels and neurotoxicity in the newborn. The aim of this study was to examine the effect of intrapartum antibiotic exposure on neonatal jaundice. We retrospectively collected data from 972 neonates born to 963 mothers. Five hundred forty-five mothers (56.6%) received intrapartum antibiotics. There were no statistically significant differences in maximum bilirubin level (7.82 ± 3.65 vs 7.63 ± 3.71, P = .43) or need for phototherapy (9 [1.62%] vs 4 [0.94%], P = .52) between exposed and non-exposed newborns. The rate of phototherapy was significantly higher only in the group of infants born to mothers who received broad-spectrum antibiotics at 2 to 3.9 hours prior to delivery (χ2 = 10.453, P = .015) and was not higher in the group of exposure >4 hours, which may represent a short transient effect of antibiotics exposure on bilirubin turnover. Further studies are needed to validate this finding.

Risk factors for readmission for hyperbilirubinemia in neonates with ABO hemolytic disease: a single-center retrospective cohort study

OBJECTIVE

ABO hemolytic disease of the newborn (ABO-HDN) is a major risk factor for severe hyperbilirubinemia, a common readmission reason for newborns. In this study, we aimed to assess the risk factors for readmission associated with hyperbilirubinemia in neonates with ABO-HDN.

METHODS

A retrospective cohort study was conducted including newborns with gestational age ≥35 weeks and ABO-HDN in 2018. Among 291 newborns, 36 were readmitted for hyperbilirubinemia and defined as the readmission group. The remaining 255 cases were used as a control group. We then performed between-group comparisons of clinical conditions associated with hyperbilirubinemia. Logistic regression was used to select risk predictors of readmission associated with hyperbilirubinemia due to ABO-HDN.

RESULTS

Baseline characteristics were similar between both groups (p > .05, respectively). However, total serum bilirubin (TSB) before initiating phototherapy was significantly higher in the readmission group when compared with that in the control group at 0-24 h, 24-48 h, and 48-72 h (183.70 µmol/L [interquartile range (IQR) 161.18-196.48] vs. 150.35 µmol/L [IQR 131.73-175.38], p = .005; 229.90 µmol/L [IQR 212.45-284.30] vs. 212.50 µmol/L [IQR 197.85-230.28], p = .026; 268.10 µmol/L [IQR 257.70-279.05] vs. 249.50 µmol/L [IQR 236.80-268.70], p = .045, respectively). The age of initiation of phototherapy in the readmission group was significantly lower than that in control group (30.0 h [IQR 18.0-49.00] vs. 42.0 h [IQR 23.0-61.0], p = .012). The rate of rebound hyperbilirubinemia after the first phototherapy treatment was significantly higher in the readmission group compared to that in the control group (9 [25%] vs. 13 [5.1%], p = .000), and the rate of positive direct antiglobulin testing was significantly higher than that in control group (17 [47.2%] vs. 74 [29.0%], p = .027). Logistic regression analysis showed that the age of initiation of photography, TSB level before the first phototherapy, and rebound hyperbilirubinemia after first phototherapy were independent risk factors for readmission in newborns with hyperbilirubinemia associated with ABO-HDN.

CONCLUSIONS

Earlier age of phototherapy initiation, higher TSB levels at the time of initiating phototherapy and rebound hyperbilirubinemia after the first phototherapy treatment may increase the risk of readmission for hyperbilirubinemia in neonates with ABO-HDN. These factors should be considered in discharge planning and follow-up for newborns with ABO-HDN associated hyperbilirubinemia.

Race, Ethnicity, and Ancestry in Clinical Pathways: A Framework for Evaluation

Clinical algorithms, or "pathways," promote the delivery of medical care that is consistent and equitable. Race, ethnicity, and/or ancestry terms are sometimes included in these types of guidelines, but it is unclear if this is appropriate for clinical decision-making. At our institution, we developed and applied a structured framework to determine whether race, ethnicity, or ancestry terms identified in our clinical pathways library should be retained, modified, or removed. First, we reviewed all text and associated reference documents for 132 institutionally-developed clinical pathways and identified 8 pathways that included race, ethnicity, or ancestry terms. Five pathways had clear evidence or a change in institutional policy that supported removal of the term. Multispecialty teams conducted additional in-depth evaluation of the 3 remaining pathways (Acute Viral Illness, Hyperbilirubinemia, and Weight Management) by applying the framework. In total, based on these reviews, race, ethnicity, or ancestry terms were removed (n = 6) or modified (n = 2) in all 8 pathways. Application of the framework established several recommended practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether inclusion of the term is likely to mitigate or exacerbate existing inequities; and (4) exercise caution when applying population-level data to individual patient encounters. This process and framework may be useful to other institutional programs and national organizations in evaluating the inclusion of race, ethnicity, and ancestry in clinical guidelines.

Demystifying non-invasive approaches for screening jaundice in low resource settings: a review

All national and international pediatric guidelines universally prescribe meticulous bilirubin screening for neonates as a critical measure to mitigate the incidence of acute bilirubin encephalopathy (ABE) and Kernicterus. The prevailing gold standard for jaundice detection in neonates necessitates invasive blood collection, followed by subsequent biochemical testing. While the invasive procedure provides dependable bilirubin measurements and continues to be the sole gold standard diagnostic method for assessing bilirubin concentration. There exists a pressing need to innovate non-invasive screening tools that alleviate the sampling stress endured by newborns, mitigate iatrogenic anemia, and expedite the turnaround time for obtaining results. The exploration of non-invasive modalities for bilirubin measurements is gaining momentum, driven by the overarching goal of minimizing the number of pricks inflicted upon neonates, thereby rendering screening a swift, efficient, comfortable, and dependable process. This comprehensive review article delves extensively into the array of non-invasive approaches and digital solutions that have been proposed, implemented, and utilized for neonatal bilirubin screening, with a particular emphasis on their application in low-resource settings. Within this context, the review sheds light on the existing methodologies and their practical applications, with a specific focus on transcutaneous bilirubin meters. Moreover, it underscores the prevailing open challenges in this domain and outlines potential directions for future research endeavors. Notably, the review underscores the imperative need for robust educational programs targeted at both families and healthcare personnel to expedite the process of seeking timely care for neonatal jaundice. Additionally, it underscores the necessity for the development of enhanced screening and diagnostic tools that can offer greater accuracy in clinical practice.

Early-Term Neonates Demonstrate a Higher Likelihood of Requiring Phototherapy Compared to Those Born Full-Term

Early-term neonates (with a gestational age (GA) of 37 and 0/7 weeks to 38 and 6/7 weeks) face higher morbidities, including respiratory and neurodevelopmental issues, than full-term (39 and 0/7 weeks to 40 and 6/7 weeks) infants. This study explores whether hyperbilirubinemia necessitating phototherapy also differs between these groups. A retrospective study was conducted on neonates born from January 2021-June 2022, excluding those with specific conditions. Evaluated factors included GA, birth weight, bilirubin levels, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and feeding type, with phototherapy given as per AAP guidelines. Of 1085 neonates, 356 met the criteria. When stratifying the neonates based on the need for phototherapy, a higher proportion of early-term neonates required phototherapy compared to full-term (p < 0.05). After factoring in various risks (GA; birth weight; gender; feeding type; G6PD deficiency; transcutaneous bilirubin levels at 24 h and 24-48 h postpartum; maternal diabetes; and the presence of caput succedaneum or cephalohematoma), early-term neonates were more likely to need phototherapy than full-term babies (OR: 2.15, 95% CI: 1.21 to 3.80). The optimal cut-off for transcutaneous bilirubin levels 24-48 h postpartum that were used to predict phototherapy need was 9.85 mg/dl. In conclusion, early-term neonates are at a greater risk for developing jaundice and requiring phototherapy than full-term neonates. Monitoring bilirubin 24-48 h postpartum enhances early prediction and intervention.

A review of existing neonatal hyperbilirubinemia guidelines in Indonesia

BACKGROUND

Neonatal hyperbilirubinemia is one of the most common conditions for neonate inpatients. Indonesia faces a major challenge in which different guidelines regarding the management of this condition were present. This study aimed to compare the existing guidelines regarding prevention, diagnosis, treatment and monitoring in order to create the best recommendation for a new hyperbilirubinemia guideline in Indonesia.

METHODS

Through an earlier survey regarding adherence to the neonatal hyperbilirubinemia guideline, we identified that three main guidelines are being used in Indonesia. These were developed by the Indonesian Pediatric Society (IPS), the Ministry of Health (MoH), and World Health Organization (WHO). In this study, we compared factors such as prevention, monitoring, methods for identifying, risk factors in the development of neonatal jaundice, risk factors that increase brain damage, and intervention treatment threshold in the existing guidelines to determine the best recommendations for a new guideline.

RESULTS

The MoH and WHO guidelines allow screening and treatment of hyperbilirubinemia based on visual examination (VE) only. Compared with the MoH and WHO guidelines, risk assessment is comprehensively discussed in the IPS guideline. The MoH guideline recommends further examination of an icteric baby to ensure that the mother has enough milk without measuring the bilirubin level. The MoH guideline recommends referring the baby when it looks yellow on the soles and palms. The WHO and IPS guidelines recommend combining VE with an objective measurement of transcutaneous or serum bilirubin. The threshold to begin phototherapy in the WHO guideline is lower than the IPS guideline while the exchange transfusion threshold in both guidelines are comparably equal.

CONCLUSIONS

The MoH guideline is outdated. MoH and IPS guidelines are causing differences in approaches to the management hyperbilirubinemia. A new, uniform guideline is required.

A review of existing neonatal hyperbilirubinemia guidelines in Indonesia

Background

Neonatal hyperbilirubinemia is one of the most common conditions for neonate inpatients. Indonesia faces a major challenge in which different guidelines regarding the management of this condition were present. This study aimed to compare the existing guidelines regarding prevention, diagnosis, treatment and monitoring in order to create the best recommendation for a new hyperbilirubinemia guideline in Indonesia.

Methods

Through an earlier survey regarding adherence to the neonatal hyperbilirubinemia guideline, we identified that three main guidelines are being used in Indonesia. These were developed by the Indonesian Pediatric Society (IPS), the Ministry of Health (MoH), and World Health Organization (WHO). In this study, we compared factors such as prevention, monitoring, methods for identifying, risk factors in the development of neonatal jaundice, risk factors that increase brain damage, and intervention treatment threshold in the existing guidelines to determine the best recommendations for a new guideline.

Results

The MoH and WHO guidelines allow screening and treatment of hyperbilirubinemia based on visual examination (VE) only. Compared with the MoH and WHO guidelines, risk assessment is comprehensively discussed in the IPS guideline. The MoH guideline recommends further examination of an icteric baby to ensure that the mother has enough milk without measuring the bilirubin level. The MoH guideline recommends referring the baby when it looks yellow on the soles and palms. The WHO and IPS guidelines recommend combining VE with an objective measurement of transcutaneous or serum bilirubin. The threshold to begin phototherapy in the WHO guideline is lower than the IPS guideline while the exchange transfusion threshold in both guidelines are comparably equal.

Conclusions

The MoH guideline is outdated. MoH and IPS guidelines are causing differences in approaches to the management hyperbilirubinemia. A new, uniform guideline is required.

Validating the early phototherapy prediction tool across cohorts

Background

Hyperbilirubinemia of the newborn infant is a common disease worldwide. However, recognized early and treated appropriately, it typically remains innocuous. We recently developed an early phototherapy prediction tool (EPPT) by means of machine learning (ML) utilizing just one bilirubin measurement and few clinical variables. The aim of this study is to test applicability and performance of the EPPT on a new patient cohort from a different population.

Materials and methods

This work is a retrospective study of prospectively recorded neonatal data from infants born in 2018 in an academic hospital, Regensburg, Germany, meeting the following inclusion criteria: born with 34 completed weeks of gestation or more, at least two total serum bilirubin (TSB) measurement prior to phototherapy. First, the original EPPT-an ensemble of a logistic regression and a random forest-was used in its freely accessible version and evaluated in terms of the area under the receiver operating characteristic curve (AUROC). Second, a new version of the EPPT model was re-trained on the data from the new cohort. Third, the predictive performance, variable importance, sensitivity and specificity were analyzed and compared across the original and re-trained models.

Results

In total, 1,109 neonates were included with a median (IQR) gestational age of 38.4 (36.6-39.9) and a total of 3,940 bilirubin measurements prior to any phototherapy treatment, which was required in 154 neonates (13.9%). For the phototherapy treatment prediction, the original EPPT achieved a predictive performance of 84.6% AUROC on the new cohort. After re-training the model on a subset of the new dataset, 88.8% AUROC was achieved as evaluated by cross validation. The same five variables as for the original model were found to be most important for the prediction on the new cohort, namely gestational age at birth, birth weight, bilirubin to weight ratio, hours since birth, bilirubin value.

Discussion

The individual risk for treatment requirement in neonatal hyperbilirubinemia is robustly predictable in different patient cohorts with a previously developed ML tool (EPPT) demanding just one TSB value and only four clinical parameters. Further prospective validation studies are needed to develop an effective and safe clinical decision support system.

Hyperbilirubinemia Among Infants Born Preterm: Peak Levels and Association with Neurodevelopmental Outcomes

OBJECTIVE

To describe the distribution of peak bilirubin levels among infants born before 29 weeks of gestation in the first 14 days of life and to study the association between quartiles of peak bilirubin levels at different gestational ages and neurodevelopmental outcomes.

STUDY DESIGN

Multicenter, retrospective, nationwide cohort study of neonatal intensive care units in the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network, including neonates born preterm at 220/7 to 286/7 weeks of gestation born between 2010 and 2018. Peak bilirubin levels were recorded during the first 14 days of age. Main outcome was significant neurodevelopmental impairment, defined as cerebral palsy with Gross Motor Function Classification System ≥3, or Bayley III-IV scores of <70 in any domain, or visual impairment, or bilateral hearing loss requiring hearing aids.

RESULTS

Among 12 554 included newborns, median gestational age was 26 weeks (IQR 25-28) and birth weight was 920 g (IQR 750-1105 g). The median peak bilirubin values increased as gestational age increased (112 mmol/L [6.5 mg/dL] at 22 weeks and 156 mmol/L [9.1 mg/dL] at 28 weeks). Significant neurodevelopmental impairment was identified in 1116 of 6638 (16.8%) of children. Multivariable analyses identified an association between peak bilirubin in the highest quartile and neurodevelopmental impairment (aOR 1.27, 95% CI 1.01-1.60) and receipt of hearing aid/cochlear implant (aOR 3.97, 95%CI: 2.01-7.82) compared with the lowest quartile.

CONCLUSION

In this multicenter cohort study, peak bilirubin levels in neonates of <29 weeks of gestation increased with gestational age. Peak bilirubin values in the highest gestational age-specific quartile were associated with significant neurodevelopmental and hearing impairments.

Overdiagnosis of Newborn Hyperbilirubinemia: A Natural Experiment in Quality Improvement Fundamentals

Two hospitals noted increased newborn hyperbilirubinemia coinciding with an undisclosed total serum bilirubin (TSB) assay change. Clinicians rapidly applied quality improvement methodologies to ascertain increased jaundice evaluations, readmissions, and possible safety issues.

Methods

In January 2020, 2 hospitals (A and B) transitioned to a new method of measuring TSB using a new clinical chemistry analyzer (Siemens Atellica CH), which measured TSB by vanadate oxidase assay instead of the previous diazo assay. Five affiliated hospitals (C-G) continued to utilize the diazo assay. This natural experiment led to a comparison of data across the 7 hospitals. We analyzed: (1) TSB levels, (2) hospital hyperbilirubinemia readmissions, and (3) paired TSB measurements comparing the diazo assay and vanadate oxidase method.

Results

Compared to the 2019 baseline, Hospitals A and B had a significant increase in TSBs ≥17.0 mg/dl and TSBs ≥20 mg/dl in 2020; Hospitals C-G did not. Readmissions for phototherapy significantly increased in hospitals A and B in 2020 compared to 2019. Paired blood samples showed bias-elevated TSBs by vanadate assay compared to the diazo method. By 2021, the laboratory resumed processing TSB samples by diazo assay, and the frequency of elevated TSBs and hyperbilirubinemia readmissions returned to 2019 levels.

Conclusions

Factitious TSB elevation related to an assay change significantly increased newborn hyperbilirubinemia evaluations and phototherapy readmissions. Imbedded quality improvement methodologies of careful structure, process, and outcomes review hastened resolution.

Diagnostic Accuracy of Cord Bilirubin to Predict the Need for Phototherapy in Healthy Neonates >35-Week Gestational Age: A Systematic Review and Meta-Analysis

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.

Implementation of neonatal phototherapy with the BiliCocoon Bag® device in the maternity ward and impact on mother-infant separation

BACKGROUND

Free bilirubin jaundice is a frequent pathology in the neonatal period. The major complication is neurological toxicity, the most severe form of which is kernicterus. Overall, 5%-10% of jaundiced neonates require treatment. The first-line treatment is phototherapy, with intensive phototherapy being the gold standard. Other equipment is also available, including the BiliCocoon Bag®. It is a safe and controlled therapy that can be performed in the mother's room in the maternity ward, thereby avoiding separation and allowing for breast- or bottle-feeding during treatment. It is easy to install and does not require protective glasses, thus no scope or hospitalization. In our maternity ward, all neonates requiring intensive phototherapy are hospitalized in the neonatology ward.

OBJECTIVE

The objective of our study was to evaluate the number of avoided hospitalizations in neonatology for free bilirubin jaundice since the introduction, according to a strict protocol, of the BiliCocoon Bag® device.

MATERIAL AND METHOD

This was a single-center retrospective cohort study using data of newborns usually collected as part of standard care. Children born in our maternity ward during an 18-month period (August 1, 2020 to January 31, 2022) were included. Causes of jaundice, age at the beginning and mode of treatment, number of sessions for each device, and length of stay were compared. Results are presented as number and percentage with median (25th-75th) or mean (extremes) values for categorical and continuous variables, respectively. A t-test was used to compare the means of the independent groups.

RESULTS

A total of 316 newborns were included. Physiological jaundice was the main cause of jaundice. The median age for the first phototherapy treatment was 54.5 h (30-68). The 316 neonates needed 438 phototherapy sessions: 235 (74%) neonates required only one phototherapy session, 85 (36%) of them were treated with the BiliCocoon Bag®. For the 81 children who needed two or more phototherapy sessions, 19 children (23.5%) were treated by tunnel phototherapy and then the BiliCocoon Bag®, and eight children (10%) by BiliCocoon Bag® alone. The BiliCocoon Bag® enabled a relative reduction in the hospitalization rate of 38% and avoided hospitalization for approximately one third of the newborns treated. The BiliCocoon Bag® failure rate was 3.6% and the average length of stay was comparable between the two types of treatment.

CONCLUSION

Following a strict protocol of use, the BiliCocoon Bag® is a reliable method and a good alternative to intensive phototherapy for newborns in the maternity ward, as it avoids hospitalization and mother-infant separation.

Vitamin D metabolic pathway genes polymorphisms and vitamin D levels in association with neonatal hyperbilirubinemia in China: a single-center retrospective cohort study

BACKGROUND

Neonatal hyperbilirubinemia (NH) is a major cause of hospitalization after birth. Previous studies indicated that vitamin D deficiency might play an important role in NH susceptibility, but the results were controversial. Meanwhile, there has been limited description of the association between vitamin D related genes single nucleotide polymorphisms (SNP) and NH susceptibility. We aimed to investigate the vitamin D metabolic pathway genes polymorphisms and vitamin D levels with NH susceptibility.

METHODS

We retrospectively analyzed the clinical data, vitamin D levels and its metabolic pathway gene polymorphisms of 187 NH neonates and 149 controls at Tianjin Children's Hospital/Tianjin University Children's Hospital between April 2019 and August 2022. Vitamin D levels were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) method, and the genetic polymorphism of NADSYN1/DHCR7, GC, CYP2R1, CYP24A1 and CYP27B1 was detected by high resolution melting (HRM) analysis.

RESULTS

The frequency of vitamin D deficiency (25(OH)D < 15 ng/mL) was significantly increased in the NH group compared to controls. TT genotype of rs12785878 and GT genotype of rs10877012 were protective factors of vitamin D deficiency and NH, and GT genotype and dominant model carriers of rs12785878 had a higher risk of severe NH than the GG genotype carriers (GT genotype: OR: 2.43; 95% CI: 1.22-4.86; P = 0.012, dominant model: OR: 1.97; 95% CI: 1.04-3.73; P = 0.037). GC gene haplotype was associated with vitamin D deficiency. No significant SNP-SNP and SNP-vitamin D levels interaction combinations were found.

CONCLUSIONS

There were associations among NH, vitamin D deficiency and NADSYN1/DHCR7 and CYP27B1 polymorphisms, TT genotype of rs12785878 and GT genotype of rs10877012 could reduce the risk of vitamin D deficiency and NH. Furthermore, rs12785878 was significantly associated with severe NH.

Short-term outcomes of infants with hyperbilirubinemia-associated auditory neuropathy spectrum disorder in neonatal intensive care unit

OBJECTIVES

Hyperbilirubinemia is a high-risk factor for auditory neuropathy spectrum disorder (ANSD) as well as hearing loss in general. This study described the outcomes of hyperbilirubinemia-associated ANSD infants diagnosed in hearing screening in the neonatal intensive care unit (NICU).

METHODS

A total of 578 children with hyperbilirubinemia admitted to the NICU between October 2020 and October 2021 were included in this study. The distortion product otoacoustic emission (DPOAE) and automatic auditory brainstem response (AABR) were combined for hearing screening, and those who failed the DPOAE or/and AABR underwent an auditory brainstem response (ABR) test. Infants with ANSD were followed up for 12 months.

RESULTS

Forty infants (40/578, 6.9%) failed the DPOAE or/and AABR tests, of which, 13 (13/578, 2.2%) were diagnosed as ANSD, and 27 (27/578, 4.7%) were diagnosed as having sensorineural hearing loss (SNHL). Of the 13 ANSD infants followed up for 12 months, 7 recovered, 3 improved, 3 did not recover, and 1 was lost, equating to improved or recovered hearing in 75% (9/12) of ANSD infants at 12 months of age. Moreover, the maximum bilirubin in recovered or improved ANSD infants was 408.6 ± 129.0 μmol/L, while the maximum bilirubin in unrecovered ANSD infants was 749.3 ± 323.0 μmol/L. Furthermore, poorly differentiated and absent ABR waveforms were observed in 6 and 14 ears at 1 month, 2 ears were lost, 6 (6/6, 100.0%) and 6 (6/12, 50.0%) ears were recovered or improved at 12 months of age.

CONCLUSION

s: The incidence of hyperbilirubinemia associated-ANSD was 2.2% of infants screened in the NICU. ANSD caused by hyperbilirubinemia may be transient, with most infants improving or recovering hearing by 12 months of age. Infants with poorly differentiated ABR waveforms and low bilirubin concentration are more likely to recover and hearing aids are not recommended in hyperbilirubinemia-associated ANSD below 12 months of age.

The predictive significance of umbilical cord bilirubin and bilirubin/albumin ratio for neonatal jaundice in healthy term newborns

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.

Trajectory of serum bilirubin in offspring of women with gestational diabetes mellitus

AIMS

To investigate the trajectory of bilirubin from birth to the first 48 hours of life in neonates of women with gestational diabetes.

METHODS

In a cohort of 69 neonates of women with gestational diabetes, delivered at Policlinic Abano, Abano Terme, Italy, from October 2021 to May 2022, we conducted a case-control study (1:2 ratio) on total serum bilirubin (TSB) trajectory over the first 48 hours after birth. An ancillary analysis was conducted on arterial cord blood gas analysis at birth and on concurrent hemoglobin, hematocrit, lactate, glycemia, and bilirubin levels.

RESULTS

The neonates of women with gestational diabetes showed a significantly higher mean percent variation of TSB from birth to the first 48 hours of life (p=0.01), a finding supported by a higher, although not significant, TSB levels at 48 hours of life in comparison to controls (8.05±4.8 vs 8.05±4 mg%, p=0.082), and by a significantly lower cord TSB levels (2.3±0.9 vs 2.6 ±0.9 mg%, p=0.010).

CONCLUSIONS

The findings suggest that future primary studies on hyperbilirubinemia risk in neonates of women with gestational diabetes should consider the trajectory of TSB beyond the first 48 hours, adjusting for a more complete set of pre-pregnancy and gestational prognostic risk factors.

Development and evaluation clinical-radiomics analysis based on T1-weighted imaging for diagnosing neonatal acute bilirubin encephalopathy

Purpose

To investigate the value of clinical-radiomics analysis based on T1-weighted imaging (T1WI) for predicting acute bilirubin encephalopathy (ABE) in neonates.

Methods

In this retrospective study, sixty-one neonates with clinically confirmed ABE and 50 healthy control neonates were recruited between October 2014 and March 2019. Two radiologists' visual diagnoses for all subjects were independently based on T1WI. Eleven clinical and 216 radiomics features were obtained and analyzed. Seventy percent of samples were randomly selected as the training group and were used to establish a clinical-radiomics model to predict ABE; the remaining samples were used to validate the performance of the models. The discrimination performance was assessed by receiver operating characteristic (ROC) curve analysis.

Results

Seventy-eight neonates were selected for training (median age, 9 days; interquartile range, 7-20 days; 49 males) and 33 neonates for validation (median age, 10 days; interquartile range, 6-13 days; 24 males). Two clinical features and ten radiomics features were finally selected to construct the clinical-radiomics model. In the training group, the area under the ROC curve (AUC) was 0.90 (sensitivity: 0.814; specificity: 0.914); in the validation group, the AUC was 0.93 (sensitivity: 0.944; specificity: 0.800). The AUCs of two radiologists' and the radiologists' final visual diagnosis results based on T1WI were 0.57, 0.63, and 0.66, respectively. The discriminative performance of the clinical-radiomics model in the training and validation groups was increased compared to the radiologists' visual diagnosis (P < 0.001).

Conclusions

A combined clinical-radiomics model based on T1WI has the potential to predict ABE. The application of the nomogram could potentially provide a visualized and precise clinical support tool.

Validation of a smartphone-based screening tool (Biliscan) for neonatal jaundice in a multi-ethnic neonatal population

AIM

Neonatal jaundice is an important and prevalent condition that can cause kernicterus and mortality. This study validated a smartphone-based screening application (Biliscan) in detecting neonatal jaundice.

METHODS

A cross-sectional prospective study was conducted at the neonatal unit in a tertiary teaching hospital between August 2020 and October 2021. All babies born at the gestation of 35 weeks and above with clinical jaundice or are recommended for screening of jaundice within 21 days of post-natal age were recruited. Using Biliscan, images of the babies' skin over the sternum were taken against a standard colour card. The application uses feature extraction and machine learning regression to estimate the bilirubin level. Independent Biliscan bilirubin estimates (BsB) were made and compared with total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) levels. Bland Altman plots were used to establish the agreement between BsB and TSB, as well as TcB, using the clinically acceptable limits of agreement of ±35 μmol/L, which were defined a priori. Pearson correlation coefficient was assessed to establish the strength of the relationship between BsB versus TSB and TcB. Diagnostic accuracy was assessed through receiver operating characteristic curve analysis.

RESULTS

Sixty-one paired TSB-BsB and 85 paired TcB-BsB measurements were obtained. Bland Altman plot for the entire group showed that 54% (33/61) of the pairs of TSB and BsB readings and 66% (56/85) of the pairs of TcB and BsB readings were within the maximum clinically acceptable difference of 35 μmol/L. Pearson r for BsB versus TSB and TcB was 0.54 (P < 0.001) and 0.66 (P < 0.001) respectively. Compared with TSB, the recommended gold standard measure for jaundice, Biliscan has a sensitivity of 76.92% and specificity of 70.83% for jaundice requiring phototherapy. The positive and negative predictive values in term infants were 93.3% and 36.9%, respectively.

CONCLUSION

Our results suggest that there is moderate correlation and mediocre agreement between BsB and TSB, as well as TcB. Improvement to the application algorithm and further studies that include a larger population, and a wider range of bilirubin values are necessary before the tool may be considered for use in screening of jaundice in newborns.

ABO hemolytic disease of the newborn: a need for clarity and consistency in diagnosis

The diagnosis of ABO hemolytic disease of the newborn (ABO HDN) has been the subject of considerable debate and clinical confusion. Its use as an overarching default diagnosis for hyperbilirubinemia in all ABO incompatible neonates regardless of serological findings is problematic and lacks diagnostic precision. Data on hemolysis indexed by carbon monoxide (CO) levels in expired air (ETCOc) and blood (COHbc) support an essential role for a positive direct antiglobulin test (DAT) in making a more precise diagnosis of ABO HDN. A working definition that includes ABO incompatibility, significant neonatal hyperbilirubinemia, and a positive DAT is needed to gain clarity and consistency in the diagnosis of ABO HDN. Absent a positive DAT, the diagnosis of ABO HDN is suspect. Instead, a negative DAT in a severely hyperbilirubinemic ABO incompatible neonate should trigger an exhaustive search for an alternative cause, a search that may require the use of targeted gene panels.

Bilirubin Levels in Neonates ≥35 Weeks of Gestation Receiving Delayed Cord Clamping for an Extended Time-An Observational Study

OBJECTIVE

To describe bilirubin levels in neonates ≥35^0/7 gestational weeks, receiving delayed cord clamping (CC), in relation to the updated Bhutani nomogram.

STUDY DESIGN

This was a retrospective, observational study based on data from medical records and local data sheets. Singleton neonates, born vaginally at a gestational age ≥35^0/7, and with a registered time to CC and at least one registered bilirubin, were included. We excluded neonates with positive direct antiglobulin test or hemolytic disorders. Adjusted analyses were performed using ANOVA and linear or logistic regression.

RESULTS

We analyzed 558 neonates, mean gestational age (SD) 39.9 (1.3) weeks. CC was performed at a median (IQR) time of 6 (5-8) minutes. The dataset contained 1330 bilirubin measurements. Median (IQR) age at bilirubin measurement was 37 (22-54) hours. Bilirubin percentiles in neonates with CC time ≥2 minutes were similar, or lower, compared with the Bhutani nomogram between 12 and 72 hours, but with greater 95th percentile at later hours of age. Phototherapy was initiated in 13 (2.3 %) of the neonates. We found no association between time to CC and hyperbilirubinemia (β = -0.05, P = .07). Need for phototherapy was marginally greater in neonates with shorter time to CC.

CONCLUSIONS

Bilirubin levels were not correlated to time to CC. Our findings indicate that CC beyond 2 minutes can be performed without additional monitoring for jaundice.

Early discharge from maternity ward in response to the COVID-19 pandemic: Impact on emergency attendance

BACKGROUND

In response to the coronavirus disease 2019 (COVID-19) epidemic, our maternity department had to rapidly implement a protocol for early postpartum discharge. We evaluated the benefits and risks of early postpartum discharge.

METHODS

We performed an observational, single-center case-control study over a 3 month-period during the COVID-19 outbreak (from June 1 to August 31, 2020), following implementation of the early discharge policy. Newborns were classified into an early discharge group (within 48-72 h of a vaginal delivery and within 72-96 h of a cesarean delivery) or a standard discharge group (more than 72 h after a vaginal delivery and more than 96 h after a cesarean delivery). The primary outcome measure was inappropriate pediatric emergency department visits within 28 days of delivery.

RESULTS

A total of 546 newborns were included. A total of 22 (8.9%) of the 246 newborns in the early discharge group attended the pediatric emergency department vs. 30 (10.0%) of the 300 newborns in the standard discharge group (p = 0.65). Nine visits (40.9%) were considered inappropriate in the early discharge group vs. 13 (43.3%) in the standard discharge group (p = 0.83). Likewise, the intergroup difference in the hospital readmission rate was not statistically significant.

DISCUSSION

The implementation of early discharge and early follow-up did not result in a significantly greater need (vs. standard discharge) for inappropriate emergency visit or hospital readmission during the first 28 days postpartum, regardless of the parity and breastfeeding status.

Pre-phototherapy total serum bilirubin levels in extremely preterm infants

BACKGROUND

Extremely preterm infants are prone to hyperbilirubinemia and its sequelae. Currently recommended thresholds for initiating phototherapy in these newborns are consensus-based (CB).

METHODS

A multi-site retrospective cohort study of 642 infants born at 24^0/7 to 28^6/7 weeks' gestation, between January 2013 and June 2017, was conducted at three NICUs in Canada. Pre-phototherapy TSB percentile levels at 24 h of age were generated and contrasted with published CB thresholds.

RESULTS

Among infants born 24^0/7 to 25^6/7 weeks' gestation, the differences between our TSB percentiles vs. the CB threshold of 85.0 µmol/L were 10.0 µmol/L (95% CI, 6.0-16.0) at the 75th percentile and 35.3 µmol/L (95% CI, 26.1-42.8) at the 95th percentile. Respectively, among infants born at 26^0/7 to 27^6/7 weeks, differences were 19.4 µmol/L (95% CI, 16.8-23.4) and 43.3 µmol/L (95% CI, 34.7-46.9). Born at 28^0/7 to 28^6/7 weeks' gestation, differences between our 75th and 95th TSB percentiles and the CB threshold of 103 µmol/L were 6.9 µmol/L (95% CI, 3.2-12.0) and 36.0 µmol/L (95% CI, 31.0-44.3), respectively.

CONCLUSIONS

We provide statistically derived pre-phototherapy TSB levels that may clarify patterns of pre-phototherapy TSB levels in extremely preterm infants.

IMPACT

We present statistically derived pre-phototherapy total serum bilirubin levels in a cohort of extremely preterm infants. Most of these preterm infants received phototherapy-some at below currently published thresholds. There are notable differences between our statistically derived pre-phototherapy TSB levels and currently published lower limit TSB thresholds for phototherapy. Our study results assist in the understanding of pre-phototherapy TSB levels in extremely preterm infants.

Care of the Well Newborn

Care of the newborn infant is a critical skill for general pediatricians and other providers in the practice of pediatric medicine. Optimal care relies on a thorough understanding of risk factors that may be present during the pregnancy and delivery, as well as the ability to recognize and address unanticipated problems in the postnatal period. This article focuses on antenatal care of the newborn, issues that present in the immediate postdelivery period, and care of the newborn after discharge. It also includes updated information on current topics in pediatric practice, such as the importance of vaccination, parental hesitancy in accepting common medical interventions, and updated guidelines related to the coronavirus disease 2019 pandemic. At the conclusion of the article, the reader should have a general understanding of antenatal risk factors that could affect the transition from the intrauterine environment and have the knowledge to address common issues that arise in the care of newborn infants.

Cord clamping beyond 3 minutes: Neonatal short-term outcomes and maternal postpartum hemorrhage

BACKGROUND

Delaying cord clamping (CC) for 3-5 minutes reduces iron deficiency and improves neurodevelopment. Data on the effects of CC beyond 3 minutes in relation to short-term neonatal outcomes and maternal risk of postpartum hemorrhage are scarce.

METHODS

This was a prospective observational study performed in two delivery departments. Pregnant women with vaginal deliveries were included. Time to CC, estimated postpartum blood loss, and perinatal data were recorded. Spearman's correlation analysis and comparisons between newborns clamped before and after 3 minutes were performed.

RESULTS

In total, 904 dyads were included. The mean gestational age ± standard deviation was 40.1 ± 1.2 weeks. CC was performed at a median time of 6 minutes (range 0-23.5). Apgar scores at 5 and 10 minutes were positively correlated with time to CC (correlation coefficient .140, P &lt; .001 and .161, &lt; .001). There was no correlation between CC time and bilirubin level (correlation coefficient .021, P = .54). The median postpartum blood loss was 300 mL (70-2550 mL), with a negative correlation between CC time and postpartum blood loss (-0.115, P = .001). The postpartum blood loss was larger in the group clamped at ≤3 minutes (median [interquartile range] 400 mL [300-600] vs 300 mL [250-450], [P = .003]].

CONCLUSIONS

Umbilical CC times beyond 3 minutes in vaginal deliveries were not associated with negative short-term outcomes in newborns and were associated with a smaller maternal postpartum blood loss. Although CC time as long as 6 minutes could be considered as safe, further research is needed to decide the optimal timing.

An End-Tidal Carbon Monoxide Nomogram for Term and Late-Preterm Chinese Newborns

OBJECTIVE

To establish a reference nomogram for end-tidal CO corrected for ambient CO (ETCOc) levels in term and late-preterm Chinese newborns and then assess its efficacy to identify hemolytic hyperbilirubinemia.

STUDY DESIGN

We conducted a prospective study by measuring concurrent ETCOc and total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) levels collected postnatally at 12, 24, 48, 72, 96, and 120 hours of age. ETCOc at the 25th, 50th, 75th, and 95th percentiles at each epoch were used to construct the reference nomogram. We then explored the ability of predischarge ETCOc and TSB/TcB metrics to predict the development of hyperbilirubinemia requiring phototherapy in early postnatal period and jaundice readmission in late postnatal period.

RESULTS

Our nomogram, based on 990 measurements from 455 infants who were not nonhemolytic, displayed a steady line within 3 postnatal days, followed by a subsequent decline. From a cohort of infants with a serial ETCOc measurements (n = 130) and those readmitted (n = 21), we found that ETCOc and TSB/TcB ≥75th percentile can identify most hemolytic hyperbilirubinemia between 12 and 72 hours after birth with an area under the curve (AUC) of 0.741. An ETCOc ≥1.7 ppm alone between 96 and 120 hours after birth can identify most hemolytic hyperbilirubinemia with an AUC of 0.816. In addition, 90.5% of readmitted infants had an ETCOc ≥75th percentile.

CONCLUSIONS

An ETCOc reference nomogram during the first 5 postnatal days in nonhemolytic term and late-preterm newborns can be used to identify hemolytic hyperbilirubinemia requiring phototherapy in the early postnatal period and readmission in the late postnatal period.

Pilot study of home phototherapy for neonatal jaundice monitored in maternity ward during the enforced Italy-wide COVID-19 national lockdown

In Italy, where neonatal jaundice treatment is required, it is largely carried out in hospitals. However, it is possible to safely administer home phototherapy (HPT). We report our pilot center's experience of HPT and its potential benefits during the COVID-19-enforced national lockdown. This is an observational study performed at the Policlinic Abano Terme, a suburban hospital that covers a large catchment area near the Euganean Hills in Northeast Italy with around 1000 deliveries per year. HPT was started after regular nursery discharge, and the mothers brought the neonates back to the hospital maternity ward each day to check infants' bilirubin levels, weight, and general state of health, until it was deemed safe to stop. The efficacy of HPT in bilirubin reduction, hospital readmission rates, and parental satisfaction were evaluated. Thirty infants received HPT. In 4 of these infants, HPT was associated with total serum bilirubin (TSB) between 75 and 95th percentile (high-intermediate-risk zone) and in 26 infants HPT was associated with TSB > 95th percentile (high-risk zone) of the Bhutani nomogram. Among these 30 infants, 27 (90%) completed the HPT with a progressive decrease of TSB levels with 4 neonates requiring a second course and 3 infants requiring a third course of 24-h HPT. Three (10%) neonates failed HPT and were readmitted after one 24-h phototherapy course. No abnormalities of breastfeeding, body weight (defined as > 10% decrease), temperature, nor COVID infections were detected following HPT consultation in the neonatal ward. Home treatment efficacy with varying degrees of parental satisfaction occurred in all but 3 cases that involved difficulties with the equipment and inconsistent lamp manipulation practices.

CONCLUSION

Our pilot study suggests that HPT for neonatal jaundice can be carried out effectively and with parental satisfaction as supported by daily back bilirubin monitoring in the maternity ward during the enforced COVID-19 national lockdown in Italy.

WHAT IS KNOWN

• No high-quality evidence is currently available to support or refute the practice of phototherapy in patients' own homes.

WHAT IS NEW

• Phototherapy can be delivered at home in a select group of infants and could be an ideal option if parents are able to return with their infants to the hospital maternity ward for daily follow-up. • It can be as effective as inpatient phototherapy and potentially helps in delivering family-centered care.

Total bilirubin assay differences may cause inconsistent treatment decisions in neonatal hyperbilirubinaemia

OBJECTIVES

To assess interlaboratory variability of total serum bilirubin (TSB) results in newborns. Initiated following a clinical incident in which a neonate was transferred to a tertiary hospital for treatment of severe hyperbilirubinemia but on arrival was reclassified into a lower risk category due to a 20% difference in TSB between laboratories.

METHODS

Fresh residual plasma samples from hospital-born infants were pooled to obtain 11 samples across a range of total bilirubin concentrations. Aliquots were light-protected and measured on 7 commercial platforms at 4 accredited medical laboratories. Data from The Royal College of Pathologists of Australasia Quality Assurance Programs' (RCPAQAP) Neonatal Bilirubin program was analysed.

RESULTS

Twenty-four to 30% difference in results for individual samples, largely due to calibration differences between assays. When interpreted according to guidelines, results from different platforms would have led to different clinical interventions in some cases. RCPAQAP results showed significant within-method bias but were not shown to be commutable with patient samples.

CONCLUSIONS

There are clinically significant method-dependent differences in TSB results from neonatal samples, consistent with our clinical incident. The differences are largely due to lack of standardisation of calibrator values. This has implications for healthcare resource use and possibly for the neurodevelopment of infants. Intervention is needed at a number of levels, including clinical reporting of incidents arising from discordant results, commitment by manufacturers to ensure metrological traceability of methods with sufficiently low uncertainty in the final measurements, and availability of commutable quality assurance material to monitor assay performance, especially at the clinical decision points for neonatal jaundice.

Neonatal Jaundice: Knowledge and Practices of Healthcare Providers and Trainees in Southwest Nigeria

Severe neonatal jaundice (SNNJ) is a leading cause of neonatal morbidity and mortality in low- and middle-income countries (LMICs). Risk mitigation and management modalities for SNNJ have led to marked reduction in complications in high-income countries but not in LMICs likely in part due to knowledge gaps among healthcare providers. This study, a cross-sectional study conducted in Ogbomosho, Nigeria, aimed to identify SNNJ knowledge and practices among Nigerian healthcare providers/trainees. Healthcare providers/trainees completed a structured questionnaire. Healthcare providers/trainees included are nurse midwives (33.4%), nurses (18.6%), nursing students (15.2%), traditional birth attendants (TBAs) (12.7%), physicians (10.2%), and medical students (9.9%). Most physicians were aware of the common causes of SNNJ; however, knowledge deficits in other groups were notable. Despite most providers endorsing that glucose-6-phosphate dehydrogenase deficiency can cause SNNJ (91% of physicians, 60% of nurses, 71% of midwives, 81% of medical students, 43% of nursing students, 7% of TBAs), very few providers recognized that it is common, ranging from 3% in nurses up to a high of 47% among medical students. Gaps in provider knowledge regarding preventative measures and sequela were also noted. These data identified significant knowledge gaps regarding the etiology of SNNJ among healthcare providers/trainees, which can lead to missed opportunities in effective prevention and treatment. These deficits must be addressed if we are to eliminate tragic and preventable complications from SNNJ in Nigeria and other LMICs.

Discharge of newborns with risk factors of severe hyperbilirubinemia: description of a hospital at home-based care monitoring and phototherapy

Neonatal jaundice is common and associated with delay in hospital discharge and risk of neurological sequelae if not treated. The objectives of the study were to report on our experience of the monitoring and treatment of neonatal jaundice in a home care setting and its feasibility and safety for neonates with high risk of severe hyperbilirubinemia. The 2-year study has been led in the greater Paris University Hospital At Home (Assistance Publique-Hôpitaux de Paris). The device of the intervention was the Bilicocoon® Bag, a light-emitting diode sleeping bag worn by the neonate when the total serum bilirubin value exceeds intensive phototherapy threshold, according to the guidelines from the American Academy of Pediatrics. One hundred and thirty-nine neonates had participated in the intervention and 39 (28%) were treated by phototherapy at home, as continuation of inpatient phototherapy or started at home. Seventy-five percent of the sample had more than two risk factors for development of severe hyperbilirubinemia. Twenty five percent of the cohort who received phototherapy at home had lower gestational age (p < 0.014) and had younger age at discharge from maternity (p < 0.09). Median length of stay in hospital at home was 5 days. Two patients needed readmission in conventional hospital (1%) for less than 24 h. In multivariate model, the length of stay decreased with the higher gestational age (p < 0.001) and increased significantly with the older age at discharge, the birth weight < 10th percentile, and a treatment by phototherapy at home.    Conclusion: Hospital at home, which is a whole strategy using an effective and convenient phototherapy device combined with a specialized medical follow-up, could be an alternative to conventional hospitalization for neonates at high risk of severe jaundice. The maternity discharge is facilitated, the mother-infant bonding can be promoted, and the risk of conventional rehospitalization is minimal, while guaranteeing the safety of this specific care. What is Known: • Managing neonatal jaundice is provided in conventional hospital with phototherapy. • Neonatal jaundice increases the risk of prolonged hospitalization or readmission. What is New: • Phototherapy is feasible in hospital at home for neonates with high risk of severe hyperbilirubinemia. • The care pathway of neonates from conventional hospital to hospital at home is described.