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Joshi NS, Jun I, Wang N. Direct Admissions for Neonatal Hyperbilirubinemia: Safe, High Value Care. Hosp Pediatr 2024; 14:e273-e275. [PMID: 38766711 PMCID: PMC11137622 DOI: 10.1542/hpeds.2024-007781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Neha S. Joshi
- Stanford University School of Medicine, Palo Alto, California
| | - Irene Jun
- Stanford University School of Medicine, Palo Alto, California
| | - Nichole Wang
- Stanford University School of Medicine, Palo Alto, California
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Daggle L, Sharma N, Setiady I, Leonard K. Management of Neonatal Hyperbilirubinemia: Shedding Light on the American Academy of Pediatrics 2022 Clinical Practice Guideline Revision. Pediatr Ann 2024; 53:e208-e216. [PMID: 38852082 DOI: 10.3928/19382359-20240407-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
Neonatal hyperbilirubinemia is one of the most common conditions managed by pediatricians. Although many infants are affected, most will experience complete resolution without complication. Acute bilirubin encephalopathy and kernicterus are rare yet debilitating sequelae of severe hyperbilirubinemia that can be avoided through careful monitoring and treatment with phototherapy. Appropriate management of neonatal hyperbilirubinemia must balance the risks of these severe conditions with the effects of overtreatment. Released in 2022, the American Academy of Pediatrics revised the clinical practice guideline for the management of hyperbilirubinemia, which aims to provide that balance through updates to the previous guideline. This article will provide the reader with (1) an evidence-based harm and benefit analysis of the guideline, (2) an overview of key changes and clarifications made in the new guideline, and (3) a practical summary of guideline updates. [Pediatr Ann. 2024;53(6):e208-e216.].
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Vidavalur R, Bhutani VK. Georacial Epidemiological Estimates of Glucose-6-Phosphate Dehydrogenase Deficiency among Newborns in the United States. Am J Perinatol 2024; 41:e1841-e1849. [PMID: 37105226 DOI: 10.1055/a-2082-4859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Glucose-6-phosphate dehydrogenase deficiency (G6PDd) is the most common inherited enzyme deficiency disorder worldwide and a major risk factor for the development of severe hyperbilirubinemia. Racial diversity of phenotypes and genotypes in affected individuals is likely to exist in the United States because of changing population demographics. The aim of the present study was to predict an empirical estimate of annual prevalence of G6PDd in newborns adjusted for geography (state of birth), maternal racial identity, and sex of the infant. STUDY DESIGN Birth statistics (2019) from National Center for Vital Statistics and CDC-WONDER data and race-specific prevalence of G6PDd in the United States were evaluated from published sources. We developed Simpson's diversity index (DI) for each State and correlated these to rates of G6PDd in neonates. Descriptive statistics including modeled prevalence and its association with DI were assessed using the Spearman's rho correlation test. We modeled state-specific prevalence for six states (California, Washington DC, Illinois, Massachusetts, New York, and Pennsylvania) using population-level allele frequencies and race, based on Hardy-Weinberg equilibrium. RESULTS We estimated 78,010 (95% confidence interval: 76,768-79,252) newborns had G6PDd at birth in 2019 with cumulative median prevalence of 17.3 (interquartile range: 12.4-23.2) per 1,000 live births for United States. A strong association was noted for DI and prevalence of G6PDd (p < 0.0005). Five states (Washington DC, Mississippi, Louisiana, Georgia, and Maryland) have the highest projected G6PDd prevalence, with a range of 35 to 48 per 1,000 live births. The probability of G6PDd for female heterozygotes, based on male prevalence, ranged from 1.1 to 7.5% for each cohort in the select six states. CONCLUSION States with diverse populations are likely to have higher rates of G6PDd. These prevalence estimates exceeded by several-fold when compared with disorders screened by existing state mandated newborn screening panels. These discrepancies are further confounded by known risk of severe neonatal hyperbilirubinemia that results with G6PDd and the life-long risk of hemolysis. Combined universal newborn predischarge screening for G6PDd and bilirubin could alert and guide a clinician's practices for parental education and closer medical surveillance during the vulnerable neonatal time period. KEY POINTS · G6PDd is a common X-linked disorder that can present with varied phenotypes among newborns.. · Prevalence of G6PDd and genotype distribution varies with sex, race, and ethnicity.. · We present regional race- and sex-based estimates of G6PDd in the United States..
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Affiliation(s)
- Ramesh Vidavalur
- Department of Neonatology, Cayuga Medical Center/Weill Cornell Medicine, Ithaca, New York
| | - Vinod K Bhutani
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford Children's Health, Stanford University School of Medicine, Stanford, California
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Sarathy L, Chou JH, Romano-Clarke G, Darci KA, Lerou PH. Bilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline. Pediatrics 2024; 153:e2023063323. [PMID: 38482582 DOI: 10.1542/peds.2023-063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Guidelines for the management of neonatal hyperbilirubinemia have helped to reduce rates of significant hyperbilirubinemia. However, recent evidence suggesting overtreatment and potential harms of phototherapy have informed the American Academy of Pediatrics clinical practice guideline revision and the accompanying increase in phototherapy thresholds. These changes are predicted to safely reduce overuse; however, to date, the exact effect of these guidelines has not been established. METHODS We conducted a retrospective study of newborns born at ≥35 weeks' gestation across a network of 8 hospitals between January 2022 and June 2023. Outcomes included rates of phototherapy and total serum bilirubin (TSB) measurements before and after guideline publication, as well as clinical outcomes, including length of stay, readmissions, and duration of phototherapy. RESULTS In our cohort of >22 000 newborns, we observed a 47% decrease in phototherapy utilization, from 3.9% to 2.1% (P < .001). TSB measurements were reduced by 23%, from 712 to 551 measurements per 1000 newborns (P < .001), without an increase in outpatient TSB measurements. We did not observe an increase in readmissions receiving phototherapy, and length of stay increased by only 1 hour (P < .001). CONCLUSIONS Our study reveals that the publication of the updated American Academy of Pediatrics 2022 hyperbilirubinemia guidelines has likely yielded a significant reduction in phototherapy use and serum bilirubin measurement. Dedicated quality improvement initiatives may help determine which implementation strategies are most effective. Further population-level studies are needed to confirm safety with ongoing guideline uptake.
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Affiliation(s)
- Leela Sarathy
- Mass General for Children, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Joseph H Chou
- Mass General for Children, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Giuseppina Romano-Clarke
- Mass General for Children, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Katherine A Darci
- Mass General for Children, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Paul H Lerou
- Mass General for Children, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
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Wennberg RP, Imam ZO, Shwe DD, Hassan L, Farouk ZL, Turner LE, Brearley AM, Slusher TM, Oguche S. Antenatal jaundice instruction and acute bilirubin encephalopathy in Nigeria. Pediatr Res 2024; 95:1301-1307. [PMID: 38042946 PMCID: PMC11035125 DOI: 10.1038/s41390-023-02887-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/21/2023] [Accepted: 10/26/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Acute Bilirubin Encephalopathy (ABE) is common in Nigeria. Parents' inability to recognize jaundice and delays in seeking care are significant barriers to its prevention. METHODS We compared associations of (1) interactive antenatal maternal jaundice instruction with postnatal reinforcement, (2) standard postnatal instruction, and (3) no maternal instruction with the incidence of ABE among 647 jaundice admissions stratified for risk factors identified in initial descriptive analysis. RESULTS Eighty-three (83/647;12.8%) admissions developed ABE including eleven jaundice-related deaths. ABE was present at admission in 20/22 (90.9%) if mothers received no jaundice instruction and no antenatal care, 42/182 (23.1%) if received antenatal care but no instruction, 16/95 (16.8%) if received postnatal instruction only, and 4/337 (1.2%) if mothers received both antenatal and postnatal instruction (p < .001). ABE was highly associated with out-of-hospital delivery, number of antenatal clinic visits, and birth attendant, but these risks were mitigated by antenatal/postnatal instruction. Admission rates with bilirubin levels below treatment guidelines (12 mg/dL) were higher following instruction (30.7%) than with no instruction (14.4%). Limiting subjects to those meeting admission criteria increased ABE rates in all groups without altering conclusions. CONCLUSION Interactive antenatal instruction with postnatal reinforcement resulted in timely care seeking and a lower incidence of ABE. IMPACT Empowering mothers to participate in neonatal jaundice management is critical in low-income countries where jaundice monitoring and follow up are unreliable. Instructing mothers about jaundice in antenatal clinics with postnatal reinforcement is more effective than standard postpartum instruction in facilitating jaundice detection, timely care seeking, and lowering the incidence of acute bilirubin encephalopathy (ABE). Antenatal training also mitigates risks for ABE associated with out-of-hospital deliveries, limited antenatal care, and unskilled birth attendants. IMPACT Adding structured jaundice instruction in antenatal clinics could greatly reduce bilirubin induced brain injury in countries where ABE is common.
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Affiliation(s)
- Richard P Wennberg
- Emeritus, Department of Pediatrics, University of California, Davis, Davis, CA, USA.
| | - Zainab O Imam
- Department of Pediatrics, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - David D Shwe
- Department of Pediatrics, University of Jos, Jos, Nigeria
| | - Laila Hassan
- Department of Pediatrics, Ahmadu Bello University, Zaria, Nigeria
| | | | - Lindsey E Turner
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Ann M Brearley
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Tina M Slusher
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, USA
| | - Stephen Oguche
- Department of Pediatrics, University of Jos, Jos, Nigeria
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Fan J, He HY, Li HH, Wu PL, Tang L, Deng BY, Dong WH, Wang JH. Associations between UGT1A1, SLCO1B1, SLCO1B3, BLVRA and HMOX1 polymorphisms and susceptibility to neonatal severe hyperbilirubinemia in Chinese Han population. BMC Pediatr 2024; 24:82. [PMID: 38279097 PMCID: PMC10811893 DOI: 10.1186/s12887-024-04537-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 01/04/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Severe neonatal hyperbilirubinemia could lead to kernicterus and neonatal death. This study aimed to analyze the association between single nucleotide polymorphisms in genes involved in bilirubin metabolism and the incidence of severe hyperbilirubinemia. METHODS A total of 144 neonates with severe hyperbilirubinemia and 50 neonates without or mild hyperbilirubinemia were enrolled in 3 institutions between 2019 and 2020. Twelve polymorphisms of 5 genes (UGT1A1, SLCO1B1, SLCO1B3, BLVRA, and HMOX1) were analyzed by PCR amplification of genomic DNA. Genotyping was performed using an improved multiplex ligation detection reaction technique based on ligase detection reaction. RESULTS The frequencies of the A allele in UGT1A1-rs4148323 and the C allele in SLCO1B3-rs2417940 in the severe hyperbilirubinemia group (30.2% and 90.6%, respectively) were significantly higher than those in the controls (30.2% vs.13.0%, 90.6% vs. 78.0%, respectively, both p < 0.05). Haplotype analysis showed the ACG haplotype of UGT1A1 were associated with an increased hyperbilirubinemia risk (OR 3.122, p = 0.001), whereas the GCG haplotype was related to a reduced risk (OR 0.523, p = 0.018). CONCLUSION The frequencies of the A allele in rs4148323 and the C allele in rs2417940 are highly associated with the incidence of severe hyperbilirubinemia in Chinese Han neonates. TRIAL REGISTRATION Trial registration number:ChiCTR1800020424; Date of registration:2018-12-29.
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Affiliation(s)
- Juan Fan
- Department of Neonatology , Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Hua-Yun He
- Department of Neonatology , Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Huan-Huan Li
- Department of Neonatology, Chongqing Jiulongpo People's Hospital, Chongqing, China
| | - Pi-Liu Wu
- Department of Neonatology, Bishan Maternity & Child Hospital of Chongqing, Chongqing, China
| | - Lei Tang
- Department of Pediatrics, Affiliated Banan Hospital of Chongqing Medical University, Chongqing, China
| | - Bo-Yin Deng
- Department of Neonatology , Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
| | - Wen-Hui Dong
- Department of Neonatology , Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China.
| | - Jian-Hui Wang
- Department of Neonatology , Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Chongqing, China
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McGillivray AJ, Polverino J, Badawi N, Evans NJ. Prospective cohort study of neurodevelopmental outcomes following extreme neonatal hyperbilirubinaemia in Australia. J Paediatr Child Health 2023; 59:1244-1250. [PMID: 37724614 DOI: 10.1111/jpc.16489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/02/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023]
Abstract
AIM This study aimed to establish the incidence and nature of neurodevelopmental outcomes following extreme neonatal hyperbilirubinaemia in an Australian cohort. METHODS A prospective cohort study of neurodevelopmental outcomes up to 3 years of age of infants born between 2010 and 2013 at ≥34 weeks gestation, with total serum bilirubin ≥450 μmol/L and/or clinical signs of acute bilirubin encephalopathy. Outcome measures comprised neurological examination, Bayley Scales of Infant and Toddler Development, 3rd edition and Ages and Stages Questionnaire, 3rd edition. RESULTS The Australian estimated incidence of kernicterus is 0.35 per 100 000 live births. Within the follow-up cohort of 26, three children have clinical neurodevelopmental impairment: one has gross motor function classification system level 4 cerebral palsy, audiological deficiency and visual impairment; the second has gross motor function classification system level 1 cerebral palsy and the third has global developmental delay with autism spectrum disorder. Mean Bayley Scales of Infant and Toddler Development, 3rd edition scores were: cognition 10.3 (SD 1.5), receptive communication 9.4 (SD 1.8), expressive communication 9.2 (SD 2.4), fine motor 10.4 (SD 2.6) and gross motor 9.2 (SD 2.3). CONCLUSION The Australian national rate of kernicterus compares favourably with global estimates. Future preventative strategies in this context include universal neonatal hyperbilirubinaemia assessment and mandated adverse outcome reporting and investigation.
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Affiliation(s)
- Angela J McGillivray
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jan Polverino
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nadia Badawi
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- The Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
| | - Nicholas J Evans
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Chou HC, Lin HC, Huang KH, Chang YC. Associations between neonatal jaundice and autism spectrum disorder or attention deficit hyperactivity disorder: Nationwide population based cohort study. J Formos Med Assoc 2023; 122:1150-1157. [PMID: 37225632 DOI: 10.1016/j.jfma.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND/PURPOSE Neonatal jaundice might result brain insults. Both autistic spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are developmental disorders, which might result from early brain injury at neonatal period. We aimed to explore the association between neonatal jaundice treated with phototherapy and the ASD or ADHD. METHODS This retrospective nationwide population cohort study was based on a nationally representative database of Taiwan, and neonates born from 2004 to 2010 were enrolled. All eligible infants were divided into 4 groups, without jaundice, jaundice with no treatment, jaundice with simple phototherapy only and jaundice with intensive phototherapy or blood exchange transfusion (BET). Each infant was follow-up until the date of incident primary outcomes, death, or 7-year-old, whichever occurred first. Primary outcomes were ASD, ADHD. Using cox proportional hazard model to analyze their associations. RESULTS In total, 118,222 infants with neonatal jaundice were enrolled, including diagnosed only (7260), simple phototherapy (82,990), intensive phototherapy or BET (27,972 infants). The cumulative incidences of ASD in each group was 0.57%, 0.81%, 0.77%, and 0.83%, respectively. The cumulative incidences of ADHD in each group was 2.83%, 4.04%, 3.52% and 3.48%, respectively. Jaundice groups were significantly associated with ASD, ADHD, or either one, even after all other extraneous maternal and neonatal variables were adjusted. After stratification, the associations were still existed in subgroup with birth weights ≥2500 grams and in male subgroup. CONCLUSION Neonatal jaundice correlated with the ASD and ADHD. The associations were significant in infants of both sexes and with birth weights larger than 2500 grams.
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Affiliation(s)
- Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
| | - Hung-Chih Lin
- Division of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Asia University Hospital, Asia University, Taichung, Taiwan
| | - Kuang-Hua Huang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Yu-Chia Chang
- Department of Long Term Care, College of Health and Nursing, National Quemoy University, Kinmen County, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.
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Kaplan M, Hammerman C, Shapiro SM. Grand Rounds Hyperbilirubinemia following Phototherapy in Glucose-6-Phosphate Dehydrogenase-Deficient Neonates: Not Out of the Woods. J Pediatr 2023; 261:113452. [PMID: 37169338 DOI: 10.1016/j.jpeds.2023.113452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/22/2023] [Accepted: 04/30/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Michael Kaplan
- Department of Neonatology, Shaare Zedek Medical Center (M.K. Emeritus), Jerusalem, Israel; Faculty of Medicine of the Hebrew University, Jerusalem, Israel.
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center (M.K. Emeritus), Jerusalem, Israel; Faculty of Medicine of the Hebrew University, Jerusalem, Israel
| | - Steven M Shapiro
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS
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Cahill C, Jegatheesan P, Song D, Cortes M, Adams M, Narasimhan SR, Huang A, Angell C, Stemmle M. Implementing Higher Phototherapy Thresholds for Jaundice in Healthy Infants 35 Plus Weeks. Hosp Pediatr 2023; 13:857-864. [PMID: 37635692 DOI: 10.1542/hpeds.2022-007098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVES To determine the impact of higher bilirubin thresholds on testing and treatment of healthy infants during the neonatal period. METHODS This quality improvement study included infants born at ≥35 weeks gestation and admitted to the well-baby nursery between July 2018 and December 2020. We assessed the transition from infants treated according to the 2004 AAP guidelines (pregroup) with those following the Northern California Neonatal Consortium guidelines (postgroup). We examined the proportion of infants receiving phototherapy and total serum bilirubin (TSB) assessments as outcome measures. We examined critical hyperbilirubinemia (TSB above 25 mg/dL or TSB within 2 mg/dL of threshold for exchange transfusion), exchange transfusion, and readmission for jaundice as balancing measures. We compared the differences in outcomes over time using Statistical Process Control p charts. Balancing measures between the pre and postgroups were compared using χ square tests and t-tests. RESULTS In our population of 6173 babies, there was a significant shift in the proportion receiving phototherapy from 6.4% to 4%. There were no significant changes in incidences of bilirubin >25 mg/dL (0 of 1472 vs 7 of 4709, P = .37), bilirubin within 2 mg/dL of exchange transfusion thresholds (4 of 1472 vs 5 of 4709, P = .15), exchange transfusion (0 of 1472 vs 1 of 4709, P = .70) or readmission for phototherapy (2.9% versus 2.4%, P = .30), between the 2 groups. CONCLUSIONS Higher thresholds for phototherapy treatment of neonatal hyperbilirubinemia can decrease the need for phototherapy without increasing critical hyperbilirubinemia or readmission rate.
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Affiliation(s)
- Chris Cahill
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Priya Jegatheesan
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Dongli Song
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Maria Cortes
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
| | - Marian Adams
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
| | - Sudha Rani Narasimhan
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Angela Huang
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
| | - Cathy Angell
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
| | - Monica Stemmle
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Xue G, Zhang H, Ding X, Xiong F, Liu Y, Peng H, Wang C, Zhao Y, Yan H, Ren M, Ma C, Lu H, Li Y, Meng R, Xie L, Chen N, Cheng X, Wang J, Xin X, Wang R, Jiang Q, Zhang Y, Liang G, Li Y, Kang J, Zhang H, Zhang Y, Yuan Y, Li Y, Su Y, Liu J, Duan S, Liu Q, Wei J. Parental detection of neonatal jaundice using a low-cost colour card: a multicentre prospective study. BMJ Paediatr Open 2023; 7:e001924. [PMID: 37385734 PMCID: PMC10314627 DOI: 10.1136/bmjpo-2023-001924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/02/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Since most infants are usually discharged before age 48-72 hours, peak bilirubin levels will almost always occur after discharge. Parents may be the first to observe the onset of jaundice after discharge, but visual assessment is unreliable. The jaundice colour card (JCard) is a low-cost icterometer designed for the assessment of neonatal jaundice. The objective of this study was to evaluate parental use of JCard to detect jaundice in neonates. METHODS We conducted a multicentre, prospective, observational cohort study in nine sites across China. A total of 1161 newborns ≥35 weeks of gestation were enrolled in the study. Measurements of total serum bilirubin (TSB) levels were based on clinical indications. The JCard measurements by parents and paediatricians were compared with the TSB. RESULTS JCard values of parents and paediatricians were correlated with TSB (r=0.754 and 0.788, respectively). The parents' and paediatricians' JCard values 9 had sensitivities of 95.2% vs 97.6% and specificities of 84.5% vs 71.7% for identifying neonates with TSB ≥153.9 µmol/L. The parents' and paediatricians' JCard values 15 had sensitivities of 79.9% vs 89.0% and specificities of 66.7% vs 64.9% for identifying neonates with TSB ≥256.5 µmol/L. Areas under the receiver operating characteristic curves of parents for identifying TSB ≥119.7, ≥153.9, ≥205.2, and ≥256.5 µmol/L were 0.967, 0.960, 0.915, and 0.813, respectively, and those of paediatricians were 0.966, 0.961, 0.926 and 0.840, respectively. The intraclass correlation coefficient was 0.933 between parents and paediatricians. CONCLUSION The JCard can be used to classify different levels of bilirubin, but it is less accurate with high bilirubin levels. The JCard diagnostic performance of parents was slightly lower than that of paediatricians.
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Affiliation(s)
- Guochang Xue
- Department of Paediatrics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Huali Zhang
- Department of Paediatrics, The People's Hospital of Zhenping, Zhenping, Henan, China
| | - Xuexing Ding
- Department of Paediatrics, The People's Hospital of Anyang, Anyang, Henan, China
| | - Fu Xiong
- Department of Paediatrics, Sichuan Provincial Hospital for Women and Children, Chengdu, Sichuan, China
| | - Yanhong Liu
- Department of Neonatal, The People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Hui Peng
- Department of Paediatrics, The Third People's Hospital of Jingzhou, Jingzhou, Hubei, China
| | - Changlin Wang
- Department of Neonatal, Affiliated Children's Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Yi Zhao
- Department of Neonatal, Kaifeng Maternal and Child Health Hospital, Kaifeng, Henan, China
| | - Huili Yan
- Department of Neonatal, Jiaozuo Maternal and Child Health Hospital, Jiaozuo, Henan, China
| | - Mingxing Ren
- Department of Paediatrics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Chaoying Ma
- Department of Paediatrics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Hanming Lu
- Department of Paediatrics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yanli Li
- Department of Paediatrics, The People's Hospital of Zhenping, Zhenping, Henan, China
| | - Ruifeng Meng
- Department of Paediatrics, The People's Hospital of Zhenping, Zhenping, Henan, China
| | - Lingjun Xie
- Department of Paediatrics, The People's Hospital of Zhenping, Zhenping, Henan, China
| | - Na Chen
- Department of Paediatrics, The People's Hospital of Anyang, Anyang, Henan, China
| | - Xiufang Cheng
- Department of Paediatrics, The People's Hospital of Anyang, Anyang, Henan, China
| | - Jiaojiao Wang
- Department of Paediatrics, The People's Hospital of Anyang, Anyang, Henan, China
| | - Xiaohong Xin
- Department of Paediatrics, The People's Hospital of Anyang, Anyang, Henan, China
| | - Ruifen Wang
- Department of Paediatrics, The People's Hospital of Anyang, Anyang, Henan, China
| | - Qi Jiang
- Department of Paediatrics, Sichuan Provincial Hospital for Women and Children, Chengdu, Sichuan, China
| | - Yong Zhang
- Department of Paediatrics, Sichuan Provincial Hospital for Women and Children, Chengdu, Sichuan, China
| | - Guijuan Liang
- Department of Neonatal, The People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Yuanzheng Li
- Department of Neonatal, The People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Jianing Kang
- Department of Neonatal, The People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Huimin Zhang
- Department of Neonatal, The People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Yinying Zhang
- Department of Paediatrics, The Third People's Hospital of Jingzhou, Jingzhou, Hubei, China
| | - Yuan Yuan
- Department of Paediatrics, The Third People's Hospital of Jingzhou, Jingzhou, Hubei, China
| | - Yawen Li
- Department of Neonatal, Affiliated Children's Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Yinglin Su
- Department of Neonatal, Affiliated Children's Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Junping Liu
- Department of Neonatal, Kaifeng Maternal and Child Health Hospital, Kaifeng, Henan, China
| | - Shengjie Duan
- Department of Neonatal, Kaifeng Maternal and Child Health Hospital, Kaifeng, Henan, China
| | - Qingsheng Liu
- Department of Neonatal, Jiaozuo Maternal and Child Health Hospital, Jiaozuo, Henan, China
| | - Jing Wei
- Department of Neonatal, Jiaozuo Maternal and Child Health Hospital, Jiaozuo, Henan, China
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12
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Liang D, Veters MD. Clinical progress note: Revisions to the management of neonatal hyperbilirubinemia. J Hosp Med 2023. [PMID: 36704859 DOI: 10.1002/jhm.13046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/07/2023] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Danni Liang
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michelle D Veters
- Division of Pediatric Hospital Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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13
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Satrom KM, Farouk ZL, Slusher TM. Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities. Front Pediatr 2023; 11:1001141. [PMID: 36861070 PMCID: PMC9969105 DOI: 10.3389/fped.2023.1001141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023] Open
Abstract
Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.
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Affiliation(s)
- Katherine M Satrom
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Zubaida L Farouk
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria.,Centre for Infectious Diseases Research, Bayero University, Kano, Nigeria
| | - Tina M Slusher
- Department of Pediatrics, Global Health Program, Critical Care Division, University of Minnesota, Minneapolis, MN, United States.,Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
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14
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Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs SM, Grout RW, Bundy DG, Stark AR, Bogen DL, Holmes AV, Feldman-Winter LB, Bhutani VK, Brown SR, Maradiaga Panayotti GM, Okechukwu K, Rappo PD, Russell TL. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2022; 150:188726. [PMID: 35927462 DOI: 10.1542/peds.2022-058859] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | | | - M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Jon F Watchko
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen M Downs
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | - Randall W Grout
- Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana
| | - David G Bundy
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Debra L Bogen
- Allegheny County Health Department, Pittsburgh, Pennsylvania
| | - Alison Volpe Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Lori B Feldman-Winter
- Department of Pediatrics, Division of Adolescent Medicine, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Vinod K Bhutani
- Department of Pediatrics, Neonatal and Developmental Medicine Stanford University School of Medicine, Stanford, California
| | | | - Gabriela M Maradiaga Panayotti
- Division of Primary Care, Duke Children's Hospital and Health Center, Duke University Medical Center, Durham, North Carolina
| | - Kymika Okechukwu
- Department of Quality, American Academy of Pediatrics, Itasca, Illinois
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15
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Slaughter JL, Kemper AR, Newman TB. Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2022; 150:188725. [PMID: 35927519 DOI: 10.1542/peds.2022-058865] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Severe hyperbilirubinemia is associated with kernicterus. Informed guidance on hyperbilirubinemia management, including preventive treatment thresholds, is essential to safely minimize neurodevelopmental risk. OBJECTIVE To update the evidence base necessary to develop the 2022 American Academy of Pediatrics clinical practice guideline for management of hyperbilirubinemia in the newborn infant ≥35 weeks' gestation. DATA SOURCE PubMed. STUDY SELECTION English language randomized controlled trials and observational studies. Excluded: case reports or series, nonsystematic reviews, and investigations focused on <35-weeks' gestation infants. DATA EXTRACTION Topics addressed in the previous clinical practice guideline (2004) and follow-up commentary (2009) were updated with new evidence published through March 2022. Evidence reviews were conducted for previously unaddressed topics (phototherapy-associated adverse effects and effectiveness of intravenous immune globulin [IVIG] to prevent exchange transfusion). RESULTS New evidence indicates that neurotoxicity does not occur until bilirubin concentrations are well above the 2004 exchange transfusion thresholds. Systematic review of phototherapy-associated adverse effects found limited and/or inconsistent evidence of late adverse effects, including cancer and epilepsy. IVIG has unclear benefit for preventing exchange transfusion in infants with isoimmune hemolytic disease, with a possible risk of harm due to necrotizing enterocolitis. LIMITATIONS The search was limited to 1 database and English language studies. CONCLUSIONS Accumulated evidence justified narrowly raising phototherapy treatment thresholds in the updated clinical practice guideline. Limited evidence for effectiveness with some evidence of risk of harm support the revised recommendations to limit IVIG use.
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Affiliation(s)
| | - Alex R Kemper
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, California
| | - Thomas B Newman
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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16
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Neonatal hyperbilirubinemia and bilirubin neurotoxicity in hospitalized neonates: analysis of the US Database. Pediatr Res 2022; 91:1662-1668. [PMID: 34429513 DOI: 10.1038/s41390-021-01692-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/21/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to assess the prevalence and trends for neonatal hyperbilirubinemia, and the development of bilirubin neurotoxicity in the USA. STUDY DESIGN We used a de-identified national dataset for the years 2002-2017. The study included all newborn inpatients with postnatal age ≤28 days. Cochran-Armitage trend test was used for trend analyses. Regression analyses were performed and adjusted odds ratios (aOR) were reported. RESULTS The study included 57,989,476 infants; of them 53,259,758 (91.8%) were term infants and 4,725,178 (8.2%) were preterm infants. Bilirubin neurotoxicity decreased over the years in term infants (Z = 0.36, p = 0.03) without change in preterm infants (Z = 42.5, p = 0.12). Black neonates were less likely to be diagnosed with hyperbilirubinemia than White neonates (aOR = 0.77, 95% confidence interval (CI): 0.77-0.78, p < 0.001) and more likely to develop bilirubin neurotoxicity than White neonates (aOR = 3.0.5, 95% CI: 2.13-4.36, p < 0.001). Bilirubin neurotoxicity rate in the overall population was 2.4 per 100,000 live births. CONCLUSIONS Bilirubin neurotoxicity has significantly decreased in term infants and did not change in preterm infants. Despite the less diagnosis of hyperbilirubinemia in Black newborns, they are disproportionately at increased risk of developing bilirubin neurotoxicity when compared to White newborns. IMPACT In this article, we analyzed the National Inpatient Database. This is the largest study of its kind using data on 57,989,476 neonates. The article has multiple novel findings: (1) it demonstrated that utilization of phototherapy has increased significantly over the years, (2) the rate of kernicterus for neonates decreased in term infants and did not change in preterm babies, (3) kernicterus was mostly encountered in infants without isoimmunization jaundice, and (4) there is a clear racial disparity in neonatal jaundice; although Black newborns have less neonatal jaundice, they are at increased risk of developing kernicterus.
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17
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Bhatt P, Parmar N, Ayensu M, Umscheid J, Vasudeva R, Donda K, Doshi H, Dapaah-Siakwan F. Trends and Resource Use for Kernicterus Hospitalizations in the United States. Hosp Pediatr 2022; 12:e185-e190. [PMID: 35578911 DOI: 10.1542/hpeds.2021-006502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the trends in hospitalization for kernicterus in the United States from 2006 through 2016. METHOD Repeated, cross-sectional analysis of the 2006 to 2016 editions of the Kids' Inpatient Database. All neonatal hospitalizations with an International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification code for kernicterus and admitted at age ≤28 days were included. RESULTS Among 16 094 653 neonatal hospitalizations from 2006 to 2016, 20.5% were diagnosed with jaundice with overall incidence of kernicterus 0.5 per 100 000. The rate of kernicterus (per 100 000) was higher among males (0.59), Asian or Pacific Islanders (1.04), and urban teaching hospitals (0.72). Between 2006 and 2016, the incidence of kernicterus decreased from 0.7 to 0.2 per 100 000 (P-trend = .03). The overall median length of stay for kernicterus was 5 days (interquartile range [IQR], 3-8 days). The overall median inflation-adjusted cost of hospitalization was $5470 (IQR, $1609-$19 989). CONCLUSIONS Although the incidence of kernicterus decreased between 2006 and 2016, its continued occurrence at a higher rate among Asian or Pacific Islander and Black race or ethnicity in the United States require further probing. Multipronged approach including designating kernicterus as a reportable event, strengthening newborn hyperbilirubinemia care practices and bilirubin surveillance, parental empowerment, and removing barriers to care can potentially decrease the rate of kernicterus further.
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Affiliation(s)
- Parth Bhatt
- Department of Pediatrics, United Hospital Center, Bridgeport, West Virginia
| | - Narendrasinh Parmar
- Department of Pediatrics, Brookdale University Hospital and Medical Center, Brooklyn, New York
| | - Marian Ayensu
- Outpatient Department, The Trust Hospital, Accra, Ghana
| | - Jacob Umscheid
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Rhythm Vasudeva
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Keyur Donda
- Section of Neonatology, Department of Pediatrics, University of South Florida, Tampa, Florida
| | - Harshit Doshi
- Neonatal Intensive Care Unit, Golisano Children's hospital of Southwest Florida, Fort Myers, Florida
| | - Fredrick Dapaah-Siakwan
- Neonatal Intensive Care Unit, Department of Medicine, Valley Children's Hospital, Madera, California
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18
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Evaluation of a new transcutaneous bilirubinometer in newborn infants. Sci Rep 2022; 12:5835. [PMID: 35393482 PMCID: PMC8989875 DOI: 10.1038/s41598-022-09788-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/18/2022] [Indexed: 11/09/2022] Open
Abstract
To avoid brain damage in newborn infants, effective tools for prevention of excessive neonatal hyperbilirubinemia are needed. The objective of this study was to evaluate a new transcutaneous bilirubinometer (JAISY). For this purpose, 930 bilirubin measurements were performed in 141 newborn infants born near-term or at term (gestational age 35–41 weeks; postnatal age 1–6 days; 71 boys; including 29 infants with darker skin) and compared to those of a previously validated instrument (JM105). In each infant, the mean of three repeated measurements in the forehead was calculated for each instrument, followed by a similar measurement on the chest. The bilirubin values varied between 0 and 320 µmol/l (0–18.8 mg/dl). There was a high degree of agreement with significant correlations between bilirubin values measured with the two devices on the forehead (Pearson’s r = 0.94, p < 0.001) and the chest (r = 0.94, p < 0.001). The correlations remained after stratifying the data by gestational age, postnatal age and skin color. The coefficient of variation for repeated bilirubin measurements was 8.8% for JAISY and 8.0% for JM105 (p = 0.79). In conclusion, JAISY provides accurate and reproducible information on low to moderately high bilirubin levels in newborn infants born near-term or at term.
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20
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Clinical and Genetic Etiologies of Neonatal Unconjugated Hyperbilirubinemia in the China Neonatal Genomes Project. J Pediatr 2022; 243:53-60.e9. [PMID: 34953813 DOI: 10.1016/j.jpeds.2021.12.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 11/09/2021] [Accepted: 12/13/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the clinical and genetic causes of neonatal unconjugated hyperbilirubinemia. STUDY DESIGN We included 1412 neonates diagnosed with unconjugated hyperbilirubinemia (total serum bilirubin >95 percentile for age), from the China Neonatal Genomes Project between August 2016 and September 2019, in the current study. Clinical data and targeted panel sequencing data on 2742 genes including known unconjugated hyperbilirubinemia genes were analyzed. RESULTS Among the 1412 neonates with unconjugated hyperbilirubinemia, 37% had severe unconjugated hyperbilirubinemia, with total serum bilirubin levels that met the recommendations for exchange transfusion. Known clinical causes were identified for 68% of patients. The most common clinical cause in the mild unconjugated hyperbilirubinemia group was infection (17%) and in the severe group was combined factors (21%, with infection combined with extravascular hemorrhage the most common). A genetic variant was observed in 55 participants (4%), including 45 patients with variants in genes associated with unconjugated hyperbilirubinemia and 10 patients with variants that were regarded as additional genetic findings. Among the 45 patients identified with unconjugated hyperbilirubinemia-related variants, the genes were mainly associated with enzyme deficiencies, metabolic/biochemical disorders, and red blood cell membrane defects. G6PD and UGT1A1 variants, were detected in 34 of the 45 patients (76%). CONCLUSIONS Known clinical causes, which varied with bilirubin levels, were identified in approximately two-thirds of the patients. Genetic findings were identified in 4% of the patients, including in patients with an identified clinical cause, with G6PD and UGT1A1 being the most common genes in which variants were detected.
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21
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Stannsoporfin with phototherapy to treat hyperbilirubinemia in newborn hemolytic disease. J Perinatol 2022; 42:110-115. [PMID: 34635771 DOI: 10.1038/s41372-021-01223-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of tin mesoporphyrin (SnMP) in neonates with hyperbilirubinemia (HB) due to hemolysis. STUDY DESIGN This multicenter, placebo-controlled phase 2b study (NCT01887327) randomized newborns (35-42 weeks) with hemolysis started on phototherapy (PT) to placebo (Ctrl), SnMP 3.0 mg/kg, or SnMP 4.5 mg/kg given once IM within 30 min of initiation of PT. RESULTS In all, 91 patients were randomized (Ctrl: n = 30; 3 mg/kg SnMP: n = 30; 4.5 mg/kg SnMP: n = 31). At 48 h TSB significantly increased in Ctrl by 17.5% (95% CI 5.6-30.7; p = 0.004) and significantly decreased by -13% (95% CI -21.7 to -3.2; p = 0.013) in the 3.0 mg/kg and by -10.5% (95% CI -19.4 to -0.6; p = 0.041) in the 4.5 mg/kg group. Decreases in SnMP groups were significant (p < 0.0001) vs Ctrl. CONCLUSION SnMP with PT significantly reduced TSB by 48 h. SnMP may be useful as a treatment for HB in neonates with hemolysis.
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22
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Lahmann JM, Faase RA, Leu HY, Jacques SL, Scottoline B, Schilke KF, Baio JE, Higgins AZ. Microfluidic photoreactor to treat neonatal jaundice. BIOMICROFLUIDICS 2021; 15:064104. [PMID: 34853627 PMCID: PMC8616629 DOI: 10.1063/5.0066073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/09/2021] [Indexed: 06/13/2023]
Abstract
While in most cases, jaundice can be effectively treated using phototherapy, severe cases require exchange transfusion, a relatively risky procedure in which the neonate's bilirubin-rich blood is replaced with donor blood. Here, we examine extracorporeal blood treatment in a microfluidic photoreactor as an alternative to exchange transfusion. This new treatment approach relies on the same principle as phototherapy but leverages microfluidics to speed up bilirubin removal. Our results demonstrate that high-intensity light at 470 nm can be used to rapidly reduce bilirubin levels without causing appreciable damage to DNA in blood cells. Light at 470 nm was more effective than light at 505 nm. Studies in Gunn rats show that photoreactor treatment for 4 h significantly reduces bilirubin levels, similar to the bilirubin reduction observed for exchange transfusion and on a similar time scale. Predictions for human neonates demonstrate that this new treatment approach is expected to exceed the performance of exchange transfusion using a low blood flow rate and priming volume, which will facilitate vascular access and improve safety.
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Affiliation(s)
- John M. Lahmann
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Ryan A. Faase
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Hsuan Yu Leu
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Steven L. Jacques
- Department of Bioengineering, University of Washington, Seattle, Washington 98105, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon 97239, USA
| | - Kate F. Schilke
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Joe E. Baio
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Adam Z. Higgins
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
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23
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Tchou MJ, Schondelmeyer AC, Alvarez F, Holmes AV, Lee V, Lossius MN, O'Callaghan J, Rajbhandari P, Soung PJ, Quinonez R. Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value. Hosp Pediatr 2021; 11:1179-1190. [PMID: 34667087 DOI: 10.1542/hpeds.2021-006037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.
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Affiliation(s)
- Michael J Tchou
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Francisco Alvarez
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Alison V Holmes
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michele N Lossius
- Pediatric Hospital Medicine, Department of Pediatrics, University of Florida Shands Children's Hospital, Gainesville, Florida
| | - James O'Callaghan
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Prabi Rajbhandari
- Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Paula J Soung
- Section of Hospital Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Texas Children's Hospital and Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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24
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Ding Y, Wang S, Guo R, Zhang A, Zhu Y. High levels of unbound bilirubin are associated with acute bilirubin encephalopathy in post-exchange transfusion neonates. Ital J Pediatr 2021; 47:187. [PMID: 34526082 PMCID: PMC8444375 DOI: 10.1186/s13052-021-01143-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although it is known that unbound bilirubin can enter the brain, there is little evidence of its association with the development of acute bilirubin encephalopathy. Here, we investigated this potential relationship in neonates who had undergone exchange transfusion. METHODS Data from 46 newborns who underwent exchange transfusion between 2016 and 1-1 to 2018-12-31 at the First People's Hospital of Changde City in China were analyzed. The unbound bilirubin level was taken as the independent variable and the development of the acute bilirubin encephalopathy as the dependent variable. The covariates were age, birth weight, sex, red blood cell count, blood glucose, hemolytic disease, and whether the infant had received phototherapy. RESULTS The mean age and gestational age of the neonates were 146.5 ± 86.9 h and 38.6 ± 1.3 weeks [38.7(34.6-41.1) weeks] old, respectively; 52.17% were male. Binary logistic regression analysis after adjustment for covariates showed a positive association between the levels of unbound bilirubin and the development of acute bilirubin encephalopathy (odds ratio = 1.41, 95% confidence intervals 1.05-1.91, P = < 0.05). CONCLUSION There is a significant association between unbound bilirubin levels and the development of acute bilirubin encephalopathy in neonates. Further investigations are required to explore the mechanisms.
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Affiliation(s)
- Yiyi Ding
- grid.459514.80000 0004 1757 2179Department of Pediatrics, The First People’s Hospital of Changde, Changde, 415003 China
| | - Shuo Wang
- grid.411912.e0000 0000 9232 802XJishou University School of Medicine, Jishou, 416007 China
| | - Rui Guo
- grid.459514.80000 0004 1757 2179Department of Pediatrics, The First People’s Hospital of Changde, Changde, 415003 China
| | - Aizhen Zhang
- grid.459514.80000 0004 1757 2179Department of Pediatrics, The First People’s Hospital of Changde, Changde, 415003 China
| | - Yufang Zhu
- Department of Pediatrics, The First People's Hospital of Changde, Changde, 415003, China.
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Vidavalur R, Devapatla S. Trends in hospitalizations of newborns with hyperbilirubinemia and kernicterus in United States: an epidemiological study. J Matern Fetal Neonatal Med 2021; 35:7701-7706. [PMID: 34470114 DOI: 10.1080/14767058.2021.1960970] [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: 10/20/2022]
Abstract
BACKGROUND Hyperbilirubinemia is one of the most common diagnosis in newborn nurseries in United States. Universal pre-discharge bilirubin screening decreased the incidence of extreme hyperbilirubinemia and risk of kernicterus. OBJECTIVES We sought to assess temporal population trends of hyperbilirubinemia, kernicterus and usage of phototherapy, intravenous immunoglobulin (IVIG), and exchange transfusion. DESIGN/METHODS Data from Healthcare Cost and Utilization Project (HCUP)-the Kids' Inpatient Database (KID) obtained for years 1997-2012. All neonatal discharges with ICD-9 codes for neonatal jaundice (774.2, 774.6), kernicterus (773.4, 774.7) and procedure codes for phototherapy (99.83), IVIG infusion (99.14), exchange transfusion (99.01) were extracted. We compared the trends of diagnosis of hyperbilirubinemia, kernicterus, use of phototherapy, IVIG, and exchange transfusion. RESULTS During the study period, the proportion of infants diagnosed with hyperbilirubinemia increased by 65% (9.4% vs. 15.5%; p<.001) in term infants and 34.5% (33.5% vs. 45%; p<.001) in preterm infants, respectively. Rate of kernicterus discharges significantly reduced from 7 to 1.9 per 100,000 newborns. Overall, the number of exchange transfusions has decreased by 67% during study period while phototherapy and IVIG use increased by 83% and 170%, respectively. CONCLUSIONS In last two decades, there was a significant decrease in neonatal discharges with a history of exchange transfusion or with a diagnosis of kernicterus. However, there was a significant increase in number of neonates discharged home with a history of phototherapy during birth hospitalization and decreased number of exchange transfusions were observed during the study period. Incremental implementation of universal predischarge bilirubin screening and treatments based on 2004 AAP recommended risk-based strategies might have contributed to timely interventions in infants with significant hyperbilirubinemia.
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Abstract
This article attempts to highlight contemporary issues relating to term neonatal hyperbilirubinemia and to focus attention on controversial issues and concepts with the potential to effect change in clinical approach. On the one hand, the focus is bilirubin neurotoxicity, which is now known to encompass a wide, diverse spectrum of features. The various aspects of this spectrum are outlined and defined. On the other hand, bilirubin also possesses antioxidant properties. As such, mild hyperbilirubinemia is suggested as actually offering the neonate some protective advantage.
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Horn D, Ehret D, Gautham KS, Soll R. Sunlight for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates. Cochrane Database Syst Rev 2021; 7:CD013277. [PMID: 34228352 PMCID: PMC8259558 DOI: 10.1002/14651858.cd013277.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute bilirubin encephalopathy (ABE) and the other serious complications of severe hyperbilirubinemia in the neonate occur far more frequently in low- and middle-income countries (LMIC). This is due to several factors that place babies in LMIC at greater risk for hyperbilirubinemia, including increased prevalence of hematologic disorders leading to hemolysis, increased sepsis, less prenatal or postnatal care, and a lack of resources to treat jaundiced babies. Hospitals and clinics face frequent shortages of functioning phototherapy machines and inconsistent access to electricity to run the machines. Sunlight has the potential to treat hyperbilirubinemia: it contains the wavelengths of light that are produced by phototherapy machines. However, it contains harmful ultraviolet light and infrared radiation, and prolonged exposure has the potential to lead to sunburn, skin damage, and hyperthermia or hypothermia. OBJECTIVES To evaluate the efficacy of sunlight administered alone or with filtering or amplifying devices for the prevention and treatment of clinical jaundice or laboratory-diagnosed hyperbilirubinemia in term and late preterm neonates. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 5), MEDLINE, Embase, and CINAHL on 2 May 2019. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster RCTs. We updated the searches on 1 June 2020. SELECTION CRITERIA We included RCTs, quasi-RCTs, and cluster RCTs. We excluded crossover RCTs. Included studies must have evaluated sunlight (with or without filters or amplification) for the prevention and treatment of hyperbilirubinemia or jaundice in term or late preterm neonates. Neonates must have been enrolled in the study by one-week postnatal age. DATA COLLECTION AND ANALYSIS We used standard methodologic procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were: use of conventional phototherapy, treatment failure requiring exchange transfusion, ABE, chronic bilirubin encephalopathy, and death. MAIN RESULTS We included three RCTs (1103 infants). All three studies had small sample sizes, were unblinded, and were at high risk of bias. We planned to undertake four comparisons, but only found studies reporting on two. Sunlight with or without filters or amplification compared to no treatment for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates One study of twice-daily sunlight exposure (30 to 60 minutes) compared to no treatment reported the incidence of jaundice may be reduced (risk ratio [RR] 0.61, 95% confidence interval [CI] 0.45 to 0.82; risk difference [RD] -0.14, 95% CI -0.22 to -0.06; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 17; 1 study, 482 infants; very low-certainty evidence) and the number of days that an infant was jaundiced may be reduced (mean difference [MD] -2.20 days, 95% CI -2.60 to -1.80; 1 study, 482 infants; very low-certainty evidence). There were no data on safety or potential harmful effects of the intervention. The study did not assess use of conventional phototherapy, treatment failure requiring exchange transfusion, ABE, and long-term consequences of hyperbilirubinemia. The study showed that sunlight therapy may reduce rehospitalization rates within seven days of discharge for treatment for hyperbilirubinemia, but the evidence was very uncertain (RR 0.55, 95% CI 0.27 to 1.11; RD -0.04, -0.08 to 0.01; 1 study, 482 infants; very low-certainty evidence). Sunlight with or without filters or amplification compared to other sources of phototherapy for the treatment of hyperbilirubinemia in infants with confirmed hyperbilirubinemia Two studies (621 infants) compared the effect of filtered-sunlight exposure to other sources of phototherapy in infants with confirmed hyperbilirubinemia. Filtered-sunlight phototherapy (FSPT) and conventional or intensive electric phototherapy led to a similar number of days of effective treatment (broadly defined as a minimal increase of total serum bilirubin in infants less than 72 hours old and a decrease in total serum bilirubin in infants more than 72 hours old on any day that at least four to five hours of sunlight therapy was available). There may be little or no difference in treatment failure requiring exchange transfusion (typical RR 1.00, 95% CI 0.06 to 15.73; typical RD 0.00, 95% CI -0.01 to 0.01; 2 studies, 621 infants; low-certainty evidence). One study reported ABE, and no infants developed this outcome (RR not estimable; RD 0.00, 95% CI -0.02 to 0.02; 1 study, 174 infants; low-certainty evidence). One study reported death as a reason for study withdrawal; no infants were withdrawn due to death (RR not estimable; typical RD 0.00, 95% CI -0.01 to 0.01; 1 study, 447 infants; low-certainty evidence). Neither study assessed long-term outcomes. Possible harms: both studies showed a probable increased risk for hyperthermia (body temperature greater than 37.5 °C) with FSPT (typical RR 4.39, 95% CI 2.98 to 6.47; typical RD 0.30, 95% CI 0.23 to 0.36; number needed to treat for an additional harmful outcome [NNTH] 3, 95% CI 2 to 4; 2 studies, 621 infants; moderate-certainty evidence). There was probably no difference in hypothermia (body temperature less than 35.5 °C) (typical RR 1.06, 95% CI 0.55 to 2.03; typical RD 0.00, 95% CI -0.03 to 0.04; 2 studies, 621 infants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Sunlight may be an effective adjunct to conventional phototherapy in LMIC settings, may allow for rotational use of limited phototherapy machines, and may be preferable to families as it can allow for increased bonding. Filtration of sunlight to block harmful ultraviolet light and frequent temperature checks for babies under sunlight may be warranted for safety. Sunlight may be effective in preventing hyperbilirubinemia in some cases, but these studies have not demonstrated that sunlight alone is effective for the treatment of hyperbilirubinemia given its sporadic availability and the low or very low certainty of the evidence in these studies.
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Affiliation(s)
- Delia Horn
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Danielle Ehret
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Kanekal S Gautham
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Dong XY, Wei QF, Li ZK, Gu J, Meng DH, Guo JZ, He XL, Sun XF, Yu ZB, Han SP. Causes of severe neonatal hyperbilirubinemia: a multicenter study of three regions in China. World J Pediatr 2021; 17:290-297. [PMID: 34047994 DOI: 10.1007/s12519-021-00422-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Available evidence suggests that our country bear great burden of severe hyperbilirubinemia. However, the causes have not been explored recently in different regions of China to guide necessary clinical and public health interventions. METHODS This was a prospective, observational study conducted from March 1, 2018, to February 28, 2019. Four hospitals in three regions of China participated in the survey. Data from infants with a gestational age ≥ 35 weeks, birth weight ≥ 2000 g, and total serum bilirubin (TSB) level ≥ 17 mg/dL (342 µmol/L) were prospectively collected. RESULTS A total of 783 cases were reported. Causes were identified in 259 cases. The major causes were ABO incompatibility (n = 101), glucose-6-phosphate dehydrogenase deficiency (n = 76), and intracranial hemorrhage (n = 70). All infants with glucose-6-phosphate dehydrogenase deficiency were from the central south region. Those from the central south region had much higher peak total bilirubin levels [mean, 404 μmol/L; standard deviation (SD), 75 μmol/L] than those from the other regions (mean, 373 μmol/L; SD, 35 μmol/L) (P < 0.001). CONCLUSIONS ABO incompatibility was the leading cause in the east and northwest regions, but cases in the central south region were mainly caused by both ABO incompatibility and glucose-6-phosphate dehydrogenase deficiency, and infants in this region had a much higher peak total bilirubin level. Intracranial hemorrhage may be another common cause. More thorough assessments and rigorous bilirubin follow-up strategies are needed in the central south region.
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Affiliation(s)
- Xiao-Yue Dong
- Department of Neonatology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Qiu-Fen Wei
- Department of Neonatology, Guangxi Maternal and Child Health Care Hospital, Nanning, China
| | - Zhan-Kui Li
- Department of Neonatology, NorthWest Women's and Children's Hospital, Xi'an, China
| | - Jie Gu
- Department of Neonatology, Yinchuan Maternal and Child Health Care Hospital, Yinchuan, China
| | - Dan-Hua Meng
- Department of Neonatology, Guangxi Maternal and Child Health Care Hospital, Nanning, China
| | - Jin-Zhen Guo
- Department of Neonatology, NorthWest Women's and Children's Hospital, Xi'an, China
| | - Xiao-Li He
- Department of Neonatology, Yinchuan Maternal and Child Health Care Hospital, Yinchuan, China
| | - Xiao-Fan Sun
- Department of Neonatology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Zhang-Bin Yu
- Department of Neonatology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China
| | - Shu-Ping Han
- Department of Neonatology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing, China.
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Qu Y, Huang S, Fu X, Wang Y, Wu H. Nomogram for Acute Bilirubin Encephalopathy Risk in Newborns With Extreme Hyperbilirubinemia. Front Neurol 2020; 11:592254. [PMID: 33329342 PMCID: PMC7732469 DOI: 10.3389/fneur.2020.592254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives: This work aimed to develop a predictive model of neonatal acute bilirubin encephalopathy. Methods: We retrospectively analyzed the data on extreme hyperbilirubinemia (EHB) newborns hospitalized in the First Hospital of Jilin University from January 1, 2012 to December 31, 2019. The demographic characteristics, pathological information, and admission examination results of newborns were collected to analyze the factors affecting acute bilirubin encephalopathy and to establish a predictive model. Results: A total of 517 newborns were included in this study, of which 102 (19.7%) had acute bilirubin encephalopathy. T1WI hyperintensity [18.819 (8.838–40.069)], mother's age > 35 years [2.618 (1.096–6.2530)], abnormal white blood cell (WBC) [6.503 (0.226–18.994)], TSB level [1.340 (1.242–1.445)], and albumin level [0.812 (0.726–0.907)] were independently associated with neonatal acute bilirubin encephalopathy (ABE). All independently associated risk factors were used to form an ABE risk estimation nomogram. The bootstrap validation method was used to internally validate the resulting model. The nomogram demonstrated good accuracy in predicting the risk of ABE, with an unadjusted C index of 0.943 (95% CI, 0.919–0.962) and a bootstrap-corrected C index of 0.900. Conclusion: A nomogram was constructed using five risk factors of ABE. This model can help clinicians determine the best treatment for neonatal hyperbilirubinemia.
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Affiliation(s)
- Yangming Qu
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Shuhan Huang
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Xin Fu
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Youping Wang
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Hui Wu
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
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Choi KY, Lee BS, Choi HG, Park SK. Analysis of the Risk Factors Associated with Hearing Loss of Infants Admitted to a Neonatal Intensive Care Unit: A 13-Year Experience in a University Hospital in Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218082. [PMID: 33147853 PMCID: PMC7663230 DOI: 10.3390/ijerph17218082] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/16/2022]
Abstract
Early detection of hearing loss in neonates is important for normal language development, especially for infants admitted to the neonatal intensive care unit (NICU) because the infants in NICU have a higher incidence of hearing loss than healthy infants. However, the risk factors of hearing loss in infants admitted to the NICU have not been fully acknowledged, especially in Korea, although they may vary according to the circumstances of each country and hospital. In this study, the risk factors of hearing loss in NICU infants were analyzed by using the newborn hearing screening (NHS) and the diagnostic auditory brainstem response (ABR) test results from a 13-year period. A retrospective chart review was performed using a list of NICU infants who had performed NHS from 2004 to 2017 (n = 2404) in a university hospital in Korea. For the hearing loss group, the hearing threshold was defined as 35 dB nHL or more in the ABR test performed in infants with a 'refer' result in the NHS. A four multiple number of infants who had passed the NHS test and matched the age and gender of the hearing loss group were taken as the control group. Various patient factors and treatment factors were taken as hearing loss related variables and were analyzed and compared. From the 2404 infants involved, the prevalence of hearing loss was 1.8% (n = 43). A comparison between the hearing loss group (n = 43) and the control group (n = 172) revealed that history of sepsis, peak total bilirubin, duration of vancomycin use, days of phototherapy, and exposure to loop-inhibiting diuretics were significantly different, and can be verified as significant risk factors for hearing loss in NICU infants.
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Affiliation(s)
- Kyu Young Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Korea; (K.Y.C.); (B.S.L.)
| | - Bum Sang Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Korea; (K.Y.C.); (B.S.L.)
| | - Hyo Geun Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, Korea;
| | - Su-Kyoung Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Korea; (K.Y.C.); (B.S.L.)
- Correspondence:
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Etiology and therapeutic management of neonatal jaundice in Iran: a systematic review and meta-analysis. World J Pediatr 2020; 16:480-493. [PMID: 32052364 DOI: 10.1007/s12519-020-00339-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Jaundice is a life-threatening disorder in the neonates. In the present study, we aimed to assess systematically available evidence on causes and management of jaundice in Iranian newborn patients. METHODS We searched the databases of PubMed, Web of Sciences, Scopus and Google Scholar for English articles published since inception until May 2019. A search was also done for Persian articles in Magiran and Scientific Information Database. Studies were evaluated based on predefined criteria by two reviewers. Data analysis was performed by STATA software. RESULTS A total of 33 articles were finally included. The overall pooled prevalence of causes of jaundice among Iranian neonates was as follows: ABO blood groups incompatibility, 16.9% [95% confidence interval (CI) 10.9-22.8]; Rh blood group incompatibility, 4% (95% CI 2.5-5.5); ABO and Rh blood groups incompatibility, 3.6% (95% CI 0-7.7); glucose-6-phosphate dehydrogenase (G6PD) deficiency, 6.3% (95% CI 5.1-7.5); infection, 6.6% (95% CI 5.2-8.1); hypothyroidism, 4.2% (95% CI 0.1-8.3); infant of diabetic mother: 2.3% (95% CI 0.1-4.5); unknown, 50.7% (95% CI 33.4-68); cephalohematoma, 0.6% (95% CI 0.3-0.9). Regarding treatment of icterus, seven and eight articles were found on phototherapy and exchange transfusion, respectively. In five studies, all patients underwent phototherapy, but rate of exchange transfusion use was between 6.6% and 50.9%. CONCLUSIONS According to the results, unknown factors were the most common causes of icterus in Iranian neonates, followed by ABO blood groups incompatibility, infections and G6PD deficiency. By the way, phototherapy and exchange transfusion were found as therapeutic choices of neonatal jaundice.
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Chang N, Wang G. Diagnostic value of combination of cranial MRI, serum homocysteine and procalcitonin for hyperbilirubinemia complicated with brain injury in neonates. Exp Ther Med 2020; 20:51. [PMID: 32952641 PMCID: PMC7480122 DOI: 10.3892/etm.2020.9179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 04/21/2020] [Indexed: 12/01/2022] Open
Abstract
The present study aimed to explore the diagnostic value of the combination of cranial magnetic resonance imaging (MRI), serum homocysteine (HCY) and procalcitonin (PCT) for hyperbilirubinemia complicated with brain injury in neonates. One hundred and forty-nine children with hyperbilirubinemia admitted to Shandong Medical Imaging Research Institute from January 2014 to April 2016 were collected as research subjects, and were divided into a brain injury group (n=67) and a non-brain injury group (n=82) according to whether children suffered from brain injury. PCT levels were detected by electrochemiluminescence (ECL), and HCY levels by enzymatic cycling assay (ECA). The combination of cranial MRI, HCY and PCT was used to diagnose hyperbilirubinemia complicated with brain injury in neonates. The concentrations of HCY and PCT in the brain injury group were significantly higher than those in the non-brain injury group (P<0.001). According to the MRI examination results, the patients were divided into an MRI normal group and an MRI abnormal group. In the brain injury group, the serum HCY and PCT levels of the MRI abnormal group were significantly higher than those of the MRI normal group, with a statistically significant difference (P<0.05). In the non-brain injury group, the serum HCY and PCT levels of the MRI abnormal group were significantly higher than those of the MRI normal group, with a statistically significant difference (P<0.05). The sensitivity of the combined detection was significantly higher than that of single detection (P<0.05); the specificity was significantly higher than that of HCY detection (P<0.05), and the accuracy was significantly higher than that of MRI and HCY single detection (P<0.05). In conclusion, the combination of cranial MRI, HCY and PCT, which has a high diagnostic value for hyperbilirubinemia complicated with brain injury in neonates, is conducive to the early diagnosis and timely treatment of the disease and the reduction of sequelae.
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Affiliation(s)
- Na Chang
- Department of Medical Imaging, Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Medical Imaging, Jinan Vocational College of Nursing, Jinan, Shandong 250102, P.R. China
| | - Guangbin Wang
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, Shandong 250021, P.R. China
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Ahmad M, Rehman A, Adnan M, Surani MK. Acute bilirubin encephalopathy and its associated risk factors in a tertiary care hospital, Pakistan. Pak J Med Sci 2020; 36:1189-1192. [PMID: 32968378 PMCID: PMC7501022 DOI: 10.12669/pjms.36.6.2222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the incidence of acute bilirubin encephalopathy (ABE) and its risk factors in neonates presenting with hyperbilirubinemia in a tertiary care children hospital. METHODS This descriptive observational study was conducted from June 2018 to June 2019. A total of 300 infants who were admitted in neonatal ICU with diagnosis of hyperbilirubinemia in The Children's Hospital & The Institute of Child Health, Multan, Pakistan were included in this period. Incidence of ABE was noted. ABE was divided into two categories on the basis of severity of symptoms; mild ABE and moderate to severe ABE. Total serum bilirubin (TSB) in all neonates was measured in all patients in hospital laboratory using colorimetric method. ABO incompatibility and Rh factor incompatibility was also noted for each neonate. RESULTS Out of 300 neonates who presented with hyperbilirubinemia, ABE was diagnosed in only 42 (14.0%) neonates (mild ABE in 17 (5.7%) and moderate in 25 (8.3%). Out of 42 neonates of ABE, total serum bilirubin levels were 20-29.9 mg/dL in 24 (40.5%) neonates, and >30 mg/dL in 18 (42.8%) neonates. Pre-term birth was a significant risk factor of ABE; 23.8% in ABE and 10.70% in non-ABE (p-value 0.01). During treatment, 02 (4.76%) neonates expired due to ABE. CONCLUSION In present study, ABE was diagnosed in 14.0% neonates who presented with hyperbilirubinemia. We found pre-term delivery as a significant risk factor of ABE.
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Affiliation(s)
- Munir Ahmad
- Dr. Munir Ahmad (FCPS Pediatric Medicine), Medical Officer Pediatric Medicine, The Children's Hospital & The Institute of Child Health, Multan, Pakistan
| | - Abdur Rehman
- Dr. Abdur Rehman (FCPS Pediatric Medicine, FCPS Neonatology), Assistant Professor, The Children's Hospital & The Institute of Child Health, Multan, Pakistan
| | - Mudasser Adnan
- Dr. Mudasser Adnan (FCPS Pediatric Medicine), Senior Registrar Pediatric Medicine, The Children's Hospital & The Institute of Child Health, Multan, Pakistan
| | - Muhammad Khalil Surani
- Dr. Muhammad Khalil Surani (FCPS Pediatric Medicine), Senior Registrar Pediatric Medicine, The Children's Hospital & The Institute of Child Health, Multan, Pakistan
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Maisels MJ, Watchko JF. Improving post-discharge neonatal surveillance for the jaundiced newborn. Acta Paediatr 2020; 109:872-873. [PMID: 32017238 DOI: 10.1111/apa.15154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Beaumont Children's Hospital, Royal Oak, MI, USA
| | - Jon F Watchko
- Division of Newborn medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Zhang F, Chen L, Shang S, Jiang K. A clinical prediction rule for acute bilirubin encephalopathy in neonates with extreme hyperbilirubinemia: A retrospective cohort study. Medicine (Baltimore) 2020; 99:e19364. [PMID: 32118780 PMCID: PMC7478475 DOI: 10.1097/md.0000000000019364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
To establish a clinical prediction rule for acute bilirubin encephalopathy (ABE) in term/near-term neonates with extreme hyperbilirubinemia.A retrospective cohort study was conducted between January 2015 and December 2018. Six hundred seventy-three out of 26,369 consecutive neonates with extreme hyperbilirubinemia were enrolled in this study. Data included demographic characteristics, total serum bilirubin (TSB), albumin, bilirubin/albumin ratio (B/A), direct antiglobulin test, glucose-6-phosphate deficiency, asphyxia, sepsis, acidosis. ABE was defined as a bilirubin induced neurological dysfunction score of 4 to 9. We used stepwise logistic regression to select predictors of ABE and devised a prediction score.Of the 673 eligible infants, 10.8% suffered from ABE. Our prediction score consisted of 3 variables: TSB (as a continuous variable; odds ratio [OR] 1.16; 95% confidence interval [CI], 1.02-1.31; logistic coefficient 0.15), B/A (as a continuous variable; OR 1.88; 95% CI, 1.19-2.97; logistic coefficient 0.67), and sepsis (OR 3.78; 95% CI, 1.40-10.21; logistic coefficient 1.19). Multiplying the logistic coefficients by 10 and subtracting 75, resulted in the following equation for the score: Score = 12 × (if sepsis) + 1.5 × (TSB) + 7 × (B/A) - 75. The model performed well with an area under the curve of 0.871.The risk of ABE can be quantified according to TSB, B/A, and sepsis in term/near-term neonates with extreme hyperbilirubinemia.
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Affiliation(s)
| | | | - Shiqiang Shang
- Department of Laboratory, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kewen Jiang
- Department of Laboratory, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Extreme neonatal hyperbilirubinemia and kernicterus spectrum disorder in Denmark during the years 2000-2015. J Perinatol 2020; 40:194-202. [PMID: 31907395 DOI: 10.1038/s41372-019-0566-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 11/17/2019] [Accepted: 12/17/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the incidence and etiology of extreme neonatal hyperbilirubinemia, defined as total serum bilirubin (TSB) ≥450 µmol/L, and kernicterus spectrum disorder (KSD) in Denmark between 2000 and 2015. STUDY DESIGN We identified all infants born between 01.01.2000 and 31.12.2015 with TSB ≥450 µmol/L, ratio of conjugated to TSB <0.30, gestational age ≥35 weeks, and postnatal age ≤4 weeks, using Danish hospitals' laboratory databases. RESULT We included 408 infants. The incidence of extreme neonatal hyperbilirubinemia among infants with gestational age ≥35 weeks was 42/100,000 during the study period with a seemingly decreasing incidence between 2005 and 2015. Twelve of the 408 infants developed KSD, (incidence 1.2/100,000) Blood type ABO isohemolytic disease was the most common explanatory etiology. CONCLUSIONS Our study stresses the importance of a systematic approach to neonatal jaundice and ongoing surveillance of extreme neonatal hyperbilirubinemia and KSD.
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Lai NM, Lee SWH, Wai SX, Teh ZW, Chan MY, Lim YS, Ovelman C, Soll R. The Choice of Population and Outcomes in Neonatal Trials on Hyperbilirubinemia: Are They Relevant? An Analysis of Cochrane Neonatal Reviews. Neonatology 2020; 117:687-693. [PMID: 33264799 DOI: 10.1159/000511656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neonates with jaundice are usually managed according to their serum bilirubin despite an unclear overall correlation between bilirubin levels and patient-important outcomes (PIOs) such as kernicterus spectrum disorder (KSD). OBJECTIVES We examined data from Cochrane Neonatal reviews to assess whether conditions that constituted KSD were included as key outcomes and how commonly they occurred in the population studied. METHODS We identified Cochrane reviews, published till November 2017 that evaluated interventions for neonatal jaundice (NNJ). We extracted the following information at the review and study levels: included population, outcomes assessed (in particular, whether PIOs such as KSD were listed as the primary outcomes), as well as their cumulative incidence in the reviews. RESULTS Out of 311 reviews, 11 evaluated interventions for NNJ with 78 randomized controlled trials (RCTs) included. Among the reviews, a total number of 148 outcomes were predefined and 30 (20.3%) were PIOs related to KSD, with 11 (36.7%) listed as primary outcomes. Among the 78 included RCTs (total participants = 8,232), 38 (48.7%) enrolled predominantly high-risk and 40 (51.3%) enrolled predominantly low-risk population. A total number of 431 outcomes were reported, and 40 (9.2%) were PIOs related to KSD (of which 37 were from studies with high-risk infants), with 13 (32.5%) listed as primary outcome. Cumulatively, no infant developed KSD across all studies. CONCLUSIONS There is suboptimal representation of PIOs such as KSD in neonatal trials and Cochrane reviews on NNJ. Over half of the trials included populations with very low risk of KSD, which does not represent judicious use of resources. Amidst our continued search for a more reliable surrogate marker for NNJ, studies should evaluate the whole spectrum KSD alongside serum bilirubin in high-risk populations with sufficiently significant event rates, as this will make the trial methodologically feasible, with findings that will impact the population concerned.
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Affiliation(s)
- Nai Ming Lai
- School of Medicine, Taylor's University, Subang Jaya, Malaysia, .,School of Pharmacy, Monash University, Bandar Sunway, Malaysia,
| | | | - Sheng Xuan Wai
- University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zhi Wei Teh
- Hospital Sultanah Nora Ismail, Ministry of Health, Batu Pahat, Malaysia
| | - Min Yao Chan
- Hospital Tawau, Ministry of Health, Tawau, Malaysia
| | - Yin Sear Lim
- School of Medicine, Taylor's University, Subang Jaya, Malaysia
| | | | - Roger Soll
- Cochrane Neonatal, Burlington, Vermont, USA.,Division of Pediatrics-Neonatology, The University of Vermont Medical Center, Burlington, Vermont, USA
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Wouda EMN, Thielemans L, Darakamon MC, Nge AA, Say W, Khing S, Hanboonkunupakarn B, Ngerseng T, Landier J, van Rheenen PF, Turner C, Nosten F, McGready R, Carrara VI. Extreme neonatal hyperbilirubinaemia in refugee and migrant populations: retrospective cohort. BMJ Paediatr Open 2020; 4:e000641. [PMID: 32537522 PMCID: PMC7264833 DOI: 10.1136/bmjpo-2020-000641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To describe neonatal survival and long-term neurological outcome in neonatal hyperbilirubinaemia (NH) with extreme serum bilirubin (SBR) values. DESIGN Retrospective chart review, a one-off neurodevelopmental evaluation. SETTING Special care baby unit in a refugee camp and clinics for migrant populations at the Thailand-Myanmar border with phototherapy facilities but limited access to exchange transfusion (ET). PATIENTS Neonates ≥28 weeks of gestational age with extreme SBR values and/or acute neurological symptoms, neurodevelopment evaluation conducted at 23-97 months of age. MAIN OUTCOME MEASURES Neonatal mortality rate, prevalence of acute bilirubin encephalopathy (ABE) signs, prevalence of delayed development scores based on the Griffiths Mental Development Scale (GMDS). RESULTS From 2009 to 2014, 1946 neonates were diagnosed with jaundice; 129 (6.6%) had extreme SBR values during NH (extreme NH). In this group, the median peak SBR was 430 (IQR 371-487) µmol/L and the prevalence of ABE was 28.2%. Extreme NH-related mortality was 10.9% (14/129). Median percentile GMDS general score of 37 survivors of extreme NH was poor: 11 (2-42). 'Performance', 'practical reasoning' and 'hearing and language' domains were most affected. Four (10.8%) extreme NH survivors had normal development scores (≥50th centile). Two (5.4%) developed the most severe form of kernicterus spectrum disorders. CONCLUSION In this limited-resource setting, poor neonatal survival and neurodevelopmental outcomes, after extreme NH, were high. Early identification and adequate treatment of NH where ET is not readily available are key to minimising the risk of extreme SBR values or neurological symptoms.
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Affiliation(s)
- Eva Maria Nadine Wouda
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,University Medical Center, University of Groningen, Groningen, Netherlands
| | - Laurence Thielemans
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Neonatology-Pediatrics Department, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Mue Chae Darakamon
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Aye Aye Nge
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Wah Say
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Sanda Khing
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Borimas Hanboonkunupakarn
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Thatsanun Ngerseng
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Jordi Landier
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,IRD-INSERM-SESSTIM, Aix-Marseille Université, Marseille, France
| | | | - Claudia Turner
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Verena Ilona Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
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39
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Chang PW, Newman TB. A Simpler Prediction Rule for Rebound Hyperbilirubinemia. Pediatrics 2019; 144:peds.2018-3712. [PMID: 31196939 DOI: 10.1542/peds.2018-3712] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We previously reported a clinical prediction rule to estimate the probability of rebound hyperbilirubinemia using gestational age (GA), age at phototherapy initiation, and total serum bilirubin (TSB) relative to the treatment threshold at phototherapy termination. We investigated (1) how a simpler 2-variable model would perform and (2) the absolute rebound risk if phototherapy were stopped at 2 mg/dL below the threshold for treatment initiation. METHODS Subjects for this retrospective cohort study were infants born 2012-2014 at ≥35 weeks' gestation at 1 of 17 Kaiser Permanente hospitals who underwent inpatient phototherapy before age 14 days. TSB reaching the phototherapy threshold within 72 hours of phototherapy termination was considered rebound. We simplified by using the difference between the TSB level at the time of phototherapy termination and the treatment threshold at the time of phototherapy initiation as 1 predictor, and kept GA as the other predictor. RESULTS Of the 7048 infants treated with phototherapy, 4.6% had rebound hyperbilirubinemia. The area under the receiver operating characteristic curve was 0.876 (95% confidence interval, 0.854 to 0.899) for the 2-variable model versus 0.881 (95% confidence interval, 0.859 to 0.903) for the 3-variable model. The rebound probability after stopping phototherapy at 2 mg/dL below the starting threshold was 2.5% for infants ≥38 weeks' GA and 10.2% for infants <38 weeks' GA. CONCLUSIONS Rebound hyperbilirubinemia can be predicted by a simpler 2-variable model consisting of GA and the starting threshold-ending TSB difference. Infants <38 weeks' gestation may need longer phototherapy because of their higher rebound risk.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; Departments of
| | - Thomas B Newman
- Epidemiology and Biostatistics and.,Pediatrics, University of California, San Francisco, San Francisco, California; and.,Division of Research, Kaiser Permanente Northern California, Oakland, California
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40
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Le (乐娟) J, Yuan (袁腾飞) TF, Geng (耿嘉庆) JQ, Wang (王少亭) ST, Li (李艳) Y, Zhang (张炳宏) BH. Acylation derivatization based LC-MS analysis of 25-hydroxyvitamin D from finger-prick blood. J Lipid Res 2019; 60:1058-1064. [PMID: 30902903 PMCID: PMC6495167 DOI: 10.1194/jlr.d092197] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/20/2019] [Indexed: 12/13/2022] Open
Abstract
Vitamin D metabolite analysis possessed significant clinical value for the pediatric department. However, invasive venipuncture sampling and high blood consumption inflicted much suffering on patients. For alleviation, we carried out a LC-MS method for 25-hydroxyvitamin D quantification in only 3 μl of plasma from the considerably less invasive finger-prick blood samples. To improve sensitivity, acylation on C3-hydroxyl (by isonicotinoyl chloride) rather than Diels-Alder adduction on s-cis-diene structure was for the very first time introduced into vitamin D metabolite derivatization. Compared with the existing derivatization approaches, this novel strategy not only prevented isomer interference, but also exhibited higher reacting throughput. For certification, the methodology was systematically validated and showed satisfying consistency with SRM927a. During clinical application, we found a convincing correlation between 25-hydroxyvitamin D and indirect/total bilirubin in jaundiced newborns. Such an observation indicated that vitamin D supplementation may help to achieve optimal outcomes in neonatal jaundice.
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Affiliation(s)
- Juan Le (乐娟)
- Department of Clinical LaboratoryRenmin Hospital of Wuhan University, 430060 Wuhan, China
| | - Teng-Fei Yuan (袁腾飞)
- Department of Clinical LaboratoryRenmin Hospital of Wuhan University, 430060 Wuhan, China
| | - Jia-Qing Geng (耿嘉庆)
- Pediatric DepartmentRenmin Hospital of Wuhan University, 430060 Wuhan, China
| | - Shao-Ting Wang (王少亭)
- Department of Clinical LaboratoryRenmin Hospital of Wuhan University, 430060 Wuhan, China
| | - Yan Li (李艳)
- Department of Clinical LaboratoryRenmin Hospital of Wuhan University, 430060 Wuhan, China
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41
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Variation in Transcutaneous Bilirubin Nomograms across Population Groups. J Pediatr 2019; 208:273-278.e1. [PMID: 30853197 DOI: 10.1016/j.jpeds.2019.01.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/10/2018] [Accepted: 01/17/2019] [Indexed: 12/15/2022]
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42
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Horn D, Ehret D, Suresh G, Soll R. Sunlight for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates. Cochrane Database Syst Rev 2019. [DOI: 10.1002/14651858.cd013277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Delia Horn
- Larner College of Medicine at the University of Vermont; Division of Neonatal-Perinatal Medicine, Department of Pediatrics; Burlington Vermont USA
| | - Danielle Ehret
- Larner College of Medicine at the University of Vermont; Division of Neonatal-Perinatal Medicine, Department of Pediatrics; Burlington Vermont USA
| | - Gautham Suresh
- Baylor College of Medicine; Section of Neonatology, Department of Pediatrics; Houston Texas USA
| | - Roger Soll
- Larner College of Medicine at the University of Vermont; Division of Neonatal-Perinatal Medicine, Department of Pediatrics; Burlington Vermont USA
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43
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Alkén J, Håkansson S, Ekéus C, Gustafson P, Norman M. Rates of Extreme Neonatal Hyperbilirubinemia and Kernicterus in Children and Adherence to National Guidelines for Screening, Diagnosis, and Treatment in Sweden. JAMA Netw Open 2019; 2:e190858. [PMID: 30901042 PMCID: PMC6583272 DOI: 10.1001/jamanetworkopen.2019.0858] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
IMPORTANCE Neonatal hyperbilirubinemia can cause lifelong neurodevelopmental impairment (kernicterus) even in high-resource settings. A better understanding of the incidence and processes leading to kernicterus may help in the design of preventive measures. OBJECTIVES To determine incidence rates of hazardous hyperbilirubinemia and kernicterus among near-term to term newborns and to evaluate health care professional adherence to best practices. DESIGN, SETTING, AND PARTICIPANTS This population-based nationwide cohort study used prospectively collected data on the highest serum bilirubin level for all infants born alive at 35 weeks' gestation or longer and admitted to neonatal care at all 46 delivery and 37 neonatal units in Sweden from 2008 to 2016. Medical records for newborns with hazardous hyperbilirubinemia were evaluated for best neonatal practices and for a diagnosis of kernicterus up to 2 years of age. Data analyses were performed between September 2017 and February 2018. EXPOSURES Extreme (serum bilirubin levels, 25.0-29.9 mg/dL [425-509 μmol/L]) and hazardous (serum bilirubin levels, ≥30.0 mg/dL [≥510 μmol/L]) neonatal hyperbilirubinemia. MAIN OUTCOMES AND MEASURES The primary outcome was kernicterus, defined as hazardous neonatal hyperbilirubinemia followed by cerebral palsy, sensorineural hearing loss, gaze paralysis, or neurodevelopmental retardation. Secondary outcomes were health care professional adherence to national guidelines using a predefined protocol with 10 key performance indicators for diagnosis and treatment as well as assessment of whether bilirubin-associated brain damage might have been avoidable. RESULTS Among 992 378 live-born infants (958 051 term births and 34 327 near-term births), 494 (320 boys; mean [SD] birth weight, 3505 [527] g) developed extreme hyperbilirubinemia (50 per 100 000 infants), 6.8 per 100 000 infants developed hazardous hyperbilirubinemia, and 1.3 per 100 000 infants developed kernicterus. Among 13 children developing kernicterus, brain injury was assessed as potentially avoidable for 11 children based on the presence of 1 or several of the following possible causes: untimely or lack of predischarge bilirubin screening (n = 6), misinterpretation of bilirubin values (n = 2), untimely or delayed initiation of treatment with intensive phototherapy (n = 1), untimely or no treatment with exchange transfusion (n = 6), or lack of repeated exchange transfusions despite indication (n = 1). CONCLUSIONS AND RELEVANCE Hazardous hyperbilirubinemia in near-term or term newborns still occurs in Sweden and was associated with disabling brain damage in 13 per million births. For most of these cases, health care professional noncompliance with best practices was identified, suggesting that a substantial proportion of these cases might have been avoided.
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Affiliation(s)
- Jenny Alkén
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Stellan Håkansson
- Department of Clinical Science/Pediatrics, Umeå University, Umeå, Sweden
- Swedish Neonatal Quality Registry, Umeå, Sweden
| | - Cecilia Ekéus
- Division of Reproductive Health, Department of Women’s and Children’s Health, Karolinska Institutet, Sweden
| | | | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Swedish Neonatal Quality Registry, Umeå, Sweden
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44
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Bassett HK, Rowinsky P. The Snowball Effect of Low-Value Care. Hosp Pediatr 2018; 8:793-795. [PMID: 30498164 DOI: 10.1542/hpeds.2018-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Hannah K Bassett
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California;
| | - Peter Rowinsky
- Department of Pediatrics, Kaiser Permanente Santa Rosa, Santa Rosa, California; and
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
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45
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Bilirubin binding in jaundiced newborns: from bench to bedside? Pediatr Res 2018; 84:494-498. [PMID: 29967530 DOI: 10.1038/s41390-018-0010-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 02/23/2018] [Accepted: 03/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bilirubin-induced neurologic dysfunction (BIND) is a spectrum of preventable neurological sequelae in jaundiced newborns. Current total plasma bilirubin (BT) concentration thresholds for phototherapy and/or exchange transfusion poorly predict BIND. METHODS The unbound (free) bilirubin (Bf) measured at these BT thresholds provides additional information about the risk for BIND. Bf can be readily adapted to clinical use by determining Bf population parameters at current BT thresholds. These parameters can be established using a plasma bilirubin binding panel (BBP) consisting of BT, Bf, and two empiric constants, the maximum BT (BTmax) and the corresponding equilibrium association bilirubin constant (K). RESULTS BTmax and K provide the variables needed to accurately estimate Bf at BT < BTmax to obtain Bf at threshold BT in patient samples. Once Bf population parameters are known, the BBP in a newborn can be used to identify poor bilirubin binding (higher Bf at the threshold BT compared with the population) and increased risk of BIND. CONCLUSION The BBP can also be used in jaundice screening to better identify the actual BT at which intervention would be prudent. The BBP is used with current BT thresholds to better identify the risk of BIND and whether and when to intervene.
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46
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Wennberg RP. Commentary: Bench to bedside-one step closer? Pediatr Res 2018; 84:483-484. [PMID: 30209388 DOI: 10.1038/s41390-018-0057-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/01/2018] [Indexed: 11/09/2022]
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47
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Taylor JA. Phototherapy and Seizures: Should We Change Practice? Pediatrics 2018; 142:peds.2018-2241. [PMID: 30249625 DOI: 10.1542/peds.2018-2241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- James A Taylor
- Department of Pediatrics, University of Washington, Seattle, Washington
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48
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Kuzniewicz MW, Niki H, Walsh EM, McCulloch CE, Newman TB. Hyperbilirubinemia, Phototherapy, and Childhood Asthma. Pediatrics 2018; 142:peds.2018-0662. [PMID: 30209075 DOI: 10.1542/peds.2018-0662] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aim was to quantify the associations of both hyperbilirubinemia and phototherapy with childhood asthma using a population-based cohort with total serum bilirubin (TSB) levels. METHODS Retrospective cohort study of infants born at ≥35 weeks' gestation in the Kaiser Permanente Northern California health system (n = 109 212) from 2010 to 2014. Cox models were used to estimate hazard ratios (HRs) for a diagnosis of asthma. RESULTS In the study, 16.7% of infants had a maximum TSB level of ≥15 mg/dL, 4.5% of infants had a maximum TSB level of ≥18 mg/dL, and 11.5% of infants received phototherapy. Compared with children with a maximum TSB level of 3 to 5.9 mg/L, children with a TSB level of 9 to 11.9 mg/dL, 12 to 14.9 mg/dL, and 15 to 17.9 mg/dL were at an increased risk for asthma (HR: 1.22 [95% confidence interval (CI): 1.11-1.3], HR: 1.18 [95% CI: 1.08-1.29], and HR: 1.30 [95% CI: 1.18-1.43], respectively). Children with a TSB level of ≥18 mg/dL were not at an increased risk for asthma (HR: 1.04; 95% CI: 0.90-1.20). In propensity-adjusted analyses, phototherapy was not associated with asthma (HR: 1.07; 95% CI: 0.96-1.20). CONCLUSIONS Modest levels of hyperbilirubinemia were associated with an increased risk of asthma, but an association was not seen at higher levels. No dose-response relationship was seen. Using phototherapy to prevent infants from reaching these modest TSB levels is unlikely to be protective against asthma.
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Affiliation(s)
- Michael W Kuzniewicz
- Division of Research, Kaiser Permanente, Oakland, California; and .,Departments of Pediatrics and
| | - Hamid Niki
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Charles E McCulloch
- Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Thomas B Newman
- Departments of Pediatrics and.,Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
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Diala UM, Wennberg RP, Abdulkadir I, Farouk ZL, Zabetta CDC, Omoyibo E, Emokpae A, Aravkin A, Toma B, Oguche S, Slusher T. Patterns of acute bilirubin encephalopathy in Nigeria: a multicenter pre-intervention study. J Perinatol 2018; 38:873-880. [PMID: 29593357 DOI: 10.1038/s41372-018-0094-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 01/16/2018] [Accepted: 02/26/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute bilirubin encephalopathy (ABE) is an important cause of neonatal morbidity in Nigeria, accounting for 5-14% of neonatal deaths. Most newborns with severe ABE have irreversible damage before receiving treatment emphasizing the need for timely pre-admission monitoring and referral. There is limited evidence that educational interventions targeting mothers and health care providers will reduce delayed care. OBJECTIVE To provide baseline data on the incidence of ABE and associated pre-admission risk factors in five centers of Nigeria in order to evaluate the effect of subsequent educational interventions on outcome. STUDY DESIGN The incidence of ABE among newborns treated for hyperbilirubinemia was documented prospectively. Bivariate analysis and multivariate logistic regression were used to evaluate risk factors for acute bilirubin encephalopathy and reasons for regional differences in its occurrence. RESULTS Of 1040 infants, 159 treated for hyperbilirubinemia (15.3%) had mild to severe bilirubin encephalopathy (including 35 deaths), but the incidence ranged from 7 to 22% between centers. Logistic regression identified four common predictors: total serum bilirubin (odds ratio 1.007 per mg/dl rise), out-of-hospital births (OR 2.6), non-alloimmune hemolytic anemia (OR 2.8), and delayed care seeking (OR 4.3). CONCLUSION The high occurrence of bilirubin encephalopathy in Nigeria is due in large part to a delay in seeking care. A planned intervention strategy will target conditions leading to severe hyperbilirubinemia and delay.
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Affiliation(s)
| | | | | | | | | | | | | | - Aleksandr Aravkin
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | | | | | - Tina Slusher
- University of Minnesota and Hennepin County Medical Center, Minneapolis, MN, USA
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50
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Mehrpisheh S, Memarian A, Mahyar A, Valiahdi NS. Correlation between serum vitamin D level and neonatal indirect hyperbilirubinemia. BMC Pediatr 2018; 18:178. [PMID: 29803223 PMCID: PMC5970522 DOI: 10.1186/s12887-018-1140-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 05/02/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Considering the significant prevalence of Neonatal Indirect Hyperbilirubinemia (NIH) and its irreversible neurological complications, identifying the factors involved in the prevalence of neonatal jaundice is essential. The present study was conducted to determine the relationship between serum vitamin D levels and the prevalence of NIH in infants admitted to Qods Hospital of Qazvin in Iran in 2015-16. METHODS In this case-control study, 30 term infants with NIH (the case group) were compared with 30 healthy, non- icteric, term infants (the control group) in terms of serum levels of 25-hydroxyvitamin D. The results were analyzed and compared between the two groups using t-test and the Chi-square test. RESULTS The mean and standard deviation of serum 25-hydroxyvitamin D levels were 10.76 ± 8.6 ng/dl in the case group and 14.88 ± 11.38 ng/dl in the control group. There were no significant differences between the two groups (P = 0.11). CONCLUSION The results suggest the lack of a relationship between vitamin D levels and NIH. However, further prospective studies are needed to conclude that vitamin D has no role in the pathogenesis of NIH.
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Affiliation(s)
- Shahrokh Mehrpisheh
- Department of Neonatology, Mazandaran University of Medical Sciences, Mazandaran, Iran
| | - Azadeh Memarian
- Department of Forensic Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Abolfazl Mahyar
- Department of Pediatrics, Qazvin University of Medical Sciences, Tehran, Iran
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