Tx Rates Similar With Routine Bilirubin Screening

Major Finding: There were 125 blood draws per month for bilirubin before and 117 after implementation of a routine screening protocol. An average of 6.8 infants per month underwent predischarge phototherapy before and 4.6 after routine screening was adopted. When readmission phototherapy was included, 9.5 infants received treatment before and 8 infants after routine screening was implemented.

Data Source: Retrospective analysis of 2,055 term infants.

Disclosures: The study was funded by the Clinical Practice Innovation program at the Mayo Clinic. The authors disclosed no conflicts of interest.

VANCOUVER, B.C. — Universal neonatal screening for hyperbilirubinemia can be implemented without increasing blood draws or phototherapy usage, according to a retrospective analysis involving 2,055 newborns.

The number of blood draws for bilirubin was similar at 125 per month before implementation of a routine transcutaneous bilirubin screening protocol vs. 117 per month after implementation.

The average number of infants who underwent phototherapy during initial hospitalization was 6.8 before vs. 4.6 after implementation. The decrease approached statistical significance, with a P value of .053, reported Dr. Andrea Wickremasinghe of the Mayo Clinic in Rochester, Minn.

Overall monthly phototherapy usage was also similar when readmission phototherapy was included, at 9.5 infants before and 8 infants after adoption of the protocol, the researchers found.

Several professional organizations have endorsed such screening, including the Canadian Paediatric Society and the American Academy of Pediatrics, which recommends that all infants undergo systematic assessment for hyperbilirubinemia before discharge. Last year, however, the U.S. Preventive Services Task Force concluded that there is insufficient evidence to determine if universal screening can prevent chronic bilirubin encephalopathy (kernicterus).

Jaundice occurs in two-thirds of newborns in the first week of life and typically resolves without sequelae, but in rare cases it leads to acute or chronic bilirubin encephalopathy.

Hyperbilirubinemia is increasingly being missed because more newborns are discharged from hospitals within 2 days of birth. Bilirubin levels peak at 3–5 days after birth, when hyperbilirubinemia usually becomes clinically evident, Dr. Wickremasinghe said. Problems with breastfeeding and late follow-up care also increase the risk for missed cases.

Transcutaneous bilirubin (TcB) testing is gaining in popularity as a predischarge screening method, and is thought to reasonably approximate total serum bilirubin (TSB) levels without the pain of a puncture or need to wait for lab results, she said. In one study, selective TcB screening did not change the number of blood draws for bilirubin, but did decrease readmissions for jaundice within 7 days of discharge (Clin. Chem. 2005;51:540–4).

Last year, a study conducted by two of Dr. Wickremasinghe's coauthors suggested that TcB testing systematically overestimates serum bilirubin levels and that 1 mg/dL should be subtracted from TcB levels.

The current analysis looked at electronic medical records from August 2008 through January 2009 and February 2009 through August 2009—before and after implementation of TcB screening.

During the first study period, serum bilirubin was obtained based on clinical judgment from 906 infants and plotted on an hour-specific nomogram (www.bilitool.org

During the second period, TcB measurements were obtained shortly before discharge using the BiliChek device (Philips) on the forehead in 1,149 infants. The values were adjusted by 1 mg/dL and plotted on the same serum bilirubin nomogram. A serum bilirubin level was obtained if patients were thought to be high risk, defined by a bilirubin value in the 95th percentile for their age on the nomogram, or high-intermediate risk, defined by a value in the 75th or higher percentile for age, Dr. Wickremasinghe said.

The average monthly nursery census was similar in each group, at 151 infants during the first period and 161 infants during the second.

Dr. Wickremasinghe acknowledged that the study limitations were that it was retrospective, that TcB values were plotted on a TSB nomogram, and that it may be difficult to generalize the results to other ethnicities because the population was predominantly white. The effect of TcB screening on costs was not determined, but may be analyzed in the future.

During a discussion of the findings, Dr. M. Jeffrey Maisels, chair of pediatrics at Beaumont Hospitals in Royal Oak, Mich., applauded the authors for adjusting TcB values in the analysis, noting that such values have been as much as 2–3 mg higher than those obtained with other methods in some studies. He said that although it may never be known if predischarge bilirubin screening can prevent an infant from developing kernicterus, screening does seem to reduce the number of infants readmitted with very high bilirubin levels.

This view is supported by a recent prospective study reporting a dramatic decline in severe hyperbilirubinemia among more than 1 million infants born between May 2004 and December 2008. The incidence of infants with total bilirubin levels of 25.0–29.9 mg/dL declined from 43/100,000 before implementation of universal predischarge bilirubin screening to 27/100,000 after implementation, while the incidence of infants with total bilirubin levels of at least 30 mg/dL dropped from 9/100,000 to 3/100,000. The change was associated with a small but statistically significant increase in use of phototherapy (Pediatrics 2010;125:e1143–8).