Neonatal hyperbilirubinemia: An evidence-based approach
This review provides the latest advice on the screening and management of hyperbilirubinemia in term infants.
PRACTICE RECOMMENDATIONS
› Diagnose hyperbilirubinemia in infants with bilirubin measured at >95th percentile for age in hours. Do not use visual assessment of jaundice for diagnosis as it may lead to errors. C
› Determine the threshold for initiation of phototherapy by applying serum bilirubin and age in hours to the American Academy of Pediatrics phototherapy nomogram along a risk curve assigned based on gestational age and neurotoxicity risk factors (not major and minor risk factors for severe hyperbilirubinemia). C
› Make arrangements to ensure that all infants are seen by a health care provider within 2 days of discharge (within 1 day if significant risk factors for development of severe hyperbilirubinemia are present). C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The US Preventative Services Task Force, however, found insufficient evidence to recommend universal screening for infants ≥35 weeks’ gestation.27 The main rationale for their “I” recommendation was that although screening can identify infants at risk of developing severe hyperbilirubinemia, there is no clear evidence that identifying and treating elevated bilirubin levels results in the prevention of kernicterus.
The United Kingdom’s National Institute for Health and Care Excellence (NICE) guidelines do not support universal screening either.28 NICE recommends risk factor assessment and visual inspection for jaundice in all newborns and also additional physical examination for newborns with risk factors. NICE recommends against routine monitoring of bilirubin levels in infants who do not appear jaundiced.
All infants who appear jaundiced should be evaluated with either risk factor assessment or bilirubin measurement (TSB or TcB). Infants born to mothers who are Rh-negative or have type O blood should have cord blood tested for blood type, Rh status, and other antibodies with a direct Coombs test, as ABO and Rh incompatibility are major risk factors for development of hyperbilirubinemia because of hemolysis.8,9
A question of cost-efficacy? Data from a multicenter prospective clinical trial suggest a number needed to screen of 128,600 to prevent 1 case of kernicterus,29 making cost another important factor in the discussion about screening for neonatal hyperbilirubinemia. Universal screening is associated not only with the cost of TSB and TcB measurements, but also with the cost of phototherapy, rates of which are increased with universal screening.24,29,30 The cost of caring for 1 patient with kernicterus over a lifetime is estimated at $900,000, while the estimated cost to prevent 1 case of kernicterus with universal TSB/TcB screening is between $5.7 and $9.2 million.31
In Canada, universal screening was found to decrease emergency department visits for jaundice, but did not affect rates of readmission for hyperbilirubinemia, length of hospital stay, or rates of phototherapy after discharge.30
Continue to: Phototherapy: What kind of light, when to initiate
