Total Serum Bilirubin Exceeding Exchange Transfusion Thresholds in the Setting of Universal Screening
Department of Pediatrics, University of California, San Francisco, CA, USA. The Journal of pediatrics
(Impact Factor: 3.79).
11/2011; 160(5):796-800.e1. DOI: 10.1016/j.jpeds.2011.09.063
To describe the incidence and predictors of total serum bilirubin (TSB) levels that meet or exceed American Academy of Pediatrics (AAP) exchange transfusion (ET) thresholds in the setting of universal screening.
We conducted a retrospective cohort analysis of electronic data on 18 089 newborns ≥35 weeks gestation born at Northern California Kaiser Permanente Medical Care Program hospitals implementing universal TSB screening in 2005 to 2007, with chart review for subjects with TSB levels reaching the AAP threshold for ET.
The outcome developed in 22 infants (0.12%); 14 (63.6%) were <38 weeks gestation. Only one infant received an ET; none of the infants had documented sequelae. The first TSB was at least high-intermediate risk on the AAP risk-nomogram for all 22 infants and high-risk for those ≥38 weeks, but was less than the phototherapy level in 15 infants (68%). Of these 15 infants, 2 failed phototherapy and 13 did not have a TSB repeated in <24 hours. However, re-testing all infants at high-intermediate risk or greater would have required 2166 additional bilirubin tests.
Screening was sensitive but not specific for predicting exchange threshold.
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ABSTRACT: Because heme catabolism leads to the formation of equimolar amounts of carbon monoxide (CO) and bilirubin, a variety of techniques have been developed to correlate CO production rates as indices of bilirubin production. The use of end-tidal breath CO measurements for estimating rates of bilirubin production in infants has been well documented and validated in a number of clinical studies for its use and predictive value in identifying infants who are high producers of bilirubin and hence at risk for developing pathologic neonatal hyperbilirubinemia. Recently, end-tidal breath CO has been suggested as a marker for chronic lung disease and developmental problems. Trace gas analysis remains an area for interesting investigation in the future. © 2012 by the American Academy of Pediatrics. All rights reserved.
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ABSTRACT: We report a series of neonates who developed a total serum bilirubin (TSB) >20mg/dL during a recent ten-year period in a multihospital healthcare system. The incidence of a TSB >20mg/dL fell after instituting a pre-hospital discharge bilirubin screening program in 2003/2004 (91.3 cases/10,000 births before vs. 72.4/10,000 after), but the incidence has subsequently remained unchanged. No specific cause for the hyperbilirubinemia was identified in 66% of (n=32) cases with a TSB >30mg/dL or in 76% of (n=112) cases with a TSB 25.0-29.9mg/dL. We hypothesized that hemolysis was a common contributing mechanism, but our review of hospital records indicated that in most instances these infants were not evaluated sufficiently to test this hypothesis. Records review showed maternal and neonatal blood types and direct antiglobulin testing were performed in >95% cases, but rarely were other tests for hemolysis obtained. In the ten-year period reviewed there were zero instances where erythrocyte morphology from a blood film examination or Heinz body evaluation by a pediatric hematologist or pathologist were performed. In 3% of cases pyruvate kinase was tested, 3% were evaluated by hemoglobin electrophoresis, 3% had a haptoglobin measurement, and 16% were tested for G6PD deficiency. Thus, determining the cause for hyperbilirubinemia in neonates remains a problem at Intermountain Healthcare and, we submit, elsewhere. As a result, the majority of infants with a TSB >25mg/dL have no specific causation identified. We speculate that most of these cases involve hemolysis and that the etiology could be identified if searched for more systematically. With this in mind, we propose a "consistent approach" to evaluating the cause(s) of hyperbilirubinemia among neonates with a TSB >25mg/dL.
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