Measurement of total plasma/serum bilirubin (TSB) combined with predischarge transcutaneous bilirubin (TcB) levels plus clinical factors best identifies neonates who require phototherapy, research shows.
Vinod Bhutani (Stanford University, Palo Alto, California, USA) and team found that predischarge TSB identified 41 (4.2%) and 34 (3.5%) infants out of a total of 972 infants with jaundice who required phototherapy before and after discharge, respectively.
Transcutaneous bilirubin (TcB) was measured at 24 hours, with TSB at 24-60 hours and at 3- to 5- and 7- to 14-day follow-up visits.
Prediction of postdischarge phototherapy was comparable when using combined clinical risk factors - early gestational age (<39 weeks), bruising, positive direct antiglobulin test, Asian race, exclusive breastfeeding, blood type incompatibility, and jaundice extent - and age-adjusted TSB and TcB, at area under the curve (AUC) values of 0.86 and 0.87, respectively.
"The predictive role of gestational age as a preeminent clinical risk factor for subsequent phototherapy highlights the need for close monitoring of infants of less than 38 weeks' gestational age during the first week after birth," the authors say.
They also found that combined screening with TSB and TcB was more accurate than either of these prediction methods alone, at an AUC value of 0.95. Moreover, TcB or TSB combined with gestational age alone was equally as predictive as the combined screening method, also with an AUC of 0.95.
Bhutani et al say that the finding that the combination of hour-specific bilirubin measurements and gestational age alone was as predictive of subsequent phototherapy as the hour-specific bilirubin measurement combined with multiple clinical risk factors "offers this approach as more practical and easier to implement" than documentation and ranking of multiple clinical risk factors.
The study included 983 healthy infants of 35 weeks gestation or more at six centres that practice universal predischarge TSB screening. Twenty five percent of the babies were nonWhite and 55% were Hispanic or Latino. Of the total cohort, more than 90% were breastfed.
"We have shown in this racially and ethnically diverse cohort that the combined use of a bilirubin measurement at 24-48 hours postnatal age and gestational age is the best predictor of subsequent use of phototherapy," remark the authors in the Journal of Pediatrics.
"The predictability of this combination (AUC=0.95) provides evidence that supports the recommendations made by the American Academy of Pediatrics Expert Panel."
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