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S l i
Solving the
h CControversies
i
Assoc. Prof. Pimol Wongsiridej, MD.
Division of Neonatology,
Department of Pediatrics
FROM GUIDELINES TO CLINICAL
PRACTICE
FOCUS OF AAPs 2004
GUIDELINE
z universal systematic
y assessment for the
risk of severe hyperbilirubinemia
z Close follow
follow-up
up
z Prompt intervention when indicated
Key elements of the
recommendations:
Visual
assessment:
accuracy
Bilirubin
measurement
Follow up plan
Treatment
SCREENING INFANT AT RISK
FOR SIGNIFICANT
HYPERBILIRUBINEMIA
Case 1.
z A 3-day-old
y infant,, born at 39 weeks byy
cesarean section, has no visibly apparent
jjaundice on the morning g of discharge.
g Is it
medically necessary to measure a bilirubin
g
before discharge?
Screening methods available
z Jaundice assessment
z Bilirubin measurement
z Clinical risk assessment
z Combination
Visual assessment of jaundice
extent
zQ
Questions in clinical p
practice??
Good correlation with bilirubin level ?
Predicting
g risk of significant
g neonatal
hyperbilirubinemia??
z Riskin A et al. J Pediatr 2008;152:782-7
;
z Karen T et al. Arch Dis Child Fetal
Neonatal Ed 2009;94:F317F322
Authors Riskin A et al Karen T et al
J Pediatr Arch Dis Child Fetal
2008;152:782-7) Neonatal Ed
2009;94:F317F322
z A 3-day-old
y infant,, born at 39 weeks byy
cesarean section, has no visibly apparent
jjaundice on the morning g of discharge.
g Is it
medically necessary to measure a bilirubin
before discharge?
g
z Answers:
No clinically apparent jaundice
more than 60 h old and above 38-week
gestation
gestat o
visual assessment alone may be appropriate
clinical risk factor assessment performed
early newborn follow-up arranged
Clinical risk factors for severe
neonatal hyperbilirubinemia
Clinical risk factors for severe
neonatal hyperbilirubinemia
Clinical risk factors for severe
neonatal hyperbilirubinemia
Case 2:
z Purpose
p of Predischarge
g bilirubin
screening (age 18 to 48 h)
identifies infants with bilirubin levels >75th
percentile for age in hours
tracks infants with rapid rates of bilirubin rise
(>0.2 mg per 100 ml per h)
Total serum bilirubin
measurement
zp
powerful and significant
g screening
g tool in
term and late preterm infants
Possible errors
z Pre-analytical
y errors
related to blood procurement procedure
rapidity
p y and conditions of transportation
p to the
laboratory
z Analytical
y errors
haemolysis, when collecting blood from a heel
p
prick,
, release of haemoglobin
g and other
intracellular compounds interfere with
chemical-based measurement of bilirubin
Nomogram for designation of risk in 2840 well newborns at 36 or
more weeks gestational age with birth weight of 2000 g or more
or 35 or more weeks gestational age and birth weight of 2500 g or
more based on the hour-specific serum bilirubin values
Outcome of newborns in the low-risk
zone
n =1756 (61.8%)
Outcome of newborns in the lower
intermediate-risk zone
n = 556 (19.6%
Outcome of newborns in the
upper intermediate-risk zone
n = 356 (12.5%)
Outcome of newborns in the high
risk zone
n = 172 (6.0%)
Predictive abilities of the 40th, 75th,
and the 95th percentile-based risk
zones
TRANSCUTANEOUS BILIRUBIN
MEASUREMENTS
Benefit of TcB as point of care
z non-invasive
z Reduce Turnaround time, to access results
z fewer readmissions
z decrease hospitalization charges
z reducing number of skin punctures
drawback
z increased operational
p costs
z May increased number of newborns
treated with phototherapy prior to
discharge
TcB measurement sites
z multiracial p
population
p of 289 neonates
z gestational age 35 to 41 weeks
z Devices: Bilicheck
Bilicheck, BiliMed
BiliMed, JM-103
z TSB>14 mg/dl used as cut-off
z correlation analysis : good results for
Bilicheck (r = 0.86) and JM-103 (r = 0.85)
but poor for BiliMed (r = 0,70)
bilicheck: underestimate TSB
JM-103: overestimate TSB
z Answers:
TcB measurement is above 12 mg/dl, a TSB
measurement should be performed
Nomogram for transcutaneous
bilirubin measurements among
healthy newborns
Maisels MJ, Kring E. Transcutaneous bilirubin levels in the first 96 h in a normal newborn
population of > or 35 weeks gestation. Pediatrics 2006;117:11691173.
Use of TcB Measurements
z Clarifications
2 categories of Risk factors
z Update
Universal predischarge TSB/TcB Screening
after age 18 h and prior to discharge
Algorithm for management and follow up
TABLE 1 Important Risk Factors
yp
for Severe Hyperbilirubinemia
Bilicheck
JM 103
TcB
z SpectRx,
p , Bilicheck
R = 0.95 (p < 0.05)
Overestimate TSB
z mean difference 0.35 + 0.63 mg/dl (p > 0.05)