When to look harder at jaundice

Even though most babies with jaundice have uncomplicated jaundice, 18% of them will have their course complicated by hemolysis. If one is following American Academy of Pediatrics (AAP) guidelines,¹ said Janelle L Aby, MD, FAAP, one might need to treat at a little lower level than one otherwise would, depending on the clinical situation.

When one looks at data from across the country, there is significant variation in how phototherapy is used, and a sense that phototherapy is overused in some cases and underused in others, Aby told pediatricians in her session “Neonatal jaundice: When to look further, when to be concerned” at the American Academy of Pediatrics (AAP) National Conference. These data aren't new, she said, but the concept of crash-cart phototherapy is, particularly to community pediatricians.

Crash-cart phototherapy means starting phototherapy in the office, the moment one confirms an urgent need for it. If a pediatrician seeing a baby grows very concerned about high levels of jaundice and perhaps lethargy because of bilirubin toxicity, he or she should not just call a local neonatal intensive care unit and arrange for ambulance transport. Start phototherapy right in the office at that moment, so the baby can get treatment while being transported.

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Urgently starting phototherapy can make a significant difference in outcomes, while delays longer than an hour can be problematic. Just as hospitals stock oxygen or EpiPens, a community pediatrician might need a phototherapy device in his or her office. That's not standard practice for community pediatricians presently.

To think through a clinical scenario in a stepwise fashion, remember the RAINBOW acronym:

·      Risk of bilirubin toxicity.

·      Assess rate of bilirubin rise.

·      Investigate causes of hyperbilirubinemia.

·      Number (total bilirubin/TB) at which to treat.

·      Breastfeeds to continue.

·      Outcome.

·      Well-being at follow-up.

Another invaluable tool is available at www.bilitool.org. Plugging in information such as the baby's age and bilirubin level calls up published nomograms and AAP treatment guidelines for that case. Not every baby with the same numeric bilirubin level is the same. Say a preterm baby's bilirubin level falls into the Bhutani nomogram² low-intermediate risk category. If the baby is late preterm with hemolysis, he or she might already have surpassed the threshold at which AAP guidelines recommend phototherapy.

It's a 2-step process-the Bhutani nomogram provides a general picture of risk, while AAP guidelines drill down into actual treatment recommendations. Using these guidelines is somewhat tricky because the AAP uses slightly different risk categories. Consider a bilirubin level of 15 mg/dL at 60 hours. For a term neonate without risk factors, the AAP does not recommend phototherapy until 16 mg/dL or higher. However, if a baby has hemolysis, AAP guidelines recommend phototherapy at 15 mg/dL. There's no specific number that drives treatment decisions because every hour the threshold changes, for all categories.

Ultimately, said Aby, we are trying to identify the babies who really need to start phototherapy at a lower TB level, versus those who perhaps do not.

REFERENCES

1. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297-316. Erratum in: Pediatrics. 2004;114(4):1138.

2. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103(1):6-14.

NEXT: Commentary

COMMENTARY

Approximately 70% of newborns will have evidence of clinical jaundice within the first week of life. A smaller fraction of these babies will need phototherapy to avoid bilirubin encephalopathy due to severe hyperbilirubinemia. Dr. Aby’s presentation emphasizes key strategies in the assessment and management of newborns at risk for worsening hyperbilirubinemia.

The concept of in-office phototherapy, however, is indeed new to most community pediatricians. For clinicians practicing in remote areas, initiating phototherapy in the office prior to transport to a local medical center may improve both short-term and long-term outcomes of newborns with severe hyperbilirubinemia. However, physicians and office staff in this scenario must be cognizant of the proper use of phototherapy, ensuring appropriate irradiance and maximal surface area exposure of the infant.

For some office practices, the cost of purchasing and maintaining phototherapy devices also must be weighed against the frequency with which such equipment is used. Furthermore, community practices should consider implementing phototherapy only as a bridge to hospital evaluation and management of severely jaundiced infants, avoiding the temptation to become "phototherapy centers." Further study will be necessary to determine whether in-office phototherapy prior to hospital transfer is of clinical benefit.

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Additional emphasis also should be placed on determining prior to hospital discharge which infants are at highest risk of requiring phototherapy. Bhutani et al¹ reported that a combination of predischarge bilirubin level and specific clinical factors is highly predictive of subsequent phototherapy use. Recent and evolving work on genetic factors affecting bilirubin metabolism also may give clinicians insight into which infants may require extra vigilance for progressive jaundice during the early neonatal period.

Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.