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PEDIATRICS Vol. 103 No. 1 January 1999, pp. 6-14
Received Apr 30, 1998; accepted Jul 13, 1998.
From the Section on Newborn Pediatrics, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Objective. To assess the predictive ability of a universal predischarge serum bilirubin measurement to screen for risk of subsequent significant hyperbilirubinemia in the direct Coombs negative healthy term and near-term newborn during the first postnatal week.
Methods. Total serum bilirubin (TSB) levels were obtained at the time of the routine metabolic screen in all term and near-term newborns cared for in the Pennsylvania Hospital Well Baby Nursery (n = 13 003). Postnatal age (in hours) at the time of TSB measurement was recorded. A percentile-based bilirubin nomogram for the first week was constructed from hour-specific predischarge and postdischarge TSB values of newborns (n = 2840; median BW = 3230 g and median gestational age = 39 weeks) who met classification criteria for healthy newborns (excluding those with a positive direct Coombs test or those requiring phototherapy before age 60 hours) and who were enrolled in a hospital supervised home or outpatient follow-up program. The accuracy of the predischarge TSB as a predictor of subsequent degree of hyperbilirubinemia was determined.
Results. The study patients in the nomogram were racially
diverse. Nearly 60% were breastfed. Predischarge, 6.1% of the study
population (172/2840) had TSB values in the high-risk zone (
95th
percentile) at 18 to 72 hours; of these, 39.5% (68/172) remained in
that zone (likelihood ratio [LR] = 14.08, sensitivity = 54%; specificity = 96.2%, probability = 39.5%).
Predischarge, 32.1% of the population (912/2840) had TSB values in the
intermediate-risk zone. In a clinically significant minority of these
newborns (58/912 or 6.4%), the postdischarge TSB moved into the
high-risk zone (LR of this move: 3.2 from the upper-intermediate zone
and .48 from the lower-intermediate risk zone). The predischarge TSB in
61.8% of the newborns (1756/2840) was in the low-risk zone (<40th
percentile) and there was no measurable risk for significant
hyperbilirubinemia (LR = 0, sensitivity = 100%;
specificity = 64.7%; probability = 0%).
Conclusions. An hour-specific TSB before hospital
discharge can predict which newborn is at high, intermediate or low
risk for developing clinically significant hyperbilirubinemia
(specifically defined as TSB levels 95th percentile for age in
hours). Risk designation and subsequent increases or decreases of in
TSB can be easily monitored on an hour-specific percentile based
predictive bilirubin nomogram. A predischarge TSB measured as a
universal policy would facilitate targeted intervention and follow-up
in a safe, cost-effective manner. In conjunction with bilirubin
practice parameter of the American Academy of Pediatrics, it
could reduce the potential risk for bilirubin-induced neurologic
dysfunction.
Key words:
hyperbilirubinemia,
jaundice
prediction,
kernicterus,
universal bilirubin screen,
hour-specific
bilirubin nomogram.
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