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American Academy of Pediatrics
Commentary

Can I Stop Phototherapy for This Baby?

Ian M. Paul and M. Jeffrey Maisels
Pediatrics March 2017, 139 (3) e20163832; DOI: https://doi.org/10.1542/peds.2016-3832
Ian M. Paul
aDepartments of Pediatrics, and
bPublic Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania; and
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M. Jeffrey Maisels
cDepartment of Pediatrics, Beaumont Children’s Hospital and Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
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  • Abbreviation:
    AAP —
    American Academy of Pediatrics
  • The American Academy of Pediatrics (AAP) consensus-based guidelines for the initiation of phototherapy1,2 have been universally adopted in the United States and even applied in other countries,3,4 whereas several countries have developed their own phototherapy guidelines.5–8 Substantially less guidance, however, has been provided on when to stop birth hospitalization phototherapy to avoid retreatment. In fact, the AAP Subcommittee on Hyperbilirubinemia has acknowledged that there is no standard for discontinuation.2 Evidence-based answers to this common clinical question are now provided by Chang et al9 in this issue of Pediatrics.

    From 105 808 neonates born at ≥35 weeks’ gestation at 1 of 17 Kaiser Permanente Northern California hospitals between 2012 and 2014, Chang et al9 identified a cohort of 7048 newborns treated with phototherapy. The objective of the study was to identify predictors of “rebound,” defined as a return to treatment threshold levels within 72 hours of discontinuation of a neonate’s first round of phototherapy treatment. These data were then used to create a score that could predict the probability of rebound and help clinicians decide when to discontinue phototherapy. The rich electronic dataset available to the researchers included a number of key variables, including gestational age, sex, birth weight, feeding type, direct antiglobulin test results, and details regarding the initiation, course, and termination of phototherapy. Total serum and direct bilirubin data were also included.

    With 4.6% of the sample experiencing a return to treatment threshold after cessation of phototherapy, Chang et al9 identified multiple significant predictors of rebound hyperbilirubinemia, including Asian race and exclusive breastfeeding, but their parsimonious prediction score was formulated using only 3 variables: gestational age, age at phototherapy initiation, and “relative” total serum bilirubin (level at cessation minus the AAP phototherapy threshold). Specifically, a gestational age of <38 weeks and higher relative serum bilirubin were associated with an increased likelihood of rebound hyperbilirubinemia, whereas older age at phototherapy initiation was protective. These observations are consistent with those of other studies,10,11 and the fact that infants with hemolytic disease–associated hyperbilirubinemia are much more likely to both require early phototherapy and experience a rebound. The prediction score calculated from these variables generated thresholds where rebound hyperbilirubinemia was highly unlikely, something that can easily be included in the clinical care of such neonates. Importantly, use of this score could have resulted in a 1-day shorter hospital stay for roughly one-third of those treated with phototherapy, something that would be desirable for all stakeholders.

    Numerous previous studies have analyzed the bilirubin rebound after phototherapy,10–15 but none have approached the sample size studied by Chang et al.9 In addition, comparisons with these studies are difficult because of differences in the populations studied, the bilirubin levels chosen for phototherapy termination, and the criteria used to define rebound. In some institutions, about half of the infants receiving phototherapy for the first time are those who are readmitted,10 a population in whom the primary cause for hyperbilirubinemia is much less likely to be active hemolysis and in whom the risk of rebound is much lower.10 In the Chang et al study,9 62% of infants received their phototherapy during their birth hospitalization. Because of the strong association between older age and less rebound, we assume that many of the older infants were those readmitted for their first course of phototherapy, although the authors do not specifically address this issue.

    This prediction rule for rebound hyperbilirubinemia comes at a time when innovation around well newborn care has been increasing, providing evidence-based and guideline-based tools to improve patient care. After publication of the Bhutani nomogram for neonatal hyperbilirubinemia,16 Web-based tools, such as Bilitool (www.bilitool.org), became routinely used in daily clinical care. More recently, the Newborn Sepsis calculator17,18 (https://neonatalsepsiscalculator.kaiserpermanente.org/) and Newborn Weight Tool19,20 (www.newbornweight.org) have helped clinicians adapt evidence on sepsis risk and newborn weight loss into mobile platforms that can inform clinical care in real-time. The formula used in the new prediction rule for rebound hyperbilirubinemia is simple and easy to use, and has similar potential to influence clinical care for those newborns receiving phototherapy.

    Footnotes

      • Accepted December 19, 2016.
    • Address correspondence to Ian M. Paul, MD, MSc, Department of Pediatrics, Penn State College of Medicine, HS83, 500 University Dr, Hershey, PA 17033. E-mail: ipaul{at}psu.edu
    • Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-2896.

    References

    1. ↵
      1. Maisels MJ,
      2. Bhutani VK,
      3. Bogen D,
      4. Newman TB,
      5. Stark AR,
      6. Watchko JF
      . Hyperbilirubinemia in the newborn infant > or =35 weeks’ gestation: an update with clarifications. Pediatrics. 2009;124(4):1193–1198pmid:19786452
      OpenUrlFREE Full Text
    2. ↵
      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):297–316pmid:15231951
      OpenUrlAbstract/FREE Full Text
    3. ↵
      1. Fouzas S,
      2. Mantagou L,
      3. Skylogianni E,
      4. Mantagos S,
      5. Varvarigou A
      . Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates. Pediatrics. 2010;125(1). Available at: www.pediatrics.org/cgi/content/full/125/1/e52pmid:20008429
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. Travan L,
      2. Lega S,
      3. Crovella S,
      4. Montico M,
      5. Panontin E,
      6. Demarini S
      . Severe neonatal hyperbilirubinemia and UGT1A1 promoter polymorphism. J Pediatr. 2014;165(1):42–45pmid:24726540
      OpenUrlCrossRefPubMed
    5. ↵
      Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) - Summary. Paediatr Child Health. 2007;12(5):401–418pmid:19030400
      OpenUrlPubMed
      1. Bratlid D,
      2. Nakstad B,
      3. Hansen TW
      . National guidelines for treatment of jaundice in the newborn. Acta Paediatr. 2011;100(4):499–505pmid:21114525
      OpenUrlCrossRefPubMed
      1. Kaplan M,
      2. Merlob P,
      3. Regev R
      . Israel guidelines for the management of neonatal hyperbilirubinemia and prevention of kernicterus. J Perinatol. 2008;28(6):389–397pmid:18322551
      OpenUrlCrossRefPubMed
    6. ↵
      1. National Institute for Health and Clinical Excellence
      . Jaundice in newborn babies under 28 days. Available at: www.nice.org.uk/CG98. Accessed November 15, 2016
    7. ↵
      1. Chang PW,
      2. Kuzniewicz MW,
      3. McCulloch CE,
      4. Newman TB
      . A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139(3):e20162896
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. Maisels MJ,
      2. Kring E
      . Rebound in serum bilirubin level following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156(7):669–672pmid:12090833
      OpenUrlCrossRefPubMed
    9. ↵
      1. Kaplan M,
      2. Kaplan E,
      3. Hammerman C, et al
      . Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia. Arch Dis Child. 2006;91(1):31–34pmid:16223746
      OpenUrlAbstract/FREE Full Text
      1. Bansal A,
      2. Jain S,
      3. Parmar VR,
      4. Chawla D
      . Bilirubin rebound after intensive phototherapy for neonatal jaundice. Indian Pediatr. 2010;47(7):607–609pmid:20019393
      OpenUrlCrossRefPubMed
      1. Barak M,
      2. Berger I,
      3. Dollberg S,
      4. Mimouni FB,
      5. Mandel D
      . When should phototherapy be stopped? A pilot study comparing two targets of serum bilirubin concentration. Acta Paediatr. 2009;98(2):277–281pmid:19143666
      OpenUrlPubMed
      1. Al-Saedi SA
      . Rebound hyperbilirubinemia in term infants after phototherapy. Saudi Med J. 2002;23(11):1394–1397pmid:12506303
      OpenUrlPubMed
    10. ↵
      1. Tan KL,
      2. Lim GC,
      3. Boey KW
      . Phototherapy for ABO haemolytic hyperbilirubinaemia. Biol Neonate. 1992;61(6):358–365pmid:1525269
      OpenUrlPubMed
    11. ↵
      1. Bhutani VK,
      2. Johnson L,
      3. 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):6–14pmid:9917432
      OpenUrlAbstract/FREE Full Text
    12. ↵
      1. Puopolo KM,
      2. Draper D,
      3. Wi S, et al
      . Estimating the probability of neonatal early-onset infection on the basis of maternal risk factors. Pediatrics. 2011;128(5). Available at: www.pediatrics.org/cgi/content/full/128/5/e1155pmid:22025590
      OpenUrlAbstract/FREE Full Text
    13. ↵
      1. Escobar GJ,
      2. Puopolo KM,
      3. Wi S, et al
      . Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks’ gestation. Pediatrics. 2014;133(1):30–36pmid:24366992
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Flaherman VJ,
      2. Schaefer EW,
      3. Kuzniewicz MW,
      4. Li SX,
      5. Walsh EM,
      6. Paul IM
      . Early weight loss nomograms for exclusively breastfed newborns. Pediatrics. 2015;135(1). Available at: www.pediatrics.org/cgi/content/full/135/1/e16pmid:25554815
      OpenUrlAbstract/FREE Full Text
    15. ↵
      1. Miller JR,
      2. Flaherman VJ,
      3. Schaefer EW, et al
      . Early weight loss nomograms for formula fed newborns. Hosp Pediatr. 2015;5(5):263–268pmid:25934810
      OpenUrlAbstract/FREE Full Text
    • Copyright © 2017 by the American Academy of Pediatrics
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    Ian M. Paul, M. Jeffrey Maisels
    Pediatrics Mar 2017, 139 (3) e20163832; DOI: 10.1542/peds.2016-3832

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    Can I Stop Phototherapy for This Baby?
    Ian M. Paul, M. Jeffrey Maisels
    Pediatrics Mar 2017, 139 (3) e20163832; DOI: 10.1542/peds.2016-3832
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