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Early prediction of serious hyperbilirubinaemia

lacking for babies in the first 24 hours of life and also for those with jaundice due to haemolytic
disease of the newborn.
The GDG review of the evidence supports our recommendations, namely that parents and
carers need to made aware of the risk factors for hyperbilirubinaemia (see recommendations in
Chapter 8 on information for parents and carers).

All those responsible for the care of newborn babies should also be aware of the importance of
risk factors (see Section 3.1), and should take them into account when examining the baby (see
Section 5.1) and deciding on management options (see Section 7.1.1).
Recommendations

See the end of Section 4.1.
Effectiveness of a pre-discharge bilirubin screening programme

Description of included studies
47
Two studies 47;48 from the USA have been included in this section. The first study was a non-
comparative observational study evaluating the impact of the introduction of universal pre-
discharge bilirubin screening and a comprehensive post-discharge follow-up programme. The
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second study was a retrospective cohort study that assessed the effectiveness of a universal
pre-discharge bilirubin screening programme on the number of readmissions and incidence of
hyperbilirubinaemia.

Review findings
47
An observational study was conducted in a large urban hospital in the USA to evaluate the
effectiveness of an incremental systems approach to the management of neonatal
hyperbilirubinaemia. The study cohort included all near-term and full-term babies born from
1 January 1990 to 31 December 2000 who were discharged from the well-baby nursery of the
hospital. Low-birthweight preterm babies and babies admitted to the intensive care nursery for
any neonatal illness were excluded. The sample population was 31 059 babies of mean
birthweight 3318 ± 457 g and mean gestational age 38.7 ± 1.3 weeks. The approaches
implemented in chronological order were:

1. selective pre-discharge serum bilirubin measurements (1990–92)
2. universal serum bilirubin measurement at the time of metabolic screening, with nurses
having discretion to order serum bilirubin in individual babies on clinical grounds (1993–95)
3. universal serum bilirubin screening along with post-discharge follow-up based on the serum
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bilirubin position on the hour-specific nomogram (1996–98)
4. comprehensive, systems-based management of newborn jaundice (1999–2000).
The impact of the complete approach was assessed in 2001–2003. In the systems-based
approach, all babies had pre-discharge bilirubin estimation (serum bilirubin or transcutaneous
bilirubin), and follow-up care for jaundice was provided either at the hospital (more than 85%
of cases) or at home within 24–48 hours of discharge. Other components of the approach
included lactation support, provision of information and advice about jaundice to parents, and
close follow-up of jaundiced babies based on their hour-specific bilirubin levels. Clinical
evaluation for jaundice severity was recommended for all babies at about 4 days of age, along
with targeted follow-up of at-risk babies at 7 days and 14 days. Phototherapy was initiated
according to the AAP guidelines. Adverse outcomes included exchange transfusion conducted
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for severe hyperbilirubinaemia or following failure of phototherapy to prevent rise in serum
bilirubin levels during both the pre-discharge and post-discharge period, readmission for
phototherapy following discharge, and presence of clinical signs of acute bilirubin
encephalopathy.

A significant decline in the use of intensive phototherapy and in the need for exchange
transfusion during the first 7 days after birth was observed following the introduction of the
systems-based approach. From 1990 to 1998 the incidence of intensive phototherapy use was
about 4%, but it declined to 2.5% during 1999–2000 and was 1.3% during 2001–2003. During
1990–2000, the incidence of exchange transfusion following the failure of intensive

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