Page 91 - 16Neonatal Jaundice_compressed

Neonatal jaundice

phototherapy was 1 in 1827, and it declined to 1 in 11 995 during 2001–2003. A similar
reduction in readmission rates for intensive phototherapy was reported: from 14 per 1000
babies discharged in 1994 to 5.5 per 1000 in 2001–2003. No babies developed serum bilirubin
levels ≥ 513 micromol/litre during the study period, while the frequency of reported serum
bilirubin levels ≥ 427 micromol/litre was 1 in 15 000 compared with the reported incidence of
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1 in 625 in previous studies. [EL III]
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Another historical cohort study from the USA evaluated the effectiveness of a bilirubin
screening programme in a private healthcare organisation involving 18 hospitals. The
programme, started in December 2002, involved measurement of bilirubin in every newborn
baby, either on recognition of jaundice or before discharge from hospital. Two hospitals used
BiliChek to measure transcutaneous bilirubin levels while others used serum bilirubin; the
bilirubin measurements were plotted on the hour-specific nomogram. Any bilirubin level
≥ 40th centile was notified to the relevant healthcare provider and the baby managed
according to his/her discretion. All babies born at gestational age ≥ 35 weeks were enrolled in
the study. Those born after the initiation of the programme (1 January 2003 to 31 December
2004) formed the cohort group (n = 52 483), while those born before the programme started
(1 March 2001 to 31 December 2002) formed the comparison group (n = 48 798). Other details
of the two groups were not given and no comparison was made between their baseline
characteristics.

Compliance with the programme was good – within 2 months of starting it, more than 99% of
the babies had at least one pre-discharge bilirubin level measured. After the first 3 months of the
study, the percentiles of the hour-specific nomogram were modified since a large number of
babies were reported to have bilirubin measurements in the high or intermediate-high zones.
A significant decline in the incidence of hyperbilirubinaemia was reported after implementation
of the screening programme. The proportion of babies with serum bilirubin levels
≥ 342 micromol/litre declined from 1 in 77 to 1 in 142 (P < 0.0001), while the proportion
with serum bilirubin levels ≥ 427 micromol/litre) declined from 1 in 1522 to 1 in 4037
(P < 0.005). The incidence of hospital readmission for hyperbilirubinaemia also fell
significantly, from 5.5 per 1000 before the programme to 4.3 per 1000 babies after its
introduction (P < 0.005). The authors concluded that a universal screening programme coupled
with evaluation of bilirubin using a percentile-based nomogram can lead to significant reduction
in the incidence of hyperbilirubinaemia and hospital readmissions for phototherapy. [EL II]

Evidence summary
There is no good-quality prospective comparative study assessing the impact of universal pre-
discharge bilirubin testing. Results from two studies with EL III and EL II suggest that the
introduction of universal bilirubin screening is followed by reduction in the number of hospital
readmissions for phototherapy. The non-comparative observational study also found a reduction
in the incidence of intensive phototherapy and exchange transfusion, while the retrospective
study reported a decrease in the frequency of reported serum bilirubin levels
≥ 342 micromol/litre.

GDG translation from evidence
Low-quality evidence suggests that universal pre-discharge bilirubin testing may reduce the
need for intensive phototherapy and exchange transfusions, and the readmission rate for
significant hyperbilirubinaemia. These studies did not report on bilirubin encephalopathy and
stated that there were no recorded cases of kernicterus. However, the lack of high-quality
evidence to show that universal pre-discharge bilirubin measurement reduces the frequency of
hospital readmission, exchange transfusions and bilirubin encephalopathy means that it is not
possible to make a recommendation on the role of universal pre-discharge bilirubin testing in
the UK but a research recommendation has been made on this topic.

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