Wednesday, January 14, 2015

Treating Jaundice in the NICU and Lowering Cases of Readmission

By: Beth Tarini, Editorial Board Member

 Courtesy of Jim Champion
Jaundice continues to vex those who care for newborns.  The majority of babies are jaundiced to some degree.but must don't need treatment. The challenge is to identify those that need treatment without over treating the healthy or overlooking those that need treatment.

In years past, conversations about jaundiced newborns focused on our vigintiphobia – our fear that a bilirubin level of 20 mg/dL would lead to kernicterus unless treated with exchange transfusion.  Now our conversations focus on the effect of early discharge after birth.  According to the AAP, early discharge is defined as less than 48 hours for vaginal birth and more than 96 hours for Caesarean section. (1)  The conundrum is that the greatest risk for severe jaundice occurs at a time after “early discharge” babies have left the hospital.  This can create a challenge for monitoring babies – especially if they don’t have timely follow-up with a healthcare provider after discharge.

The debate over whether early discharge increases the readmission rate for jaundice among newborns is ongoing.  To this debate, Dr. Lain et al. (doi:10.1542/peds.2014-2388) add data based on the first population-based study of the issue.  The study, conducted in Australia from 2001-2010, examined the readmission rate for over 780,000 newborns, looking specifically at how factors such as gestational age might influence the readmission rate.  The authors found that 0.8% of all the infants studied were readmitted for jaundice.   However, those at highest risk for readmission were infants born early term (37 & 38 weeks gestation) and discharged less than 48 hours [aOR 9.43 (95% CI: 8.34-10.67) and 4.05 (95% CI: 3.62-4.54) respectively]. 

What is the reason for these findings?  One theory is that early discharge causes jaundice among this subset of newborns.  However, since this is a cohort study, these findings are associative and should not be viewed as causal.  It is also possible that early term infants are followed more closely after early discharge, which increases their chance of being identified as having an elevated bilirubin, which leads to a readmission.  In this study, we don’t know the bilirubin level that prompted the readmission.  We are left to assume that the level required treatment.

What can we do with these data?  Well, the authors themselves admit that prolonging the hospital stay is unlikely to be an economical viable solution.  It would mean that we would have to keep over 80 infants in the hospital longer just to prevent one admission.  Also noted is that unlike the U.S., Australia does not have universal bilirubin screening guidelines prior to discharge.  It would be interesting to see if these findings persist in those countries that have universal bilirubin screening.  Of course, as we already know, universal screening has been associated with increased use of phototherapy and increased readmission rates, likely due, in part, to over treatment (2).

So, in some ways, the more the conversation about jaundice has changed, the more it has stayed the same.  While we are not talking about vigintiphobia, we are still talking about fear - fear of kernicterus in the shadow of early hospital discharge.



1:American Academy of Pediatrics.Committee on Fetus and Newborn.Hospital stay for
healthy term newborns. Pediatrics.2010 Feb;125(2):405-9. doi:10.1542/peds.2009-3119.

2:Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe hyperbilirubinemia. Pediatrics. 2009 Oct;124(4):1031-9. Oct;124(4):1031-9. 
doi:10.1542/peds.2008-2980.
 

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1 comment:

  1. Good post....thanks for sharing.. very useful for me i will bookmark this for my future needs. Thanks. Fetal Monitor

    ReplyDelete

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