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Perspectives: D Manning American Academy of Pediatrics guidelines for detecting neonatal hyperbilirubinaemia and preventing kernicterus Arch. Dis. Child. Fetal Neonatal Ed. 2005; 90: F450-F451 [Full text] [PDF]

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AAP Guidelines for detecting neonatal hyperbilirubinemia and preventing kernicterus

M.Jeffrey Maisels   (2 November 2005)

Author's reply to Maisels

Donal J Manning   (14 November 2005)

AAP Guidelines for detecting neonatal hyperbilirubinemia and preventing kernicterus 2 November 2005
M.Jeffrey Maisels, Physician William Beaumont Hospital Send letter to journal: Re: AAP Guidelines for detecting neonatal hyperbilirubinemia and preventing kernicterus jmaisels{at}beaumont.edu M.Jeffrey Maisels	Dear Editor In his commentary on the recent American Academy of Pediatrics Guidelines for the management of neonatal hyperbilirubinemia [1] Dr Manning notes that the "British system of midwifery based universal surveillance of recently discharged infants should not be abandoned" and I enthusiastically endorse this view. The AAP recommendations for follow-up are quite specific – any infant who is discharged before age 72 hours should be seen within 2 days of discharge. This recommendation applies to all infants although it is noted that even earlier follow-up might be necessary for infants who have several risk factors whereas those discharged with few or no risk factors might be seen after a longer interval. There is no suggestion that predischarge bilirubin levels should be the sole determinant of follow up. It is true, as noted by Dr Manning, that the actual values provided in the AAP (Bhutani) nomogram [2] might not apply to every population and it would be helpful if nomograms could be devised for different populations. This would also take into account the variability encountered in the laboratory measurement of bilirubin. On the other hand, there is little doubt that the principle of risk assessment using a transcutaneous or serum bilirubin level before discharge has universal application. The Bhutani nomogram was used in an international study of infants in the USA, Japan, Hong Kong and Israel and its predictive power was fully confirmed.[3] A more recent US study has also validated this methodology [4] as have similar, if not identical, studies in Turkey, [5] Spain [6] and Israel.[7] It would be surprising if this approach was not similarly effective in Britain. The clinical risk factors listed in the AAP guideline are also not unique to the North American population. Unfortunately, in the USA, we do not enjoy the superb public health service provided in the United Kingdom where all mothers and infants receive at least one and often more postnatal home visits from a midwife in the first week after hospital discharge. But it is hard to imagine that knowing whether or not a baby is at high or low risk for developing severe hyperbilirubinemia would not be of some value to a midwife when she assesses a newborn and makes a decision about the need for obtaining a bilirubin level. Dr Manning notes that kernicterus is also occurring in the UK and I wonder if some form of predischarge risk assessment, by drawing attention to certain infants, might have helped to prevent some of these unfortunate outcomes. Universal post-discharge surveillance is one of the principles enunciated in the AAP guideline. Unfortunately, we have a long way to go before we can be satisfied that this recommendation is being followed by physicians throughout the USA. A home visit by a midwife on the day after discharge followed by additional visits in the first week provides marvelous support for the mother and baby and is a tribute to the British health care system. Please don’t give this up but do help your physicians and midwives by also assessing the risk of subsequent severe hyperbilirubinemia before the baby leaves the hospital. References (1) Manning D. American Academy of Pediatrics guidelines for detecting neonatal hyperbilirubinaemia and preventing kernicterus. Arch Dis Child Neonatal Ed 2005; 90:F450-F451. (2) Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy-term and near-term newborns. Pediatrics 1999; 103:6-14. (3) Stevenson DK, Fanaroff AA, Maisels MJ, Young BWY, Wong RJ, Vreman HJ et al. Prediction of hyperbilirubinemia in near-term and term infants. Pediatrics 2001; 108:31-39. (4) Newman TB, Liljestrand P, Escobar GJ. Combining clinical risk factors with bilirubin levels to predict hyperbilirubinemia in newborns. Arch Pediatr Adolesc Med 2005; 159:113-119. (5) Alpay F, Sarici S, Tosuncuk HD, Serdar MA, Inanc N, Gokcay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics 2000; 106:E16. (6) Carbonell X, Botet F, Figueras J, Riu-Godo A. Prediction of hyperbilirubinaemia in the healthy term newborn. Acta Paediatr 2001; 90:166-170. (7) Kaplan M, Hammerman C, Feldman R, Brisk R. Predischarge bilirubin screening in glucose-6-phosphate dehydrogenase-deficient neonates. Pediatrics 2000; 105:533-537.
Author's reply to Maisels 14 November 2005
Donal J Manning, Consultant paediatrician Wirral Hospital NHS Trust Send letter to journal: Re: Author's reply to Maisels donal.manning{at}whnt.nhs.uk Donal J Manning	Dear Editor I thank Dr Maisels for his comments. I agree that pre-discharge serum bilirubin measurement in newborn infants can predict with reasonable sensitivity the risk of later significant hyperbilirubinaemia. Given the rarity of extreme hyperbilirubinaemia and associated encephalopathy, however, the numbers of infants studied in the papers cited by Dr Maisels are too small to determine whether universal pre-discharge bilirubin measurement reduces the frequency of these adverse outcomes. The findings of Newman et al, that combining this measurement with clinical risk factors enhances its predictive value, lend support to the notion that bilirubin measurement alone is insufficient, and must be considered in the clinical context. [1] Apart from the difficulties in obtaining evidence of clinical benefit, I have concerns with the suggestion to incorporate universal pre- discharge bilirubin measurement into the UK system of surveillance for two reasons; first, this would increase the complexity of the system and second, it could lend a false sense of security to surveillance of infants who are considered to be at low risk for later significant hyperbilirubinaemia. The current UK system of universal clinical surveillance, while labour intensive, is conceptually simple. Undoubtedly, however, it sometimes fails and this may lead, as Dr Maisels suggests, to some infants suffering severe hyperbilirubinaemia. Maintaining compliance would become more difficult as the system becomes more complex, and professionals making individual risk assessments 'in the field' based on timed serum bilirubin measurements may not perform as effectively as might be assumed from the findings of the studies cited by Dr Maisels. When population-derived risk assessments are applied to individuals, both health professionals and lay persons may misinterpret, and draw unduly optimistic conclusions from, low risk assignment. While the Bhutani nomogram has strong positive predictive value,[2] about in in 200 infants with a pre-discharge serum bilirubin mesasurement imparting low risk will later have a measurement above the 95th centile. [1,3] If professionals reduce their vigilance for infants assigned low risk status, these infants may be put at risk for significant hyperbilirubinaemia. A low early serum bilirubin concentration, furthermore, cannot reassure against the possibility of lactation failure, or systemic illness, contributing to later severe jaundice. More evidence of clinical benefit, and safety, is needed to justify the introduction of universal pre- discharge serum bilirubin measurement in the UK. References 1. Newman TB, Liljestrand P, Escobar GJ. Combining clinical risk factors with bilirubin levels to predict hyperbilirubinaemia in newborns. Arch Pediatr Adolesc Med 2005; 159: 113-119. 2. Bhutani VK, Johnson L, Sivieri EM. predictive value of a pre- discharge hour-specific serum bilirubin for subsequent significant hyperbilirubinaemia in healthy term and near-term infants. Pediatrics 1999; 103: 6-14. 3. Stevenson DK, Fanaroff AA, Maisels MJ et al. Prediction of hyperbilirubinaemia in near-term and term infants. Pediatrics 2001; 108: 3 1-39.