The October 2009 Pediatrics has a range of articles and opinions about management of jaundice. I can't repost, but to summarize, there are a couple of original research articles about the potential benefits/risks of predischarge bili measurements and then several opinion pieces about it.
A range of opinions are expressed both pro and con routine predischarge bili measurement either transcutaneously or by blood sample.
I actually had some questions about the articles and the controversy regarding bilirubin screening if I may entertain the message board. To summarize the articles I think being discussed:
1.
Impact of Universal Bilirubin Screening on Sever Hyperbilirubinemia and Phototherapy Use.
Article seems to conclude that universal screening for hyperbilirubinemia decreases severe hyperbillrubinemia, but that it is currently unclear if this decreases kernicterus.
It seems to me that universal screening does detect missed cases in the early hospitalization period and probably would prevent some cases of kernicterus.
2.
Transcutaneous Bilirubin Normogram for Prediction of Significant Neonatal Hyperbilirubinemia
Article argued for the expanded use of TcB for universal screening of infants between 12 to 72 hours to help predict which infants might need follow up because they may develop hyperbilirubinemia during the first week.
Seems to make sense to start using TcB measurements universally in hospitals in the US as it is non-invansive, and doubtlessly the technology will improve over the years to where it will become more accurate
3.
Screening of Infants for Hyperbilirubinemia to Prevent Chronic Bilirubin Encephalopathy: US Preventive Services Task Force Recommendation Statement
The USPSTF, in typical fashion, will not go out on a limb and recommend anything unless there are a lot of good trials on a controversial topic, and basically said that they can recommend universal screening of infants for hyperbilirubinemia to prevent kernicterus because the study hasn't been done yet.
My questions regarding bilirubin screening are:
1. While it hasn't been proven that universal bilirubin screening decreases the incidence of kernicterus per se, it does decrease severe hyperbilirubinemia which could lead to kernicterus in a small number of infants. Would any do the large clinical trial required to prove this? Would this be ethical?
2. Universal screening with TcB appears to be reliable in many aspects, and is noninvasive, and likely wouldn't increase cost that much in any given hospital due to ease of performing the test, so why not just do it as precaution? As some pediatricians have noted, the possible consequences of missing hyperbilirubinemia can be devastating, i.e. kernicterus, and visual estimation of bilirubin is unreliable.
*Just read one of the commentaries that the cost of universal screening would be 4 to 78 million per case of kernicterus prevented, of couse caring for a person will kernicterus over their life is also easily in the millions of dollars and there is the emotional toll, lost productivity as well. But could screening for hyperbilirubinemia have other positive benefits such as detecting occult etiologies of hyperbilirubinemia earlier?
3. Do severe or even mild hyperbilirubinemia levels have any adverse clinical effects besides kernicterus? I.e. should we be more concerned about severe hyperbilirubinemia levels besides kernicterus?
4. Some hospitals don't do universal bilirubin screening, especially for term low risk infants, but is this simply shifting the responsibility for preventing kernicterus on to the shoulders of the primary care pediatrician?
5. Detecting jaundice in a baby with moderately, or heavily pigmented skin can be difficult sometimes, would TcB be more helpful in these infants?
Any information that OBP, or anyone else could provide would be helpful, thanks
