Range of Thresholds Used for Treatment of Neonatal Hyperbilirubinemia at Different Gestational Ages across Neonatal Units in Great Britain

Puneet Kumar Arora, Sindhu Mohandas, Deborah Ridout, Narendra Aladangady

.

DOI: 10.4236/ijcm.2011.25098                

Abstract

Objectives: To review the range of thresholds used for treatment of neonatal jaundice at different gestational ages across neonatal units in Great Britain. To investigate the time at which the threshold values plateau, in terms of hours after birth, for various gestational ages. Methods: We contacted 72 neonatal units in Great Britain and enquired about the unit guidelines for management of neonatal jaundice. We requested a copy of the guidelines and jaundice action charts used. Levels for treatment with phototherapy and exchange transfusion for various times after birth and for different gestational ages were extracted and the data was transferred to an Excel spreadsheet. Identical values were excluded so that there was no duplication of charts. The data was analysed to explore the variation in charts used and the time at which the threshold value reached a plateau was recorded for each chart. Results: Of the 72 units contacted 46 responded with charts. Four neonatal units were using formulas and one hospital was using separate chart for every gestation. The data displayed wide variation in treatment levels (phototherapy and exchange transfusion) at 12 to 168 hours after birth in the three gestational groups studied (28, 32 and 37 weeks). For a term neonate at 72 hours of age the threshold to commence phototherapy varied between 220-370 micromol/l and the exchange transfusion threshold varied between 300-510 micromol/l. A wide variation in practice was seen for all three gestations. The median plateau time was also analysed and for phototherapy this corresponded to 72 hours for all three gestations. For exchange transfusion data the median time of plateau was highest for the term babies (72 hours) and lowest for 32 weeks gestation (48 hours). There was no reference of evidence quoted in the jaundice action charts surveyed. Conclusions: Jaundice action charts reviewed in our study showed significant variation in the threshold for treatment of neonatal jaundice. Both the studied parameters (variation in threshold and the median time to plateau) point towards the fact that the charts being used in the neonatal units are not evidence based and need modification. With the lack of standard treatment guidelines for this common neonatal problem, it is likely that neonatal units are either under or over treating a significant number of babies.

Keywords

Neonatal Jaundice, Phototherapy, Exchange Transfusion

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	T. B. Newman and M. J. Maisels, “Does Hyperbilirubinemia Damage the Brain of Healthy Full-Term Infants?” Clinics in Perinatology, Vol. 17, No. 2, 1990, pp. 331-358.
[2]	R. H. Dobbs and R. J. Cremer, “Phototherapy,” Archives of Disease in Childhood, Vol. 50, 1975, pp. 833-836. doi:10.1136/adc.50.11.833
[3]	W. J. Cashore and L. Stem, “The management of hyperbilirubinemia,” In: A. Zipursky, Ed., Clinics in Perinatology, WB Saunders, Philadelphia, 1984.
[4]	I. Abramov, L. Hainline, E. Lemerise and A. K. Brown, “Changes in Visual Functions of Children Exposed as Infants to Prolonged Illumination,” Journal of the American Optometric Association, Vol. 56, No. 8, 1985, pp. 614- 619.
[5]	P. Glass, G. B. Avery, S. K. N. Siva, M. P. Keys, A. M. Sostek and D. S. Friendly, “Effect of Bright Light in the Hospital Nursery on the Incidence of Retinopathy of Prematurity,” New England Journal of Medicine, Vol. 313, No. 7, 1985, pp. 401-404. doi:10.1056/NEJM198508153130701
[6]	V. A. Moyer, C. Ahn and S. Sneed, “Accuracy of Clinical Judgment in Neonatal Jaundice,” Archives of Pediatrics & Adolescent Medicine, Vol. 154, No. 4, 2000, pp. 391- 394.
[7]	R. Tayaba, D. Gribetz, I. Gribetz and I. R. Holzman, “Noninvasive Estimation of Serum Bilirubin,” Pediatrics, Vol. 102, No. 3, 1998, p. e28. doi:10.1542/peds.102.3.e28
[8]	V. Bhutani, G. R. Gourley, S. Adler, B. Kreamer, C. Dalman and L. H. Johnson, “Noninvasive Measurement of Total Serum Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia,” Pediatrics, Vol. 106, No. 2, 2000, p. e17. doi:10.1542/peds.106.2.e17
[9]	S. Yasuda, S. Itoh, K. Isobe, et al., “New Transcutaneous Jaundice Device with Two Optical Paths,” Journal of Perinatal Medicine, Vol. 31, No. 1, 2003, pp. 81-88. doi:10.1515/JPM.2003.012
[10]	M. J. Maisels, E. J. Ostrea Jr., S. Touch, et al., “Evaluation of a New Transcutaneous Bilirubinometer,” Pediatrics, Vol. 113, No. 6, 2004, pp. 1638-1645. doi:10.1542/peds.113.6.1628
[11]	A. P. Hart, “Familial Icterus Gravis of the New-Born and Its Treatment,” Canadian Medical Association Journal, Vol. 15, No. 10, 1925, pp. 1008-1011.
[12]	P. M. Dunn, “Dr Alfred Hart (1888-1954) of Toronto and Exsanguination Transfusion of the Newborn,” Archives of Disease in Childhood, Vol. 69, No. 1, 1993, pp. 95-96. doi:10.1136/adc.69.1_Spec_No.95
[13]	W. J. Keenan, K. K. Novak, J. M. Sutherland, D. A. Bryla and K. L. Fetterly, “Morbidity and Mortality Associated with Exchange Transfusion,” Pediatrics, Vol. 75, No. 2, 1985, pp. 417-421.
[14]	L. Hovi and M. A. Siimes, “Exchange Transfusion with Fresh Heparinized Blood Is a Safe Procedure: Experiences from 1069 Newborns,” Acta Paediatrica Scandinavica, Vol. 74, 1985, pp. 360-365. doi:10.1111/j.1651-2227.1985.tb10984.x
[15]	T. R. Boggs and M. C. Westphal, “Mortality of Exchange Transfusion,” Pediatrics, Vol. 26, No. 5, 1960, pp. 745- 755.
[16]	J. C. Jackson, “Adverse Events Associated with Exchange Transfusion in Healthy and Ill Newborns,” Paediatrics, Vol. 99, No. 5, May 1997, p. e7. doi:10.1542/peds.99.5.e7
[17]	U. John, M. B. Crichton, G. Henry, M. B. Dunn, A. K. McBurney, A.-M. Robertson and E. Tredger, “Long-Term Effects of Neonatal Jaundice on Brain Function in Children of Low Birth Weight,” Paediatrics, Vol. 49, No. 5, 1972, pp. 656-670.
[18]	L. S. de Vries, S. Lary and L. M. S. Dubowitz, “Relationship of Serum Bilirubin Levels to Ototoxicity and Deafness in High-Risk Low-Birth-Weight Infants,” Pediatrics, Vol. 76, No. 3, 1985, pp. 351-354.
[19]	A. L. Gordon, M. English, D. J. Tumaini, M. Karisa, C. R. Newton, “Neurological and Developmental Outcome of Neonatal Jaundice and Neonatal Sepsis in Rural Kenya,” Tropical Medicine and Health, Vol. 10, 11, 2005, pp. 1114-1120. doi:10.1111/j.1365-3156.2005.01496.x
[20]	R. K. Kumar, “Neonatal Jaundice. An Update for Family Physicians,” Australian Family Physician, Vol. 28, No. 7, 1999, pp. 679-682.
[21]	B. H. Billing, P. G. Cole and G. H. Lathe, “Increased Plasma Bilirubin in Newborn Infants in Relation to Birth Weight,” British Medical Journal, Vol. 2, No. 4899, 1954, pp. 1263-1265. doi:10.1136/bmj.2.4899.1263
[22]	R. C. Harris, “Peak Levels of Serum Bilirubin in Normal Premature Infants,” In: A. Sass-Kortsak, Ed., Kernicterus, University of Toronto Press, Toronto, 1961, pp. 10-12.
[23]	J. F. Watchko, “The Clinical Sequelae of Hyperbilirubinemia,” In: M. J. Maisels and J. F. Watchko, Eds., Neonatal Jaundice, Harwood Academic Publishers, Amsterdam, 2000, pp. 115-135.