Early neonatal hyperbilirubinemia using first day serum bilirubin level

OBJECTIVE: To evaluate the predictive value of total serum bilirubin (TSB) < or =6 mg/dl at 24 +/- 6 hr postnatal age in identifying near term and term infants, who do not develop hyperbilirubinemia subsequently. DESIGN: Prospective study. SETTING: Tertiary care hospital. METHODS: All healthy neonates with gestation > or =35 weeks, in absence of significant illness or Rh hemolysis were included. TSB was estimated at 24 +/- 6 hr by micromethod using spectrophotometry. Infants were followed up clinically every 12 hr till discharge and then after 48 hr. TSB level was estimated again whenever clinical suspicion of jaundice exceeded 10 mg/dl. Primary outcome was defined as presence of hyperbilirubinemia (TSB > or= 17 mg/dl) till day five of age. RESULTS: Of the 220 infants, 213 (96.8%) were followed up. All infants were exclusively breastfed. Mean age at bilirubin estimation was 24.7 +/- 1.9 hr with mean TSB of 5.9 +/- 1.8 mg/dl. Clinically detectable jaundice was present in 164 (77%) and hyperbilirubinemia occurred in 22 (10.3%) infants. A TSB level of < or = 6 mg/dl at 24 +/- 6 hr was present in 136 (63.8%) infants and only one infant developed hyperbilirubinemia subsequently (probability < 1%). In the remaining 77 (36.1%) infants, with TSB >6 mg/dl, subsequent hyperbilirubinemia developed in 21 (27.2%) (sensitivity 95%, specificity 70.6%, positive predictive value 27.2%, negative predictive value 99.3%, likelihood ratio of positive test 3.23 and likelihood ratio of negative test 0.07). Babies with TSB levels higher than 6 mg/dl had a significant risk of developing hyperbilirubinemia (relative risk 38; 95% confidence interval 6-1675). CONCLUSION: A TSB level of < or = 6 mg/dl at 24 +/- 6 hr of life predicted neonates who would not develop hyperbilirubinemia.     

Predictive ability of a predischarge hour-specific serum bilirubin for hyperbilirubinemia in full term infants

AIM: The aim of this paper was to assess the ability of total serum bilirubin (TSB) levels in the first 3 days of life to predict subsequent nonphysiologic hyperbilirubinemia. METHODS: The predictive ability of an hour-specific nomogram for TSB values in the first week of life was prospectively assessed in 1496 full term neonates admitted to a first level neonatal unit, using a single TSB value or two consecutive ones, when available. RESULTS: The incidence of TSB values > 12 mg/dL was 9.6%, while the incidence of TSB > 15 mg/dL was 2.6%. A sensitivity of 97.9% and a negative predictive value (NPV) of 99.6% were obtained with a single bilirubin determination applying Trend 12, while 82.5% of sensitivity and 99.4% of NPV were obtained with Trend 15. Two consecutive TSB determinations identified all infants reaching TSB values > 12 mg/dL and all neonates but 5 reaching TSB values > 15 mg/dL (92.1% of sensitivity and 99% of NPV) CONCLUSION: The hour-specific TSB determination in the first 3 days of life is able to predict all neonates at risk of nonphysiologic hyperbilirubinemia and could facilitate a safe discharge from the hospital and a targeted intervention and follow-up.     

A randomized controlled trial of fluid supplementation in term neonates with severe hyperbilirubinemia

OBJECTIVE: To evaluate the effectiveness of fluid supplementation in decreasing the rate of exchange transfusion and the duration of phototherapy in term neonates with severe nonhemolytic hyperbilirubinemia. STUDY DESIGN: This was a randomized controlled trial conducted in a tertiary care referral unit in northern India. Seventy-four term neonates with severe nonhemolytic hyperbilirubinemia (total serum bilirubin > 18 mg/dL [308 micromol/L] to < 25 mg/dL [427 micromol/L]). The subjects were randomized to an "extra fluids" group (intravenous fluid supplementation for 8 hours and oral supplementation for the duration of phototherapy; n = 37) or a control group (n = 37). RESULTS: At inclusion, 54 infants (73%) had high serum osmolality, including 28 (75%) in the extra fluids group and 26 (70%) in the control group. The proportion of infants who underwent exchange transfusion was lower in the extra fluids group than in the control group: 6 (16%) versus 20 (54%)(P = .001; relative risk = 0.30; 95% confidence interval = 0.14 to 0.66). The duration of phototherapy was also shorter in the extra fluids group: 52 +/- 18 hours versus 73 +/- 31 hours (P = .004). CONCLUSION: Fluid supplementation in term neonates presenting with severe hyperbilirubinemia decreased the rate of exchange transfusion and duration of phototherapy.     

Early hospital discharge of the healthy term neonate: the Italian perspective.

AIM: An appropriate timing of hospital discharge of the healthy, term neonate represents a balance between birth medicalization and surveillance of immediate health hazards. In the absence of European recommendations, the authors have conducted a broad national survey on the current policies of neonatal discharge. METHODS: A 13-item questionnaire was sent to 136 Italian birth centers. Quantitative variables were expressed as mean+/-range. Qualitative variables were expressed as frequencies. chi squared test was used for variables comparison. RESULTS: Mean age at discharge for a vaginally delivered neonate was 72 hours. Twelve percent of centres would not schedule a follow-up appointment. Neonates born after a cesarean section were discharged at a mean age of 97 hours. Almost all centres (95/98) would discharge an healthy infant without risk factors for hyperbilirubinemia with a total serum bilirubin (TSB) of 13 mg/dL at 72 hours but 14.7% of these centers would not recheck TSB. The same healthy neonate would be discharged at the age of 45 hours with a TSB=10 mg/dL in 67/98 centers and in 11.9% of cases would not be rechecked. CONCLUSION: Most Italian hospitals discharge healthy, term neonates born after spontaneous vaginal delivery (SVD) at over 72 hours of age. This policy should protect from missed diagnoses of clinical importance (e.g. hyperbilirubinemia). On the other hand, a prolonged hospitalization tends to increase maternal discomfort and medical costs. Implementing a protocol of home visits/clinic follow-up appointments after an earlier discharge may minimize health hazards and medical costs and optimizing the patient's feedback.     

Neonatal hyperbilirubinemia in African American males: the importance of glucose-6-phosphate dehydrogenase deficiency

OBJECTIVE: To perform risk factor analysis for the prediction of hyperbilirubinemia in an African American male neonatal cohort. STUDY DESIGN: A database of 500 previously published term and near-term African American male neonates was further analyzed to determine the role of risk factors for hyperbilirubinemia. Factors studied included birth weight >/=4.0 kg, gestational age /=75(th) percentile. Hyperbilirubinemia was defined as any bilirubin value >/=95(th) percentile on the hour-of-life-specific bilirubin nomogram. RESULTS: Forty-three (8.6%) neonates developed hyperbilirubinemia. At 48 +/- 12 hours, median transcutaneous bilirubin was 8.3 mg/dL, 75(th) percentile 10.0 mg/dL, and 95(th) percentile 12.6 mg/dL. Of the risk factors, only exclusive breast-feeding, G-6-PD deficiency and predischarge bilirubin >/=75(th) percentile were significant (Adjusted Odds Ratios [95% Confidence Intervals; CI] 3.15 [1.39-7.14], P = .006; 4.96 [2.28-10.80], P = .001; and 7.47 [3.50-15.94], P < .0001, respectively). G-6-PD-deficient neonates who were also premature and breast-feeding had the highest incidence of hyperbilirubinemia (60%). CONCLUSIONS: African American male neonates may be at higher risk for hyperbilirubinemia than previously thought. Screening for G-6-PD deficiency and predischarge bilirubin determination may be useful adjuncts in hyperbilirubinemia prediction in these newborns.     

Prediction of significant hyperbilirubinemia in term neonates by early non-invasive bilirubin measurement

Background:Neonatal jaundice is a common problem.We evaluated the utility and best cut-off values of 24-and 48-hour transcutaneous bilirubin indices (TcBI) in predicting subsequent significant hyperbilirubinemia and evaluated various associated maternal and fetal risk factors.Methods:TcBI at 24 and 48 hours and serum bilirubin levels at 72 hours of age were obtained for healthy,term,appropriate for gestational age neonates.Neonates with prematurity,birth weight ＜2500 g,ABO or Rh incompatibility,onset of clinical jaundice ＜24 hours,clinical suspicion of septicemia,positive pressure ventilation at birth,admission in neonatal intensive care unit and contraindications for BiliChek were excluded.Twently-four and 48-hour TcB indices were assessed as predictors of subsequent hyperbilirubinemia,defined as serum bilirubin ＞17 mg/dL after 72 hours of life and various cut-offs,and were evaluated by calculating sensitivity,specificity and predictive values.Results:Of 500 newborns,4.6％ had significant hyperbilirubinemia,27％ had TcBI (mg/dL) ＜5 at 24 hours,and 27.4％ had TeBI ＜8 at 48 hours.None of them had subsequent hyperbilirubinemia (100％ negative predictive value).The percentage of newborns with subsequent hyperbilirubinemia increased from 3.4％ to 13.2％ as their 24-hour TcBI increased from 6 to above 9 mg/dL and from 4.2％ to 7.4％ as their 48-hour TcBI increased from 8 to above 11 mg/dL.The best cut-off value was TcBI (mg/dL) 7 (odd ratio=4.86,95％ confidence interval:1.66-15.22) at 24 hours and 10 (odd ratio=2.87,95％ confidence interval:1.04-8.29) at 48 hours.Area under the receiver operating characteristic curve for 24-and 48-hour measurements was 0.750 and 0.715,respectively.Maternal premature rupture of membranes,deep transverse arrest,post-date pregnancy,and fetal distress were significant risk factors for hyperbilirubinemia.Conclusions:Twenty-four and 48-hour TcB indices are good predictors of subsequent hyperbilirubinemia.Twenty-four-hour TcBI had better predictive ability than 48-hour TcBI.     

胆红素-尿苷二磷酸葡萄糖醛酸基转移酶G71R基因型对广西地区新生儿黄疸程度的影响

目的 探讨胆红素-尿苷二磷酸葡萄糖醛酸基转移酶1A1(UGT 1A1)基因突变对广西新生儿黄疸的影响.方法 收集73例高胆红素血症新生儿及31例健康新生儿外周血,应用突变特异性扩增系统(amplification refractory mutation system,ARMS)法及直接测序法对所有新生儿行UGT1A1基因G71R突变检测,分析胆红素脑病发生率,胆红素峰值及总胆红素(total serum bilirubin,TSB)>20 mg/dl的机会比.结果 (1)本研究人群G71R等位基因频率为0.1915,病例组为0.2329,健康对照组为0.097,病例组的G71R等位基因频率显著高于健康对照组(P<0.05).(2)G71R纯合子的胆红素脑病发病率及72 h的TSB浓度(28.57%,23.12±4.58 mg/dl)均高于野生型组(0%,17.68±2.69 mg/dl),差异有统计学意义(P<0.001).(3)G71R纯合子组中5例的TSB>20 mg/dl,G71R纯合子TSB>20 mg/dl的机会比(odds ratio,OR)为7.955,总体机会比95%可信区间(confidence interval,CI)为(1.349,46.899).结论 G71R突变与本地新生儿黄疸的发病存在相关性.G71R纯合子的胆红素脑病发病率及生后72 h的TSB较对照组及野生型增高.G71R纯合子发生TSB>20 mg/dl的危险性是野生型的7.955倍.     

Extreme hyperbilirubinemia in newborn infants

This study was undertaken to determine the frequency and investigate the etiology of extreme hyperbilirubinemia (total serum bilirubin [TSB]>or=25 mg/dL [428 micromol/L]) in newborns admitted to a neonatal intensive care unit in southern Turkey. The charts of 93 term and near-term infants admitted with TSB levels of 25 mg/dL (428 micromol/L) or greater in the first 30 days after birth were retrospectively reviewed. During the 4.5-year study period, 774 infants were admitted to our unit with neonatal jaundice. Ninety-three (12%) of these infants had TSB levels of 25 mg/dL (428 micromol/L) or greater. The mean TSB level in the 93 cases was 30.1+/-5.7 mg/dL (514.7+/-97.5 micromol/L), and the peak levels ranged from 25.0 to 57.4 mg/dL (428-981.5 micromol/L). Thirty-three (35.5%) of the 93 babies had TSB levels of 30 mg/dL (513 micromol/L) or greater. Eighty-nine of 93 infants were being exclusively breast-fed. Nineteen babies were isoimmunized, 7 were bacteremic, 2 of the 39 babies tested for glucose-6-phosphate dehydrogenase had this enzyme deficiency, and 1 of the 71 infants tested for thyroid function had hypothyroidism. No cause for extreme hyperbilirubinemia was found in 61 (65.6%) cases.     

Pre-Discharge Screening Trans-Cutaneous Bilirubinometry in Healthy Newborns in Mahdieh Hospital,Tehran

Background:

Incidence of jaundice is high in newborn infants. Since well appearing newborns are rapidly and routinely discharged from hospital, performing an inexpensive noninvasive pre-discharge screening test for evaluation of jaundice seems to be necessary.

Objectives:

This study was conducted to compare the accuracy of cutaneous v/s serum bilirubin measurements in this regard.

Patients and Methods:

This was a prospective cross sectional study conducted in Mahdieh hospital, Tehran. 613 neonates weighing ≥ 1,800 g with gestational age of ≥ 35 weeks were enrolled. A pre discharge transcutaneous bilirubin test (TcB) was performed in all. Serum samples were taken from neonates with TcB ≥ 5 mg/dL in first and > 8 mg/dL in second 24 hours. Decision for treatment or recheck of bilirubin level after discharge was made based on serum bilirubin results.

Results:

Based on the study protocol, among 613 studied neonates, 491 (80%) revealed high TcB, of them 240 (49%) cases showed TBC ≥ 5 mg/dL in first and 251 (51 %) in second pre-discharge 24 hours. TcB ranged 3.3 - 17.1, mean TcB in first 24 hours was 6.9 ± 1 .7 (mode 6) and in second 24 hours 9.1 ± 2.1 (mode 10). Of 491 neonates with high TcB, capillary serum sample was taken as the second step and 398 neonates revealed high total serum bilirubin (TsB) with the same protocol for TcB. 108 (27.1%) neonates showed TsB ≥ 5 mg/dL in first and 290 (72.9%) in second 24 hours. According to the study results TcB has a 81% positive predictive value (PPV) in diagnosis of hyperbilirubinemia. Correlation coefficient of TcB and TsB in highest rate is equal to 72% (P value < 0.001).

Conclusions:

TcB is an inexpensive, noninvasive and precise pre-discharge screening test for evaluation of hyperbilirubinemia, with a high PPV. It is highly recommended to be performed routinely due to high incidence of hyperbilirubinemia in neonates.     

Mandibular distraction in neonates: indications, technique, results

Background

Early discharge of healthy late preterm and full term newborn infants has become common practice because of the current social and economic necessities. Severe jaundice, and even kernicterus, has developed in some term infants discharged early. This study was designed to elaborate a percentile-based hour specific total serum bilirubin (TSB) nomogram and to assess its ability to predict the absence of risk for subsequent non physiologic severe hyperbilirubinaemia before discharge.

Methods

A percentile-based hour-specific nomogram for TSB values was performed using TSB data of 1708 healthy full term neonates. The nomogram's predictive ability was then prospectively assessed in five different first level neonatal units, using a single TSB value determined before discharge.

Results

The 75 ^th percentile of hour specific TSB nomogram allows to predict newborn babies without significant hyperbilirubinemia only after the first 72 hours of life. In the first 48 hours of life the observation of false negative results did not permit a safe discharge from the hospital.

Conclusion

The hour-specific TSB nomogram is able to predict all neonates without risk of non physiologic hyperbilirubinemia only after 48 to 72 hours of life. The combination of TSB determination and risk factors for hyperbilirubinemia could facilitate a safe discharge from the hospital and a targeted intervention and follow-up.     

Neonatal jaundice in full-term infants. Role of breast-feeding and other causes

Serum bilirubin determinations were performed on 264 term infants who were consecutively delivered via the vaginal route. Forty-one infants (15.5%) had serum bilirubin concentrations greater than 12 mg/dL. No cause for this was found, initially, in 23 (56%) of these infants. On the third hospital day, the mean (+/- SD) serum bilirubin level was 6.9 +/- 3.6 mg/dL in breast-fed infants and 6.5 +/- 3.2 mg/dL in bottle-fed infants. Of the 23 infants without obvious cause for hyperbilirubinemia, eight (four bottle-fed and four breast-fed infants) had serum bilirubin concentrations greater than 12 mg/dL on the third hospital day, whereas in 15 (14 breast-fed infants and one bottle-fed infant), the elevated serum bilirubin level occurred on day 4 or 5. Breast-feeding does not seem to affect the total serum bilirubin level in the first three days of life but may be associated with an increased incidence of hyperbilirubinemia subsequently. In a normal full-term population, routine investigations do not disclose a cause for hyperbilirubinemia in about half of the patients.     

Effect of feeding type on the efficacy of phototherapy

OBJECTIVE: The objective of this study was to assess the efficacy of phototherapy for nonhemolytic hyperbilirubinemia and rebound bilirubin levels in breast-fed newborns as compared with mixed-fed (breast milk and formula) newborns. STUDY DESIGN/SETTING: Prospective study of effects of feeding type on response to phototherapy in newborns. METHODS: The subjects were 53 full-term healthy newborns with nonhemolytic hyperbilirubinemia [defined as total serum bilirubin 12 mg/dL (205.2 micromol/L) in the first 48 hours of life or 15 mg/dl (256.5 micromol/L), on subsequent days]. Groups were formed according to type of feeding. Group 1 consisted of 28 breast-fed newborns and group 2 consisted of 25 mixed-fed newborns. Phototherapy was terminated when total serum bilirubin concentration fell to 14 mg/dL (< 239.4 micromol/L). Rebound bilirubin measurements were obtained 24 hours after phototherapy ended. RESULTS: The groups were comparable with respect to age at the start of phototherapy. The amount of weight loss (relative to birth weight) recorded at the start of phototherapy was significantly greater in group 1 than in group 2 (8.1+/- 3.9% vs. 5.4+/- 2.6% p = 0.004). The duration of phototherapy was significantly longer in group 1 than in group 2 (38.6+/- 12.6 h vs. 26.8+/- 9.4 h; P < 0.001). The 24-hour rate of decrease in bilirubin concentration in group 2 was significantly higher than that in group 1 [5.4+/- 2.2 mg/dL/d (92.3+/-37.6 micromol/L/d) vs. 4+/- 1.3 mg/dL/d (68.4+/- 22.2 micromol/L/d); p = 0.01]. The overall rate of decrease in bilirubin concentration in group 1 was significantly lower than that in group 2 [0.16+/- 0.05 mg/dL/h (2.73+/- 0.85 micromol/L/h) vs. 0.22+/- 0.09 mg/dL/h (3.76+/- 1.53 micromol/L/h); p = 0.01]. There was no significant difference between the two groups with respect to rebound bilirubin concentration (P = 0.184). Conclusion: Phototherapy effectively reduced bilirubin levels in breastfed newborns with hyperbilirubinemia, but these patients show significantly slower response to this treatment than mixed-fed newborns.     

Bilirubin/Albumin Ratio for Predicting Acute Bilirubin-induced Neurologic Dysfunction

Objective

The aim of this study was to evaluate the bilirubin albumin (B/A) ratio in comparison with total serum bilirubin (TSB) for predicting acute bilirubin-induced neurologic dysfunction (BIND).

Methods

Fifty two term and near term neonates requiring phototherapy and exchange transfusion for severe hyperbilirubinemia in Children''s Medical Center, Tehran, Iran, during September 2007 to September 2008, were evaluated. Serum albumin and bilirubin were measured at admission. All neonates were evaluated for acute BIND based on clinical findings.

Findings

Acute BIND developed in 5 (3.8%) neonates. B/A ratio in patients with BIND was significantly higher than in patients without BIND (P<0.001). Receiver operation characteristics (ROC) analysis identified a TSB cut off value of 25 mg/dL [area under the curve (AUC) 0.945] with a sensitivity of 100% and specificity of 85%. Also, according to the ROC curve, B/A ratio cut off value for predicting acute BIND was 8 (bil mg/al g) (AUC 0.957) with sensitivity of 100% and specificity of 94%.

Conclusion

Based on our results, we suggest using B/A ratio in conjunction with TSB. This can improve the specificity and prevent unnecessary invasive therapy such as exchange transfusion in icteric neonates.     

Neonatal hyperbilirubinemia associated with glucose-6-phosphate dehydrogenase deficiency in Sephardic-Jewish neonates: incidence, severity, and the effect of phototherapy.

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency is frequently associated with neonatal hyperbilirubinemia, and sometimes kernicterus, often in the absence of any identifiable trigger or hematological evidence of hemolysis. The aim of this study was to compare the incidence and severity of, and the effect of phototherapy on, jaundice in G 6-PD-deficient vs G-6-PD-normal neonates in the Sephardic-Jewish community. Healthy term newborns, born to mothers of families stemming from geographic areas known to be "at risk" for G-6-PD deficiency, were screened for the condition and surveyed for hyperbilirubinemia. Seventy-five G-6-PD-deficient neonates formed the study group, while 266 neonates with normal levels of the enzyme formed the control group. Neonates with any other identifiable cause for jaundice were excluded. Phototherapy was commenced when the serum bilirubin levels reached 16 mg/dL (274 mumol/L) or more, and it was discontinued at 12 mg/dL (205 mumol/L) or less. Hyperbilirubinemia developed in 27 (36%) of the deficient neonates (serum total bilirubin greater than 13.9 mg/dL [238 mumol/L]), compared with 50 (18.8%) of control neonates (P = .002), while 20 (26.7%) of the study group required phototherapy, compared with 31 (11.7%) of control neonates (P = .002). Two neonates in the study group required exchange transfusion (serum bilirubin greater than 20 mg/dL [342 mumol/L]), vs 0 in the control group (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in BAER wave amplitudes in relation to total serum bilirubin level in term neonates

Introduction  Whether the severity of bilirubin neurotoxicity is closely related to the level of total serum bilirubin (TSB) remains to be determined. Materials and methods  We studied the amplitudes of brainstem auditory evoked response (BAER) components in 83 term neonates with TSB >10 mg/dL to detect any differences in bilirubin ototoxic effect on the amplitudes between different levels of TSB. Results and discussion  Compared to age-matched normal controls, the amplitudes of BAER waves III and V were reduced significantly (P<0.01 and 0.001). The V/I and V/III amplitude ratios were also decreased significantly (P<0.001 and 0.01). Although all amplitudes tended to be lower at higher TSB levels than at lower levels, none of the amplitudes correlated significantly with the level of TSB. Neither the V/I amplitude ratio nor the V/III amplitude ratio correlated with the TSB. No significant differences were found in any BAER wave amplitudes among the TSB levels 11–15, 16–20 and >20 mg/dL. In the comparison of amplitude data between any two of the three TSB levels, only wave V amplitude showed significant difference between TSB levels 11–15 and >20 mg/dL (P < 0.05). Conclusion  BAER wave amplitudes were significantly reduced in neonates with hyperbilirubinemia. However, there was no close correlation between the degree of amplitude reduction and the level of TSB. These results indicate that bilirubin toxicity to the neonatal brain is not closely related to the level of TSB.     

重度高胆红素血症新生儿苍白球磁共振成像特征及其临床意义

目的探讨苍白球MRI信号改变与高胆红素血症的严重程度及其相关因素关系,为胆红素脑病诊断与预后判定提供客观依据。方法36例高胆红素血症新生儿（TSB〉342μmoL／L）在生后[10±6（2～34）]d接受头部MRI检查。场强1．5～3．0Tesla,扫描序列为T1WI,T2WI和DWI。2名不知被检者病史的放射科医师分析MRI结果。结果首次MRI有20例苍白球T1WI呈对称性高信号。有苍白球信号改变组的TSB、B／A及UCB均显著高于无改变组[（605．28±89．19）μmoL／L vs．（438．19±67．89）μmoL／L,（1．08±0．18）vs．（0．77±0．16）,（555．49±92．3）μmoL／L vs．（412．01±54．8）μmoL／L,P=0．000],所有MRI-DWI均未见信号改变;TSB在342．0～427．5μmoL／L者9例,未见苍白球信号改变,427．5～513．0μmoL／L者7例,有改变者3例,超过525．0μmoL／L 20例,有改变者17例,黄疸程度与苍白球信号改变有密切关系（χ^2=15．000,P=0．000）;15例ABE苍白球T1WI均呈对称性的高信号（χ^2=17．601,P=0．000）,同时3例T2WI苍白球也呈对称性稍高信号（TSB分别为,745．3μmoL／L,735．7μmoL／L,707．6μmol/L）。7日内入院的25例中,16例苍白球有改变,平均入院时间显著晚于9例无改变者[（121．5±39．9）h vs．（68．9±35）h,P〈0．03]。6例接受了第2次MRI,其中3例ABE有2例苍白球信号转为T2WI高信号,临床均表现脑瘫,另1例苍白球信号正常,但有听力异常;余3例非ABE患儿,2例苍白球信号转为正常,1例两次均无苍白球信号异常,目前发育正常。结论MRI T1WI苍白球对称性高信号,与高胆红素血症的严重程度及暴露时间密切关系,是新生儿ABE的重要表现特征。T1WI高信号转变为T2WI高信号可能提示预后不良。     

Transcutaneous bilirubin in predicting hyperbilirubinemia in term neonates

Objective  To assess the utility of 24 and 48 hours transcutaneous bilirubin (TcB) index for predicting subsequent significant hyperbilirubinemia in healthy term neonates. Methods  TcB indices were obtained for healthy, breastfed, term AGA newborns at 24 ± 2, 48 ± 2 and subsequently at intervals of 24 hours. Neonates with illness, on treatment and positive Direct Coomb’s test were excluded. Serum bilirubin levels were obtained whenever indicated. Neonates having serum bilirubin ≥ 17 mg/dL were considered as significant hyperbilirubinemia. The 24 and 48 hour TcB indices, as risk predictors for such hyperbilirubinemia were determined. Results  Study included 461 healthy term neonates. The mean birth weight was 2949 (± 390) gm and mean gestation of 38.6 (± 1.1) weeks. Eight one (17.6%) had significant hyperbilirubinemia. Of 461, 135 (29.3%) had TcB index < 5 at 24 hours and 200 (43.3%) had index < 8 at 48 hours. None of them had later hyperbilirubinemia (100 % negative predictive value). Significant hyperbilirubinemia increased from 8.1 % to 76.4% as 24 hours TcB index raised from 5 to 9 and from 10.4 % to 83.7% as 48 hour TcB index raised from 8 to 11. Sensitivity and specificity were optimised at TcB value of 7(risk: OR=26.8, 95%Cl: 13.9–51.5) at 24 hours and 10 (risk: OR= 17.1, 95%Cl 8.9–32.9) at 48 hours. C-statistics for 24 and 48 hour measurements are 0.838 and 0.836 respectively. Conclusion  The 24 and 48 hour TcB indices are predictive for subsequent significant hyperbilirubinemia and can guide clinician in early discharge of healthy term newborns.     

Zinc Supplementation for Neonatal Hyperbilirubinemia: A Randomized Controlled Trial

Objectives

To determine the efficacy of oral zinc for treatment of idiopathic neonatal hyperbilirubinemia in near-term and term (35–41 weeks) neonates.

Design

Randomized placebo-controlled trial.

Setting

Tertiary-care teaching hospital

Participants

Eighty newborns with idiopathic neonatal hyperbilirubinemia.

Intervention

Neonates were randomized to receive either oral zinc sulfate (10 mg/d) or placebo for 7 days.

Main outcome measures

Primary: total serum bilirubin levels at 48 (±12) h, 96 (±12) h and 144 (±12) h after intervention. Secondary: duration of phototherapy, and serum zinc and copper levels.

Results

Baseline mean (SD) total serum bilirubin levels were 14.8 (3.8) and 14.4 (3.5) mg/dL in zinc and placebo groups, respectively. No significant differences were observed in total bilirubin levels between the two groups after the intervention. Mean (SD) total serum bilirubin levels in zinc and placebo groups were 13.9 (2.5) vs. 13.4 (1.9) mg/dL (mean difference 0.566; 95% CI ?0.535, 1.668, P=0.038) at 48 h, 13.1 (2.7) vs. 12.8 (2.3) mg/dL (mean difference 0.234; 95% CI ?1.011, 1.479, P =0.708) at 96 h and 8.0 (2.0) vs. 8.6 (1.2) mg/dL (mean difference ?0.569, 95% CI ?1.382, 0.242, P=0.166) at 144 h. Although the mean duration of phototherapy in the zinc group was less by 21.3 h (95% CI 11.6, 30.9, P=0.052), the difference was not significant. Postintervention, serum zinc levels were significantly higher in the zinc-supplemented group while serum copper levels were comparable between the two groups.

Conclusions

Oral zinc sulfate, in a dose of 10 mg/day, is not effective in the management of idiopathic neonatal hyperbilirubinemia.     

Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns

OBJECTIVE: To assess the predictive ability of a universal predischarge serum bilirubin measurement to screen for risk of subsequent significant hyperbilirubinemia in the direct Coombs negative healthy term and near-term newborn during the first postnatal week. METHODS: Total serum bilirubin (TSB) levels were obtained at the time of the routine metabolic screen in all term and near-term newborns cared for in the Pennsylvania Hospital Well Baby Nursery (n = 13 003). Postnatal age (in hours) at the time of TSB measurement was recorded. A percentile-based bilirubin nomogram for the first week was constructed from hour-specific predischarge and postdischarge TSB values of newborns (n = 2840; median BW = 3230 g and median gestational age = 39 weeks) who met classification criteria for healthy newborns (excluding those with a positive direct Coombs test or those requiring phototherapy before age 60 hours) and who were enrolled in a hospital supervised home or outpatient follow-up program. The accuracy of the predischarge TSB as a predictor of subsequent degree of hyperbilirubinemia was determined. RESULTS: The study patients in the nomogram were racially diverse. Nearly 60% were breastfed. Predischarge, 6.1% of the study population (172/2840) had TSB values in the high-risk zone (>/=95th percentile) at 18 to 72 hours; of these, 39.5% (68/172) remained in that zone (likelihood ratio [LR] = 14.08, sensitivity = 54%; specificity = 96.2%, probability = 39.5%). Predischarge, 32.1% of the population (912/2840) had TSB values in the intermediate-risk zone. In a clinically significant minority of these newborns (58/912 or 6.4%), the postdischarge TSB moved into the high-risk zone (LR of this move: 3.2 from the upper-intermediate zone and.48 from the lower-intermediate risk zone). The predischarge TSB in 61.8% of the newborns (1756/2840) was in the low-risk zone (<40th percentile) and there was no measurable risk for significant hyperbilirubinemia (LR = 0, sensitivity = 100%; specificity = 64.7%; probability = 0%). CONCLUSIONS: An hour-specific TSB before hospital discharge can predict which newborn is at high, intermediate or low risk for developing clinically significant hyperbilirubinemia (specifically defined as TSB levels >/=95th percentile for age in hours). Risk designation and subsequent increases or decreases of in TSB can be easily monitored on an hour-specific percentile based predictive bilirubin nomogram. A predischarge TSB measured as a universal policy would facilitate targeted intervention and follow-up in a safe, cost-effective manner. In conjunction with bilirubin practice parameter of the American Academy of Pediatrics, it could reduce the potential risk for bilirubin-induced neurologic dysfunction.     

Jaundice noted in the first 24 hours after birth in a managed care organization

OBJECTIVE: To investigate the significance of jaundice noted in the first 24 hours after birth in a community setting. DESIGN: Supplementary analyses of a nested case-control study. SETTING: Northern California Kaiser Permanente Medical Care Program. PATIENTS: Six hundred thirty-one randomly selected newborns (controls) and 140 cases with total serum bilirubin levels of 25 mg/dL (428 micro mol/L) or higher from a cohort of 105 384 newborns of at least 2000 g birth weight and at least 36 weeks' gestational age, born between January 1, 1995, and December 31, 1998. MAIN OUTCOME MEASURES: Notations of jaundice in the medical record, timing and results of bilirubin testing, use of phototherapy, and development of bilirubin levels of 25 mg/dL or higher. RESULTS: Among the controls, the cumulative probability of a notation of jaundice (corrected for early hospital discharge using survival analysis) was 2.8% within 18 hours and 6.7% within 24 hours. In these newborns, cumulative proportions that had bilirubin levels measured were 38% within 12 hours and 43% within 24 hours of when jaundice was first noted. About 40% of bilirubin levels measured within 24 hours were above the estimated 95th percentile for age. Compared with newborns not noted to be jaundiced on the first day, newborns noted to be jaundiced within 24 hours were more likely to receive phototherapy (18.9% vs 1.7%; relative risk, 10.1; 95% confidence interval, 4.2-24.4) and to develop a bilirubin level of 25 mg/dL or higher (odds ratio, 2.9; 95% confidence interval, 1.6-5.2), but the absolute risk increase for total serum bilirubin levels of 25 mg/dL or higher was 0.2%. CONCLUSION: Jaundice noted in the medical record in the first 24 hours after birth was uncommon and often clinically significant in this setting, but other factors also need to be considered in determining its importance.