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Innovations in screening and management of neonatal hyperbilirubinemia
Introduction
One of the most significant innovations in the routine management of neonatal hyperbilirubinemia was the publication of the 2004 clinical practice guidelines on the management of hyperbilirubinemia in late preterm and term newborns by the American Academy of Pediatrics (AAP) Subcommittee on Hyperbilirubinemia. These guidelines were largely based on the innovative method of using predischarge total serum bilirubin (TSB) for hour-specific risk stratification developed by Bhutani et al. The 2004 AAP guideline has largely dictated hyperbilirubinemia screening and management practices both in the United States and internationally since publication nearly 20 years ago. Perhaps given the widespread adoption of the guideline, minimal practice change has occurred in the management of hyperbilirubinemia in the nearly 2 decades since its publication.
In this chapter we discuss five practice changes that are areas of active research. These practice changes have been explored, implemented, and studied by various research groups and in various hospitals in the United States and abroad. Each is an attempt to increase the value of the care we provide as we manage hyperbilirubinemia in the newborn; that is, each attempts to decrease the cost or burden on the patient while simultaneously maintaining or increasing the quality of the care provided. These sections are focused on inpatient care of newborns during the birth hospitalization, though outpatient management is also being actively studied.
Eliminating routine blood typing and direct antiglobulin testing for neonates born to blood group O mothers
The 2004 AAP guidelines state that if the maternal blood group is O (+), it is an option to test for the infant’s blood type and to perform a direct antiglobulin test (DAT), but it is not required to do so provided there is appropriate surveillance for hyperbilirubinemia. Recent studies by our group and others support eliminating routine blood typing and DAT measurement in neonates born to blood group O (+) mothers. Specifically, studies utilizing end-tidal carbon monoxide (ETCO) measurement as a marker of hemolysis found that some DAT-positive babies did not have clinically significant hemolysis, and some DAT-negative babies had clinically significant hemolysis, evidenced by elevated ETCO measurements. These findings led us to conclude that the DAT could neither definitively rule in nor rule out hemolysis. We also found that neonates in our health care system who were blood group A or B, born to mothers of group O (+) (and thus the neonates were at some risk for ABO hemolytic disease), did not have a higher incidence of severe neonatal hyperbilirubinemia than neonates of blood group O, born to group O (+) mothers (and thus were at no risk for ABO hemolytic disease). We suggested that this supports our theory that universal bilirubin screening of neonates in the birth hospital identifies those who need phototherapy, including those with significant ABO hemolytic disease, and that this obviates the need for routine neonatal blood type and DAT.
Intermountain Healthcare, a health care system that operates 21 delivery hospitals in the intermountain western region of the United States, discontinued the practice of routine blood typing and DAT measurement in neonates born to blood group O (+) mothers in 2005, the same year universal predischarge hyperbilirubinemia screening was implemented across the health care system. Follow-up data from 2005 to 2016 in 400,000 live births showed that this change did not result in a higher incidence of severe hyperbilirubinemia. , Other hospitals in the region have also begun implementing this change in practice. The authors’ home institution routinely stores cord blood samples during the birth hospitalization and only performs a DAT on these samples if the baby qualifies for phototherapy and is found to have hemolytic jaundice by an elevated ETCO (see later).
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