Decreasing Laboratory Testing for Neonatal Jaundice Through Revision of a Clinical Practice Pathway

OBJECTIVES: The purpose of this study was to minimize unnecessary laboratory services for hospitalized neonates with hyperbilirubinemia by revising a local clinical practice pathway (CPP). METHODS: A retrospective cohort study was performed to compare the number of laboratory tests and blood draws in patients hospitalized with neonatal hyperbilirubinemia before and after implementation of a revised CPP. The study included infants with neonatal hyperbilirubinemia <14 days old admitted after their birth hospitalization between April 2017 and October 2019. Primary outcome measures included the total number of blood draws and the number of laboratory tests obtained per patient and length of stay. Secondary outcome measures included 7-day readmission rate, charges, and discharge bilirubin level. RESULTS: The median number of blood draws per patient after implementation of the CPP decreased to 2 (interquartile range [IQR], 2–3) compared with 3 (IQR, 2–3) before implementation (Poisson model–based estimated mean difference, 1.1; 95% confidence interval, 1.0–1.3; P = .018). The median number of laboratory tests per patient after implementation decreased from 4 (IQR, 3–6) to 3 (IQR, 2–4; Poisson model–based estimated mean difference, 1.3; 95% confidence interval, 1.2–1.5; P < .0001). There was no significant change in length of stay, readmission rate, charges, or discharge bilirubin level. CONCLUSIONS: Implementation of a revised CPP was associated with a significant decrease in the number of blood draws and laboratory tests per patient for infants admitted to the hospital for neonatal hyperbilirubinemia.

Effectiveness of short duration phototherapy in government hospital setup

Background: Neonatal hyperbilirubinemia is most common presentation of neonates. Phototherapy remains standard treatment for neonatal hyperbilirubinemia. Overcrowding in government hospital makes it difficult to give phototherapy for more than 1-2 days. The objectives of the study were to determine the effectiveness of short duration of phototherapy in treating hyperbilirubinemia and to determine the risk of rebound hyperbilirubinemia.Methods: Study was hospital based retrospective study. The study place was GIMS kalaburagi. The study was conducted from September 2019 to December 2019. All healthy full-term neonates with serum bilirubin above cut off range according to (American academy of pediatrics) nomogram were included in the study. Requirement of phototherapy was decided on serum bilirubin levels as per AAP (American academy of pediatrics) nomogram. Phototherapy was used as treatment modality.Results: Total 110 neonates were included in the study. Total of 56 neonates (50.9%) required 1 day of phototherapy to fall within normal limits for discharge and 46 neonates (41.8%) required 2 days of phototherapy to fall within normal limits for discharge with a significant p<0.05. Rebound hyperbilirubinemia requiring repeat phototherapy was seen in 6(10%) neonates who were discharged after 1 day of phototherapy and in 5 neonates (10%) who were discharged after 1 day of phototherapy with a p value of 0.05.Conclusions: Short duration phototherapy is the effective means of treatment for most neonates in government hospital set up. Serum bilirubin has to be reviewed during follow up to assess rebound hyperbilirunemia.

Co-inheritance of G6PD deficiency and 211 G to a variation of UGT1A1 in neonates with hyperbilirubinemia in eastern Guangdong

Background Glucose-6-phosphate dehydrogenase (G6PD) deficiency, which may manifest as neonatal hyperbilirubinemia, is the most prevalent erythrocytic enzyme-related disease in the world. Objective To investigate the association between neonatal hyperbilirubinemia and co-inheritance of G6PD deficiency and 211 G to A variation of UGT1A1 in Chaozhou city of eastern Guangdong province, the effects of G6PD deficiency and UGT1A1 gene variant on the bilirubin level were determined in neonates with hyperbilirubinemia. Method The activity of G6PD was assayed by an auto-bioanalyzer. PCR and flow-through hybridization were used to detect 14 common G6PD mutations in G6PD deficient neonates. 211 G to A variation of UGT1A1 was determined by PCR and sequencing. The data of neonatal bilirubin was collected and analyzed retrospectively. Results Seventy four cases of the 882 hyperbilirubinemia neonates were G6PD deficiency (8.39%) while 12 cases of the 585 non-hyperbilirubinemia neonates (control group) were G6PD deficiency (2.05%). The rate of G6PD deficiency in the hyperbilirubinemia group was higher than that of the control group. Moreover, the peak bilirubinin of the G6PD-deficient group of hyperbilirubinemia neonates was 334.43 ± 79.27 μmol/L, higher than that of the normal G6PD group of hyperbilirubinemia neonates (300.30 ± 68.62 μmol/L). The most common genotypes of G6PD deficiency were c.1376G > T and c.1388G > A, and the peak bilirubin of neonates with these two variants were 312.60 ± 71.81 μmol/L and 367.88 ± 75.79 μmol/L, respectively. The bilirubin level of c.1388G > A was significantly higher than that of c.1376G > T. Among the 74 hyperbilirubinemia neonates with G6PD deficiency, 6 cases were 211 G to A homozygous mutation (bilirubin levels 369.55 ± 84.51 μmol/L), 27 cases were 211 G to A heterozygous mutation (bilirubin levels 341.50 ± 63.21 μmol/L), and 41 cases were wild genotypes (bilirubin levels 324.63 ± 57.52 μmol/L). Conclusion The rate of G6PD deficiency in hyperbilirubinemia neonates was significantly higher than that of the non-hyperbilirubinemia neonates in Chaozhou. For the hyperbilirubinemia group, neonates with G6PD deficiency had a higher bilirubin level compared to those with normal G6PD. For hyperbilirubinemia neonates with G6PD deficiency, there was a declining trend of bilirubin levels among 211 G to A homozygous mutation, heterozygous mutation, and wild genotype, but there was no significance statistically among the three groups.

Role of Probiotics in Neonates with Hyperbilirubinemia Receiving Phototherapy

Study Objectives: To compare the mean duration of phototherapy in neonates with hyperbilirubinemia receiving phototherapy with vs. without probiotics. Study Design and Settings: It was a randomized controlled trial carried at Department of Pediatrics, DHQ Hospital Kasur from Jan 2021 to June 2021. Patients and Methods: The present research involved 94 neonates of both genders aged between 2 to 28 days of life diagnosed of neonatal hyperbilirubinemia (serum bilirubin level ≥15mg/dL and direct bilirubin level ≤1.5 mg/dL). These neonates were allocated into two groups randomly. Neonates in Group-I were given probiotics along with conventional treatment of phototherapy whereas neonates in Group-II received conventional phototherapy alone. Study outcome was described in terms of mean duration of phototherapy (phototherapy was stopped when serum bilirubin level was less than 10 mg/dl during the first week and less than 11 mg/dl after the first week) which was recorded and compared between the groups. An informed written consent was taken from parents of every neonate. Results of the Study: The mean age of the neonates was 6.54±4.96 days while the mean gestational age was 37.31±2.04 weeks. There were 55 (58.5%) baby boys and 39 (41.5%) baby girls with a boys to girls ratio of 1.4:1. The mean weight of the neonates was 2.89±0.49 Kg while the mean serum bilirubin level upon admission was 16.73±1.19 mg/dl. The mean duration of phototherapy was significantly shorter in neonates receiving probiotics along with phototherapy as compared to phototherapy alone (3.13±0.92 vs. 3.81±1.12 days; p=0.002). Similar significant difference was observed across various subgroups based on age, gender, gestational age, weight and serum bilirubin level upon admission. Conclusion: Addition of probiotics to conventional practice of phototherapy alone in jaundiced neonates was found to hasten the recovery evident from significant reduction in the mean duration of phototherapy advocating its routine use in future practice. Keywords: Neonatal Hyperbilirubinemia, Phototherapy, Probiotics

Risk Factors for Serum Bilirubin Rebound After Stopping Phototherapy in Neonatal Hyperbilirubinemia

Objective: To identify the factors affecting rebound increase in bilirubin levels after stopping phototherapy in neonatal hyperbilirubinemia. Setting: Tertiary-level neonatal unit. Patients: This was a hospital-based cross-sectional observational study. The study was conducted in neonatal division of rural tertiary care hospital. All neonates who were admitted for hyperbilirubinemia treatment and fulfilled the inclusion criteria were included in the study. Inclusion Criteria: All neonates 1.5 kg and above and treated in newborn intensive care unit for hyperbilirubinemia. Exclusion Criteria: (a) Critically ill patients requiring respiratory support any time after delivery, (b) neonates presenting with life-threatening surgical conditions, (c) patient with congenital malformation, (d) conjugated bilirubin elevation, (e) patients with birth asphyxia. Statistical Analysis: All the data were entered into a Microsoft Excel sheet. Appropriate tests of significance were applied. The various variables were sorted and presented as a number or percentage. The categorical variables used in the analysis were evaluated using the chi-square test (Yates’s correction and Fischer exact test were employed where applicable). The continuous data were analyzed by “t” test. The P value of less than 0.05 was taken to be level of statistical significance. Results: One hundred and fifty patients of neonatal hyperbilirubinemia were included in this study. In this study, 81 newborns (54.0%) were male and 78 (52%) of them were born by normal vaginal delivery. One hundred and nine babies (72.6%) were term babies. Fifty babies (33.3%) were low birth weight. Out of 150 neonates, 18(12%) had ABO incompatibility, 13(8.7%) Rh incompatibility, 23(15.7%) neonatal sepsis, and 4 (2.6%) had polycythemia. Out of 150 patients, 15(10%) babies had rebound hyperbilirubinemia at 24 h of life requiring phototherapy prematurity (particularly <34 weeks) ( P value: .03), low birth weight (particularly <2.0 kg) ( P value:.009), onset of jaundice requiring phototherapy before 72 h of life ( P value .04), blood group (both Rh and ABO) incompatibility ( P values: .001 and .002), neonatal sepsis ( P value: .004) were significantly associated with rebound hyperbilirubinemia. Glucose 6 phosphate dehydrogenase (G6PD) deficiency, polycythemia, maturity, mode of feeding, and gender did not show any statistical significant relationship with rebound hyperbilirubinemia. Conclusions: Rebound level of bilirubin need not be checked in all babies. Babies with risk factors like born preterm, low birth weight, having sepsis, requirement of phototherapy before 72 h of life, Rh and ABO group incompatibility, only need to be checked for serum bilirubin rebound. We recommend more studies with larger sample size to evaluate all these factors including polycythemia and G6PD deficiency.