Severe Jaundice In Infants
ironjustice
Universal screening lowers risk of severe jaundice in infants
Published: Sunday, September 27, 2009 - 23:43 in Health & Medicine
Screening all newborns for excessive bilirubin in the blood can
significantly decrease the incidence of severe jaundice which, in
extreme cases, can lead to seizures and brain damage, according to
researchers at UCSF Children's Hospital and Kaiser Permanente's
Division of Research in Oakland, CA. The study, one of the first to
examine the effectiveness of universal screening for
hyperbilirubinemia, appears in the current issue of "Pediatrics," the
official journal of the American Academy of Pediatrics. The study is
one of six in this issue to explore the topic of bilirubin and
hyperbilirubinemia.
Hyperbilirubinemia is caused by an elevation of a bile pigment, called
bilirubin, in the blood. Bilirubin is made when the body breaks down
old red blood cells, and high levels can cause jaundice, a condition
that makes the newborn's skin and the white part of the eyes look
yellow.
The researchers explain that most newborns have a rise in bilirubin in
the days following birth. However, very high blood levels can be toxic
to the nervous system. Monitoring these levels in babies with jaundice
is important so that treatment can be started before levels become
excessive, explain the researchers. They add that high bilirubin
levels can be treated with light therapy, which converts the bilirubin
into a form that the body can remove.
"While we know that early identification of bilirubin levels before
reaching toxic levels is important, bilirubin screening has not been
universal, as physicians have decided which infants to screen based
upon their degree of jaundice and clinical risk factors," said Michael
Kuzniewicz, MD, MPH, the lead author of the study and a neonatologist
at UCSF Children's Hospital. "This study provides evidence that
universal screening during the birth hospitalization is a more
effective method for monitoring bilirubin levels in order to prevent
them from rising to a point that can damage an infant's brain."
The study evaluated the impact of implementation of the 2004 American
Academy of Pediatrics (AAP) guideline on the management of jaundice in
the Northern California facilities operated by Kaiser Permanente. The
guideline recommends that every newborn be assessed for the risk of
developing severe jaundice with a bilirubin level before discharge
home and/or an assessment of clinical risk factors.
With universal screening, researchers noted a 62 percent decrease in
the number of newborns with very high bilirubin levels. The study also
describes an increase in the use of phototherapy to treat infants with
elevated bilirubin levels, sometimes even when the AAP guidelines did
not call for it.
Researchers in this study evaluated both blood tests and devices that
estimate the bilirubin level from the color of the baby's skin as
methods of screening. "The method didn't seem to matter as much as
changing the standard operating procedure, such that all babies are
screened," said study co-author Gabriel Escobar, MD, regional director
for hospital operations research and a research scientist with the
Kaiser Permanente Division of Research's Perinatal Research Unit in
Oakland, CA. "With additional education to help avoid excessive use of
phototherapy, we think universal screening is a very good tool to
reduce cases of serious hyperbilirubinemia."
"This research highlights the power of laboratory databases in
supporting research and quality improvement," according to senior
author Thomas B. Newman, MD, MPH, with the UCSF Department of
Epidemiology and Biostatistics and the UCSF Division of General
Pediatrics.
Source: University of California - San Francisco
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Task Force Finds Insufficient Evidence for Screening for Newborn
Jaundice
Released: 9/24/2009 9:00 PM EDT
Embargo expired: 9/28/2009 7:00 AM EDT
Source: Agency for Healthcare Research and Quality (AHRQ)
Newswise — According to a new recommendation from the U.S. Preventive
Services Task Force, there is insufficient evidence to assess the
balance of benefits and harms of screening infants for
hyperbilirubinemia to prevent chronic bilirubin encephalopathy.
Hyperbilirubinemia is a condition marked by a high level of bilirubin
in the blood, which is often apparent as yellow-colored skin and eyes
(jaundice). This recommendation and the accompanying summary of
evidence will appear in the October issue of Pediatrics.
About 60 percent of all infants have jaundice, and it generally clears
up without any medical treatment. Some infants are more likely to have
severe jaundice and higher bilirubin levels than others. In some
infants, hyperbilirubinemia may lead to chronic bilirubin
encephalopathy, a rare but devastating neurological condition. The
brain damage associated with chronic bilirubin encephalopathy, or
kernicterus, may result in cerebral palsy, auditory processing
problems, gaze and vision abnormalities, and cognitive problems. The
number of children who develop chronic bilirubin encephalopathy is
unknown and difficult to determine.
“There is inadequate evidence that screening all full-term and near-
term infants for elevated bilirubin leads to improved health
outcomes,” said Task Force Chair Ned Calonge, M.D., who is also chief
medical officer for the Colorado Department of Public Health and
Environment. “More research is necessary to understand how often
chronic bilirubin encephalopathy occurs, its risk factors, and whether
screening is associated with a reduction in chronic bilirubin
encephalopathy.”
There is evidence that screening using risk factor assessment or
bilirubin level measurement can identify infants at risk of developing
hyperbilirubinemia, but there is no known screening test that will
reliably identify all infants at risk of developing chronic bilirubin
encephalopathy. Not all infants with chronic bilirubin encephalopathy
have a history of hyperbilirubinemia, and not all infants who have
extremely high levels of bilirubin develop chronic bilirubin
encephalopathy.
In assessing the potential benefits and harms of screening infants for
hyperbilirubinemia, the Task Force looked for evidence that screening
reduced the number of new cases of chronic bilirubin encephalopathy.
No studies have directly addressed whether screening, either risk-
factor assessment or bilirubin testing, reduced the number of new
cases of chronic bilirubin encephalopathy. The current evidence on
screening has evaluated the effectiveness of screening to identify
infants for treatment intended to reduce high levels of bilirubin.
The Task Force found that the evidence is currently insufficient
regarding whether treating infants with high levels of bilirubin
results in fewer children developing chronic bilirubin encephalopathy.
There is a critical gap in the evidence regarding the relationship
between screening infants without symptoms of hyperbilirubinemia and
the desired outcome of reducing cases of chronic bilirubin
encephalopathy. When the Task Force finds insufficient evidence to
make a recommendation, it does not mean a clinician shouldn’t provide
a service but that the evidence is lacking, and if a service is
offered, patients should understand the uncertainty about the balance
of benefits and harms. The Task Force recognizes that clinical or
policy decisions involve more consideration than their recommendations
alone, and clinicians and policy makers should understand the evidence
but individualize decision-making to the specific patient or
situation.
Efforts have been made by clinicians to eliminate this rare disorder
by applying measures to screen for and aggressively manage high
bilirubin levels. Universal screening for jaundice is widespread in
the United States, and clinicians and parents should continue to work
together to decide whether to screen in the face of insufficient
evidence. Clinicians must remain aware that screening and resulting
treatment of hyperbilirubinemia have potential harms such as weight
loss, gastrointestinal problems, and disruption of the mother-infant
bonding.
The Task Force is the leading independent panel of experts in
prevention and primary care. The Task Force, which is supported by the
Agency for Healthcare Research and Quality, conducts rigorous,
impartial assessments of the scientific evidence for the effectiveness
of a broad range of clinical preventive services, including screening,
counseling and preventive medications. Its recommendations are
considered the gold standard for clinical preventive services.
Once the embargo lifts at 7:00 a.m., EDT, on September 28, the
recommendations and materials for clinicians will be available on the
AHRQ Web site at http://www.ahrq.gov/clinic/uspstf/uspshyperb.htm.
Previous Task Force recommendations, summaries of the evidence and
related materials are also available on the AHRQ Web site.
Use Twitter to get AHRQ news updates: http://www.twitter.com/ahrqnews/
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