Efficacy of strategies for predicting hyperbilirubinemia NEMC Evidence Report

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Efficacy of strategies for predicting
hyperbilirubinemiaNEMC Evidence Report

• Stanley Ip, MD
• Division of General Pediatrics and Adolescent
  Medicine
• The Floating Hospital for Children
• Tufts-New England Medical Center

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Strategies evaluated

• Cord Bilirubin (4 studies, n1105)
• Early Serum Bilirubin (4 studies, n3105)
• End-tidal Carbon Monoxide Concentration (2
  studies, n1421)
• Predischarge Risk Index (1 study, 73 cases, 423
  controls)
• Predischarge Risk Zone, determined by
  hour-specific bilirubin percentile (1 study,
  n2840)

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Subjects from 12 studies

• U.S., China, Denmark, India ,Israel, Japan, Spain
• N 51 to 2840
• Term only, term and preterm
• Breast feeding 4 to 90
• No Rh, but some included ABO incompatibility
• Some received phototherapy

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Definitions of Hyperbilirubinemia

• TSB gt11.7 mg/dl, gt15 mg/dl, gt17 mg/dl,
• gt25 mg/dl
• TSB gt16 mg/dl at 36 hours
• TSB gt10 mg/dl at day 2, gt14 mg/dl at day 3
• gt17 mg/dl at day 4 and 5
• TSB 95tile
• Clinical jaundice (6.4 mg/dl to 19.3 mg/dl)

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Cord Bilirubin

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Test Performance of Cord Bilirubin Levels Adapted
from Knudsen, 1992
1.46mg/dl
1.75mg/dl
2.05mg/dl
2.34mg/dl
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Early Serum Bilirubin level

• Awasthi, 1998 (n274)
• TSB (18/24) gt 3.99 mg/dl predicts TSBgt15
  mg/dl sensitivity 69, specificity 66
• Carbonell, 2001 (n1563)
• TSB(24) 6 mg/dl predicts TSB gt 17 mg/dl
  sensitivity 100, specificity 45.7
• TSB (48) 9 mg/dl predicts TSB gt 17 mg/dl
  sensitivity 100, specificity 64.3
• Seidman, 1999 (n1177)
• TSB (24) gt 5 mg/dl is associated with 36.5
  O.R. of TSB(day2) gt10, (day3) gt14, (days 45) gt17

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Factors associated with JaundiceMultiple
Logistic Analysis by Seidman, 1999

• Day 1 TSB (per 1 mg/dl) 3.1 (O.R)
• ? in TSB from day 1 to2 2.4
• Maternal blood type O 2.9
• Maternal age (per year) 1.1
• Full breastfeeding 0.4
• Day 1 TSB gt 5mg/dl 36.5

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Variables associated with TSB 25 mg/dlMultiple
Logistic Analysis by Newman, 2000

• Early jaundice 7.3 (O.R.)
• FH of jaundice 6.0
• Exclusive Breastfeed 5.7
• Bruising 4.0
• Asian Race 3.5
• Cephalohematoma 3.3
• Maternal age 25 3.1
• Lower gestational age 0.6/week

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ROC of Predischarge Risk IndexSource Newman TB,
2000
RI7
RI10

RI7
RI10
RI15
RI15
RI20
RI20
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End-tidal Carbon Monoxide Concentration

• Okuyama, 2001 (N51)
• ETCOc gt 1.8 ppm at 42 hours predicts
• TSB gt 15 mg/dl
• sensitivity 86, specificity 80,
• PPV 40, NPV 97

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Predischarge Risk Zone Bhutani,
1999 Infants who fulfilled inclusion criteria
13,003 Study subjects with at least 2 TSBs
(pre and post discharge) 2840
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Distribution of TSB values at selected study
epochal periods Bhutani, 1999
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Hour Specific TSBBhutani, 1999
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Predischarge Risk ZoneBhutani, 1999
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(No Transcript)
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Predischarge Risk Zone

• 75tile predischarge zone predicts to subsequent
  95tile
• sensitivity 90.5, specificity 84.7,
• PPV 21.6, NPV 99.5

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Racial distribution of study population
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ROC Curves Comparing ETCOc, STB Alone, and
Combined ETCOc and STB at 306 hrsStevenson, 2001
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Stevenson, 2001
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Summary

• Not possible to directly compare the accuracy of
  various strategies
• Higher TSB at an early age is associated with
  hyperbilirubinemia
• Hour-specific nomogram method appears promising
  (AUC 0.93) but further validation is needed