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Efficacy of strategies for predicting hyperbilirubinemia NEMC Evidence Report

Efficacy of strategies for predicting hyperbilirubinemia NEMC Evidence Report. Stanley Ip, MD Division of General Pediatrics and Adolescent Medicine The Floating Hospital for Children Tufts-New England Medical Center. Strategies evaluated. Cord Bilirubin (4 studies, n=1105)

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Efficacy of strategies for predicting hyperbilirubinemia NEMC Evidence Report

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  1. 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

  2. Strategies evaluated • Cord Bilirubin (4 studies, n=1105) • Early Serum Bilirubin (4 studies, n=3105) • End-tidal Carbon Monoxide Concentration (2 studies, n=1421) • Predischarge Risk Index (1 study, 73 cases, 423 controls) • Predischarge Risk Zone, determined by hour-specific bilirubin percentile (1 study, n=2840)

  3. 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

  4. Definitions of Hyperbilirubinemia • TSB >11.7 mg/dl, >15 mg/dl, >17 mg/dl, >25 mg/dl • TSB >16 mg/dl at 36 hours • TSB >10 mg/dl at day 2, >14 mg/dl at day 3 >17 mg/dl at day 4 and 5 • TSB ≥ 95%tile • Clinical jaundice (6.4 mg/dl to 19.3 mg/dl)

  5. Cord Bilirubin

  6. Test Performance of Cord Bilirubin Levels Adapted from Knudsen, 1992 1.46mg/dl 1.75mg/dl 2.05mg/dl 2.34mg/dl

  7. Early Serum Bilirubin level • Awasthi, 1998 (n=274) TSB (18/24) > 3.99 mg/dl predicts TSB>15 mg/dl; sensitivity 69%, specificity 66% • Carbonell, 2001 (n=1563) TSB(24) ≥ 6 mg/dl predicts TSB > 17 mg/dl; sensitivity 100%, specificity 45.7% TSB (48) ≥ 9 mg/dl predicts TSB > 17 mg/dl; sensitivity 100%, specificity 64.3% • Seidman, 1999 (n=1177) TSB (24) > 5 mg/dl is associated with 36.5 O.R. of TSB(day2) >10, (day3) >14, (days 4&5) >17

  8. 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 > 5mg/dl 36.5

  9. 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

  10. ROC of Predischarge Risk IndexSource: Newman TB, 2000 RI=7 RI=10 RI=7 RI=10 RI=15 RI=15 RI=20 RI=20

  11. End-tidal Carbon Monoxide Concentration Okuyama, 2001 (N=51) ETCOc > 1.8 ppm at 42 hours predicts TSB > 15 mg/dl sensitivity 86%, specificity 80%, PPV 40%, NPV 97%

  12. Predischarge Risk Zone Bhutani, 1999 Infants who fulfilled inclusion criteria = 13,003 Study subjects with at least 2 TSB’s (pre and post discharge) = 2840

  13. Distribution of TSB values at selected study epochal periodsBhutani, 1999

  14. Hour Specific TSBBhutani, 1999

  15. Predischarge Risk ZoneBhutani, 1999

  16. Predischarge Risk Zone • ≥75%tile predischarge zone predicts to subsequent ≥95%tile; sensitivity 90.5%, specificity 84.7%, PPV 21.6%, NPV 99.5%

  17. Racial distribution of study population

  18. ROC Curves Comparing ETCOc, STB Alone, and Combined ETCOc and STB at 30±6 hrsStevenson, 2001

  19. Stevenson, 2001

  20. 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

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