Beruflich Dokumente
Kultur Dokumente
Annual Meeting
September 12, 2018
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Also: Survey institutions & providers regarding current bill mgmt. practices -
including:
- Use of Nomogram, BiliTool - - and are these embedded in EMR or easily
accessible?
- Protocol (if any) for how often to check TSB for babies receiving
phototherapy
- Protocol (if any) used to determine when to stop phototherapy, and if/
when to do
follow-up TSB (or serum bili) to check for rebound
REBOUND RISK CALCULATOR
A Clinical Prediction Rule for Rebound Hyperbilirubinemia Following Inpatient Phototherapy
- Pearl W. Chang, Michael W. Kuzniewicz, Charles E. McCulloch, Thomas B. Newman // [Kaiser
Permanente of Northern California] // http://pediatrics aappublications.org/content/139/3/e20162896
[The numbers on the x-axis represent percent probability (10%, 20%, etc.) ]
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Pediatrics.2017;139(3): e20163832
The American Academy of Pediatrics (AAP) consensus-based guidelines for the initiation of
phototherapy1,2 have been universally adopted in the United States and even applied in other
countries,3,4 whereas several countries have developed their own phototherapy guidelines.5–8
Substantially less guidance, however, has been provided on when to stop birth hospitalization
phototherapy to avoid retreatment. In fact, the AAP Subcommittee on Hyperbilirubinemia has
acknowledged that there is no standard for discontinuation.2 Evidence-based answers to this
common clinical question are now provided by Chang et al9 …
From 105 808 neonates born at ≥35 weeks’ gestation at 1 of 17 Kaiser Permanente Northern
California hospitals between 2012 and 2014, Chang et al9 identified a cohort of 7048 newborns
treated with phototherapy. The objective of the study was to identify predictors of “rebound,”
defined as a return to treatment threshold levels within 72 hours of discontinuation of a neonate’s
first round of phototherapy treatment. These data were then used to create a score that could
predict the probability of rebound and help clinicians decide when to discontinue phototherapy.
The rich electronic dataset available to the researchers included a number of key variables,
including gestational age, sex, birth weight, feeding type, direct antiglobulin test results, and
details regarding the initiation, course, and termination of phototherapy. Total serum and direct
bilirubin data were also included. With 4.6% of the sample experiencing a return to treatment
threshold after cessation of phototherapy, Chang et al9 identified multiple significant predictors of
rebound hyperbilirubinemia, including Asian race and exclusive breastfeeding, but their
parsimonious prediction score was formulated using only 3 variables: gestational age, age at
phototherapy initiation, and “relative” total serum bilirubin (level at cessation minus the AAP
phototherapy threshold).
-cont.-
Specifically, a gestational age of <38 weeks and higher relative serum bilirubin were associated
with an increased likelihood of rebound hyperbilirubinemia, whereas older age at phototherapy
initiation was protective. These observations are consistent with those of other studies,10,11
and the fact that infants with hemolytic disease–associated hyperbilirubinemia are much more
likely to both require early phototherapy and experience a rebound. The prediction score
calculated from these variables generated thresholds where rebound hyperbilirubinemia was
highly unlikely, something that can easily be included in the clinical care of such neonates.
Importantly, use of this score could have resulted in a 1-day shorter hospital stay for roughly
one-third of those treated with phototherapy, something that would be desirable for all
stakeholders.
Numerous previous studies have analyzed the bilirubin rebound after phototherapy,10–15 but
none have approached the sample size studied by Chang et al.9 In addition, comparisons with
these studies are difficult because of differences in the populations studied, the bilirubin levels
chosen for phototherapy termination, and the criteria used to define rebound. In some
ilnstitutions, about half of the infants receiving phototherapy for the first time are those who are
readmitted,10 a population in whom the primary cause for hyperbilirubinemia is much less likely
-cont.-
to be active hemolysis and in whom the risk of rebound is much lower.10 In the Chang
et al study,9 62% of infants received their phototherapy during their birth
hospitalization. Because of the strong association between older age and less
rebound, we assume that many of the older infants were those readmitted for their first
course of phototherapy, although the authors do not specifically address this issue.
This prediction rule for rebound hyperbilirubinemia comes at a
time when innovation around well newborn care has been increasing, providing
evidence-based and guideline-based tools to improve patient care. After publication of
the Bhutani nomogram for neonatal hyperbilirubinemia,16 Web-based tools, such as
Bilitool (www.bilitool. org), became routinely used in daily clinical care. More recently,
the Newborn Sepsis calculator17,18 (https://neonatalsepsiscalculator.
kaiserpermanente.org/) and Newborn Weight Tool19,20 (www. newbornweight.org)
have helped clinicians adapt evidence on sepsis risk and newborn weight loss into
mobile platforms that can inform clinical care in real-time. The formula used in the new
prediction rule for rebound hyperbilirubinemia is simple and easy to use, and has
similar potential to influence clinical care for those newborns receiving phototherapy.
Pediatrics Nov. 1, 2016 - - Janelle L Aby, MD, FAAP (Stanford Univ. School of
Medicine) - at the 2016 American Academy of Pediatrics (AAP) National
Conference
· Breastfeeds to continue.
· Outcome.
-cont.-
Another invaluable tool is available at www.bilitool.org. Plugging in information such as the baby's
age and bilirubin level calls up published nomograms and AAP treatment guidelines for that case.
Not every baby with the same numeric bilirubin level is the same. Say a preterm baby's bilirubin
level falls into the Bhutani nomogram low-intermediate risk category. If the baby is late preterm
It's a 2-step process—the Bhutani nomogram provides a general picture of risk, while AAP
guidelines drill down into actual treatment recommendations. Using these guidelines is somewhat
tricky because the AAP uses slightly different risk categories. Consider a bilirubin level of 15 mg/
dL at 60 hours. For a term neonate without risk factors, the AAP does not recommend
phototherapy until 16 mg/dL or higher. However, if a baby has hemolysis, AAP guidelines
recommend phototherapy at 15 mg/dL. There's no specific number that drives treatment
decisions because every hour the threshold changes, for all categories.
Ultimately, said Aby, we are trying to identify the babies who really need to start phototherapy at a
lower TB level, versus those who perhaps do not.”
————————————-
“Additional emphasis also should be placed on determining prior to hospital discharge which
infants are at highest risk of requiring phototherapy. Bhutani et al reported that a combination of
predischarge bilirubin level and specific clinical factors is highly predictive of subsequent
phototherapy use. Recent and evolving work on genetic factors affecting bilirubin metabolism also
may give clinicians insight into which infants may require extra vigilance for progressive jaundice
during the early neonatal period.”
- W. Christopher Golden, MD, FAAP
(Medical Director of Newborn Nursery, Johns
Hopkins School of Medicine)
Regarding cancer risk/overuse of phototherapy -
(1) Kaiser Permanente of Northern California Study / Pediatrics - June 2016/Vol.
137, Issue 6:
“…[E]ven if the HRs [Hazard Ratios] for any phototherapy were at the top of the 95% CIs reported in this
study, absolute risk of cancer from phototherapy would be low, at least in childhood (<1/1000 over 10 years).
Is that potential risk worth taking? Phototherapy is often given at TSB levels at which the number needed to
treat to prevent 1 infant from reaching exchange levels is in the hundreds or thousands. Recent data suggest
that unless exchange transfusion thresholds are exceeded by at least 10 mg/dL, there is little or no
increased risk of cerebral palsy or hearing loss. Thus, even the low upper limit of risk of cancer may
exceed the likely benefits of treatment in many infants. The likelihood of harms exceeding benefits is
greatest in children with Down syndrome, whose much higher baseline risk of leukemia might lead
cautious clinicians to increase the treatment threshold for initiation of phototherapy in these infants, despite
the fact that the association between phototherapy and cancer has not yet been proven to be causal.
Conclusions
Although we confirmed a crude association between phototherapy and childhood cancer, particularly
nonlymphocytic leukemia, associations were diminished and no longer statistically significant after we
controlled for confounding variables. Nonetheless, consistent crude associations, clinically relevant upper
limits of adjusted 95% CIs, and the statistically significant adjusted association between multiple
phototherapy admissions and myelogenous leukemia suggest that avoiding unnecessary phototherapy
would be prudent, especially in children with Down syndrome.”
(2) Update on Pediatric Overuse
Eric R. Coon, et.al. - Pediatrics January, 2017
Findings: A multicenter study evaluating 525 409 infants born within an integrated health care
system in Northern California between 1995 and 2011 found small increases in the absolute risk
of cerebral palsy for hyperbilirubinemia in excess of recommended exchange transfusion
thresholds. Compared with infants whose total serum bilirubin levels were never above the
exchange transfusion threshold (ETT), infants with peak bilirubin values of 0 to 4.9 mg/dL above
the ETT had a slightly increased risk of cerebral palsy (absolute risk difference, 0.2%; 95% CI,
0%–0.5%). Of the 3/525 409 [< 0.0006%]* patients who developed kernicterus, all had ≥2
neurotoxicity risk factors and peak bilirubin levels >5 mg/dL higher than the currently
recommended ETT.”
[*This is lower than the incidence of 0.0015% during the period 1994-2005, as reported by B.L.
Burke et. al. in Trends in hospitalizations for neonatal jaundice and kernicterus in the United
States, 1988-2005 - Pediatrics, Feb. 2009 (Vol. 123, Issue 2)]
-cont.-
Implications: Risk of cerebral palsy and kernicterus is extremely low among infants
with modest elevations in peak serum bilirubin values beyond the current ETT.
Current treatment thresholds for hyperbilirubinemia can likely be raised without
putting infants at greater risk of brain injury.”
[29] Wu YW, Kuzniewicz MW, Wickremasinghe AC, et al. Risk for cerebral palsy in
infants with total serum bilirubin levels at or above the exchange transfusion
threshold: a population-based study. JAMA Pediatr. 2015;169(3):239–246pmid:
25560920
>> Evidence quality: 2b [Individual cohort study or low quality randomized controlled
trials (e.g. <80% follow-up) ] <<
Clinician Adherence to Guideline for Phototherapy Use in Newborns
- Diane J. Madlon-Kay, MD, MS - Journal of the American Board of Family
Practice, July-Aug. 2012 / Vol. 25, No. 4
(3) Having the phototherapy nomogram available in the chart does not likely
influence guideline adherence [? No studies evaluating the effectiveness of
BiliTool.]
(4) Use of Rebound Risk scoring should aid in making the decision on
whether/when to stop phototherapy, and on the advisability/relative
importance of follow-up bilirubin assessment within the following 72 hrs.