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Safe Bilirubin Levels
Newman TB, Liljestrand P,Jeremy RJ, et al. Outcomes among Newborns with Total Serum Bilirubin Levels of 25 mg per Deciliter or More. New Engl J Med (May 4, 2006); 354: 1889-1900. [Full Text ] [PDF]
Background:
The neurodevelopmental risks associated with high total serum
bilirubin levels in newborns are not well defined.
Methods: We identified 140 infants with neonatal total serum
bilirubin levels of at least 25 mg per deciliter (428 µmol per
liter) and 419 randomly selected
controls from a cohort
of 106,627 term and near-term infants born from 1995 through
1998 in Kaiser Permanente hospitals in northern
California.
Data on outcomes were obtained from electronic records, interviews,
responses to questionnaires, and neurodevelopmental evaluations
that had been performed in a blinded fashion.
Results: Peak bilirubin levels were between 25 and 29.9 mg
per deciliter (511 µmol per liter) in 130 of the newborns
with hyperbilirubinemia and 30 mg per deciliter (513 µmol per liter)
or more in 10 newborns; treatment involved phototherapy in 136 cases
and exchange transfusion in 5. Follow-up data to the age of at least
two years were available for 132 of 140 children with a history of
hyperbilirubinemia (94 percent) and 372 of 419 controls (89 percent)
and included formal evaluation at a mean (±SD) age of 5.1±0.12 years
for 82 children (59 percent) and 168 children (40 percent),
respectively. There were no cases of kernicterus. Neither crude nor
adjusted scores on cognitive tests differed significantly between the
two groups; on most tests, 95 percent confidence intervals excluded a
3-point (0.2 SD) decrease in adjusted scores in the
hyperbilirubinemia group. There was no significant difference between
groups in the proportion of children with abnormal neurologic
findings on physical examination or with documented diagnoses of
neurologic abnormalities. Fourteen of the children with
hyperbilirubinemia (17 percent) had "questionable" or abnormal
findings on neurologic examination, as compared with 48 controls (29
percent; P=0.05; adjusted odds ratio, 0.47; 95 percent confidence
interval, 0.23 to 0.98; P=0.04). The frequencies of parental concern
and reported behavioral problems also were not significantly
different between the two groups. Within the hyperbilirubinemia
group, those with positive direct antiglobulin tests had lower scores
on cognitive testing but not more neurologic or behavioral problems.
Conclusions: When treated with phototherapy or exchange
transfusion, total serum bilirubin levels in the range included in
this study were not associated with adverse neuro-developmental
outcomes in infants born at or near term.
Comments:
I think that the
pendulum is about to swing back toward more conservative management of
bilirubin levels between 25 and 30 mg / dL, especially in non-hemolytic
jaundice. In this group of patients, I would favor using exchange transfusion
only when patients fail to respond to treatment with aggressive phototherapy.
In fact, that is what the current AAP practice guideline tells us to do: “…if
the TSB level is above the exchange level, repeat TSB measurement every 2 to 3
hours and consider exchange if the TSB remains above the levels indicated
after intensive phototherapy for 6 hours.” To review the entire AAP practice
guideline on management of hyperbilirubinemia see: [Full
text]
[PDF] . ABK.
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