Rebound Bilirubin Checks Before Discharge
Berkwitt A, Osborn R, Grossman M
Hosp Pediatr. 2015;5:74-78
Current guidelines suggest that practitioners should not delay an infant's discharge to obtain a postphototherapy bilirubin level at less than 12 hours after cessation of phototherapy. Systematic obtainment of early (in-hospital) bilirubin levels evaluating for rebound after cessation of phototherapy could create significant delays in discharge, and it is also unclear whether this provides benefit by detecting meaningful rebound bilirubin levels. This study sought to add to the data on the necessity and utility of checking a postphototherapy rebound bilirubin level before hospital discharge. It was a retrospective review of data at a single medical center from 2007 through 2014.
The infants were 35 weeks gestational age or greater and were all readmitted to the hospital, after nursery discharge, for indirect hyperbilirubinemia. The cohort was divided into those who had an in-hospital bilirubin level checked within 12 hours of cessation of phototherapy, a group they deemed the "rebound" group, and the other infants, who were considered the "no rebound" group. The decision on whether to obtain the in-hospital rebound bilirubin level was up to each patient's physician during the study period, but the use of phototherapy generally followed the 2004 guidelines from the American Academy of Pediatrics (AAP) and the 2009 update. The analysis cohort included 226 infants, of whom 130 were in the rebound group (levels checked at a mean of 6.1 hours after phototherapy) and 96 were in the no rebound group. The groups were very similar at baseline with respect to age, gestational age, race and ethnicity, and sex. They were also mostly breast-fed (> 70%) and had similar risks for hemolysis.
The rebound group had a higher mean bilirubin level at the time of phototherapy initiation (19.5 mg/dL vs 18.8 mg/dL) as well as a higher mean bilirubin level at the end of phototherapy (13.7 mg/dL vs 13.0 mg/dL). The rebound group had a shorter duration of phototherapy (15.1 hours vs 17.7 hours). Furthermore, only 48% of the rebound group had a serum bilirubin level of ≤ 14 mg/dL at the time of phototherapy cessation compared with 69% of the no rebound group. Fourteen (6.2%) of the infants required repeat phototherapy, but only two of these 14 had demonstrated a serum bilirubin level of ≤ 14 mg/dL before phototherapy cessation, as suggested by AAP guidelines. Among the infants whose bilirubin levels at phototherapy cessation were ≤ 14 mg/dL, only two (1.6%) required repeat phototherapy compared with 12 (12.4%) of those whose bilirubin levels were > 14 mg/dL at phototherapy cessation. Checking a rebound bilirubin level was associated with a longer length of stay by approximately 4.5 hours as well as a later mean time of discharge, by approximately 2 hours. The investigators concluded that obtaining early (< 12 hours after phototherapy cessation) inpatient rebound bilirubin levels did not successfully predict who would require repeat phototherapy. They reiterated that phototherapy should be continued until the serum bilirubin level has reached 14 mg/dL or less.
The data abstraction in this study captured hemolysis risk level, but it does not appear that this was used as a control variable in the analysis. I suspect that there were not enough infants to adequately stratify the sample by hemolysis risk. Furthermore, one should remember that retrospective evaluations are not the same level of evidence as prospectively testing a cut-off for serum bilirubin—in this case, 14 mg/dL. Nevertheless, this article provides some very good epidemiologic information that can be used in daily practice. In particular, I'm struck, as were the study authors, that the rebound group spent a longer time in hospital but less time overall on treatment. This article could serve as a focal point for discussions in newborn nurseries as to whether clinicians are applying uniform approaches to treating hyperbilirubinemia to improve efficiency while also delivering care that is more consistent with guidelines.
The Utility of Inpatient Rebound Bilirubin Levels in Infants Readmitted After Birth Hospitalization for Hyperbilirubinemia
Berkwitt A, Osborn R, Grossman M
Hosp Pediatr. 2015;5:74-78
Study Summary
Current guidelines suggest that practitioners should not delay an infant's discharge to obtain a postphototherapy bilirubin level at less than 12 hours after cessation of phototherapy. Systematic obtainment of early (in-hospital) bilirubin levels evaluating for rebound after cessation of phototherapy could create significant delays in discharge, and it is also unclear whether this provides benefit by detecting meaningful rebound bilirubin levels. This study sought to add to the data on the necessity and utility of checking a postphototherapy rebound bilirubin level before hospital discharge. It was a retrospective review of data at a single medical center from 2007 through 2014.
The infants were 35 weeks gestational age or greater and were all readmitted to the hospital, after nursery discharge, for indirect hyperbilirubinemia. The cohort was divided into those who had an in-hospital bilirubin level checked within 12 hours of cessation of phototherapy, a group they deemed the "rebound" group, and the other infants, who were considered the "no rebound" group. The decision on whether to obtain the in-hospital rebound bilirubin level was up to each patient's physician during the study period, but the use of phototherapy generally followed the 2004 guidelines from the American Academy of Pediatrics (AAP) and the 2009 update. The analysis cohort included 226 infants, of whom 130 were in the rebound group (levels checked at a mean of 6.1 hours after phototherapy) and 96 were in the no rebound group. The groups were very similar at baseline with respect to age, gestational age, race and ethnicity, and sex. They were also mostly breast-fed (> 70%) and had similar risks for hemolysis.
The rebound group had a higher mean bilirubin level at the time of phototherapy initiation (19.5 mg/dL vs 18.8 mg/dL) as well as a higher mean bilirubin level at the end of phototherapy (13.7 mg/dL vs 13.0 mg/dL). The rebound group had a shorter duration of phototherapy (15.1 hours vs 17.7 hours). Furthermore, only 48% of the rebound group had a serum bilirubin level of ≤ 14 mg/dL at the time of phototherapy cessation compared with 69% of the no rebound group. Fourteen (6.2%) of the infants required repeat phototherapy, but only two of these 14 had demonstrated a serum bilirubin level of ≤ 14 mg/dL before phototherapy cessation, as suggested by AAP guidelines. Among the infants whose bilirubin levels at phototherapy cessation were ≤ 14 mg/dL, only two (1.6%) required repeat phototherapy compared with 12 (12.4%) of those whose bilirubin levels were > 14 mg/dL at phototherapy cessation. Checking a rebound bilirubin level was associated with a longer length of stay by approximately 4.5 hours as well as a later mean time of discharge, by approximately 2 hours. The investigators concluded that obtaining early (< 12 hours after phototherapy cessation) inpatient rebound bilirubin levels did not successfully predict who would require repeat phototherapy. They reiterated that phototherapy should be continued until the serum bilirubin level has reached 14 mg/dL or less.
Viewpoint
The data abstraction in this study captured hemolysis risk level, but it does not appear that this was used as a control variable in the analysis. I suspect that there were not enough infants to adequately stratify the sample by hemolysis risk. Furthermore, one should remember that retrospective evaluations are not the same level of evidence as prospectively testing a cut-off for serum bilirubin—in this case, 14 mg/dL. Nevertheless, this article provides some very good epidemiologic information that can be used in daily practice. In particular, I'm struck, as were the study authors, that the rebound group spent a longer time in hospital but less time overall on treatment. This article could serve as a focal point for discussions in newborn nurseries as to whether clinicians are applying uniform approaches to treating hyperbilirubinemia to improve efficiency while also delivering care that is more consistent with guidelines.