Ruben Bromiker

Severe Neonatal Hyperbilirubinemia and Kernicterus: Are These Still Problems in the Third Millennium?

Despite efforts to eliminate permanent and irreversible brain damage due to bilirubin encephalopathy and kernicterus, these conditions continue to accompany us into the third millennium. This phenomenon occurs not only in developing countries with emerging medical systems, but in Westernized countries as well. Comprehensive guidelines to detect newborns with jaundice and treat those in whom hyperbilirubinemia has already developed have been formulated in several countries, but have not been successful in completely eliminating the problem. In this appraisal of the situation we review selected aspects of bilirubin encephalopathy and/or kernicterus. We highlight recent reports of severe hyperbilirubinemia and kernicterus, discuss some of the factors responsible for the continuing appearance of these conditions, and briefly review what can be done to decrease bilirubin-related morbidity and mortality to the minimum.

Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia

Aim: To determine the incidence of post-phototherapy neonatal plasma total bilirubin (PTB) rebound. Methods: A prospective clinical survey was performed on 226 term and near-term neonates treated with phototherapy in the well baby nursery of the Shaare Zedek Medical Center from January 2001 to September 2002. Neonates were tested for PTB 24 hours (between 12 and 36 hours) after discontinuation of phototherapy, with additional testing as clinically indicated. The main outcome measure, significant bilirubin rebound, was defined as a post-phototherapy PTB ⩾256 μmol/l. Phototherapy was not reinstituted in all cases of rebound, but rather according to clinical indications. Results: A total of 30 (13.3%) neonates developed significant rebound (mean (SD) PTB 287 (27) μmol/l, upper range 351 μmol/l). Twenty two of these (73%) were retreated with phototherapy at mean PTB 296 (29) μmol/l. Multiple logistic regression analysis showed significant risk for aetiological risk factors including positive direct Coombs test (odds ratio 2.44, 95% CI 1.25 to 4.74) and gestational age <37 weeks (odds ratio 3.21, 95% CI 1.29 to 7.96). A greater number of neonates rebounded among those in whom phototherapy was commenced ⩽72 hours (26/152, 17%) compared with >72 hours (4/74, 5.4%) (odds ratio 3.61, 95% CI 1.21 to 10.77). Conclusion: Post-phototherapy neonatal bilirubin rebound to clinically significant levels may occur, especially in cases of prematurity, direct Coombs test positivity, and those treated ⩽72 hours. These risk factors should be taken into account when planning post-phototherapy follow up.

N-terminal-Pro-B-Type Natriuretic Peptide in Premature Patent Ductus Arteriosus: A Physiologic Biomarker, But Is It a Clinical Tool?

This study investigated whether N-terminal-pro-B-type natriuretic peptide (NT-proBNP) levels could serve as prognostic indicators of the therapeutic responsiveness of the patent ductus arteriosus to pharmacologic treatment. The levels of NT-proBNP in premature neonates with hemodynamically significant patency of the ductus arteriosus (hsPDA) were assessed before and after treatment using ibuprofen, indomethacin, or both. The baseline NT-proBNP levels were similar in both the infants who responded and those who did not respond to medical treatment. The combined data for all the subjects showed that NT-ProBNP decreased after treatment, but the decrease did not correlate significantly with treatment success or failure. Of the 38 infants, 11 did not respond to treatment with ductal closure. Although the pretreatment NT-proBNP levels were similar, the posttreatment levels in the nonresponders remained significantly higher than in the responders. Moreover, in 3 (27%) of the 11 nonresponders, NT-proBNP actually increased rather than decreased with treatment. The NT-proBNP levels of seven infants increased over the course of the study. Within this group, however, the pretreatment NT-proBNP levels were significantly lower than in the overall population, with no differences in the posttreatment levels. Overall, the decrease in NT-proBNP with treatment, presented as the ratio of pretreatment–post-treatment/pretreatment was not well correlated with the ductal therapeutic outcome. In summary, in the study population, NT-proBNP was not sufficiently sensitive for accurate prediction of ductal therapeutic responsiveness.

Neonatal Hyperbilirubinemia in the Low-Intermediate–Risk Category on the Bilirubin Nomogram

OBJECTIVE: Predischarge bilirubin screening predicts neonatal hyperbilirubinemia. We evaluated the incidence of false-negative bilirubin screening among readmissions for hyperbilirubinemia. METHODS: In healthy term and late preterm, predominantly breastfeeding newborns, predischarge transcutaneous bilirubin values were plotted on the hour of life–specific bilirubin nomogram and confirmed with plasma total bilirubin in those with a transcutaneous reading ≥75th percentile, or between the 41st and 75th percentiles in the presence of predictive icterogenic risk factors. False-negative bilirubin screen was defined as a predischarge bilirubin value ≤75th percentile in a newborn who was subsequently readmitted for phototherapy. RESULTS: Of a total of 25 439 neonates born between 2008 and 2009, 143 (0.56%) were readmitted with a mean plasma total bilirubin of 18.7 ± 1.7 mg/dL at 125 ± 54 hours. False-negative predischarge bilirubin screen was identified in 46 (32.2%). Of these, 6 (4.2%) were in the low-risk zone (≤40th percentile, relative risk [RR] = 1) and 40 (28%) in the intermediate-low–risk zone (41st–75th percentile, RR 7.62 [95% confidence interval 3.23–17.96]). Of those in the high-risk zones, 76 (53.1%) were in the intermediate-high–risk zone (76th–95th percentile, RR 25.32 [11.03–58.10]) and 21 (14.7%) in the high-risk zone (>95th percentile, RR 27.78 [11.23–68.70]). CONCLUSIONS: Predischarge bilirubin levels in newborns classified as low risk did not eliminate the risk of readmission for hyperbilirubinemia. All newborns including those at low risk must be vigilantly observed for subsequent hyperbilirubinemia.

Diagnostic accuracy of capnography during high-frequency ventilation in neonatal intensive care units.

High‐frequency ventilation (HFV) is a powerful tool for CO2 elimination, and thus requires careful monitoring of CO2. Our aim was to assess the diagnostic accuracy (correlation, agreement, and trending) of continuous distal capnography (dCap) with PaCO2 in infants ventilated with HFV.

Normal Point of Care Glucose Values after Birth in the Well-Baby Nursery

Objective Normal initial blood glucose values in healthy newborns are not well defined and are subject to controversy. Despite substantive research, there is no single initial value of glucose that can be used with certainty of safety in newborns, and thus various protocols and cutoffs have been proposed. Study Design We sought to characterize the normal values of blood glucose levels in a large cohort of neonates admitted to the well‐baby nursery in Shaare Zedek Medical Center. The blood glucose levels were measured with a point of care (POC) glucometer (Accu‐Chek Performa) within 180 minutes after birth. Results The study population included 3,912 newborns with a mean birth weight of 3,322 ± 439 g and a mean gestational age of 39.4 ± 1.3 weeks. Sampling was performed at a median age of 73 minutes (interquartile range [IQR], 55‐92 minutes). Median glucose concentration was 58 (IQR, 51‐67) mg/dL, and first, third, and fifth percentiles were 34, 39, and 41 mg/dL, respectively. Conclusion Our data describe the normal range of POC blood glucose levels in healthy neonates on admission to the nursery. Extreme low levels were rare.