Neonatal Hyperbilirubinemia:Neonatal Hyperbilirubinemia:An UpdateAn Update

Bryan Burke, MDBryan Burke, MDArkansas Children’s Hospital Arkansas Children’s Hospital

University of Arkansas for Medical University of Arkansas for Medical SciencesSciences

DefinitionsDefinitions

Hyperbilirubinemia: An unusually large amount of Hyperbilirubinemia: An unusually large amount of bilirubin in the blood resulting in jaundice.bilirubin in the blood resulting in jaundice.

Acute Bilirubin Encephalopathy: Early stage - Acute Bilirubin Encephalopathy: Early stage - lethargy, hypotonia, and poor suck. Intermediate lethargy, hypotonia, and poor suck. Intermediate stage - moderate stupor, irritability, hypertonia stage - moderate stupor, irritability, hypertonia (retrocollis and opisthotonus), fever, high-pitched (retrocollis and opisthotonus), fever, high-pitched cry, which may alternate with drowsiness and cry, which may alternate with drowsiness and hypotonia. hypotonia.

Definitions (cont.)Definitions (cont.)

Kernicterus: The chronic form of bilirubin Kernicterus: The chronic form of bilirubin encephalopathy, manifested by a severe encephalopathy, manifested by a severe form of athetoid cerebral palsy, auditory form of athetoid cerebral palsy, auditory dysfunction, dental-enamel dysplasia, dysfunction, dental-enamel dysplasia, paralysis of upward gaze, and less often paralysis of upward gaze, and less often intellectual handicaps.intellectual handicaps.

Significance of TopicSignificance of Topic

Kernicterus, though rare, still occurs in America.Kernicterus, though rare, still occurs in America.11

Newborns are being discharged from the hospital Newborns are being discharged from the hospital sooner than ever before.sooner than ever before.

Early discharge means we are less able to Early discharge means we are less able to observe newborns for the development of observe newborns for the development of jaundice.jaundice.

1.1. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr. 2002;140:396-403kernicterus. J Pediatr. 2002;140:396-403

Goals: Accentuate the Positive, Goals: Accentuate the Positive, Eliminate the NegativeEliminate the Negative

Reduce the frequency of severe neonatal Reduce the frequency of severe neonatal hyperbilirubinemia and bilirubin encephalopathy.hyperbilirubinemia and bilirubin encephalopathy.

Decrease unintended harm, such as increased Decrease unintended harm, such as increased anxiety, decreased breastfeeding, unnecessary anxiety, decreased breastfeeding, unnecessary treatment, excessive cost, and waste.treatment, excessive cost, and waste.

Acknowledgement of the PastAcknowledgement of the Past

To Jon F. Watchko, MD, and Frank A. Oski, MD, To Jon F. Watchko, MD, and Frank A. Oski, MD, for writing “Bilirubin 20mg/dl = Vigintiphobia”, for writing “Bilirubin 20mg/dl = Vigintiphobia”, subtitled “Vigintiphobia: A One-Act Play”, in the subtitled “Vigintiphobia: A One-Act Play”, in the April 1983 issue of April 1983 issue of Pediatrics, Pediatrics, Vol. 71, No. 4, Vol. 71, No. 4, pages 660-663.pages 660-663.

To the AAP’s 1994 “Practice Parameter: To the AAP’s 1994 “Practice Parameter: Management of Hyperbilirubinemia in the Healthy Management of Hyperbilirubinemia in the Healthy Term Newborn”, which dramatically changed our Term Newborn”, which dramatically changed our approach to jaundiced newborns.approach to jaundiced newborns.

Impetus for this UpdateImpetus for this Update

The publication in July 2004 of the AAP’s Clinical The publication in July 2004 of the AAP’s Clinical Practice Guideline “Management of Practice Guideline “Management of Hyperbilirubinemia in the Newborn Infant 35 or Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation”, a tremendous More Weeks of Gestation”, a tremendous reference tool.reference tool.

To understand some of what will follow, you will To understand some of what will follow, you will need to refer to the graphs and charts in your need to refer to the graphs and charts in your handout.handout.

The Big ChangesThe Big Changes

Bilirubin values should be assessed against Bilirubin values should be assessed against the infant’s age in hours.the infant’s age in hours.

The new guideline is useful in both healthy The new guideline is useful in both healthy and sick newborns.and sick newborns.

The new guideline extends down to 35 The new guideline extends down to 35 weeks gestational age.weeks gestational age.

The Big ChangesThe Big Changes

Specific newborn discharge follow-up Specific newborn discharge follow-up timeframes are specified, causing a rather timeframes are specified, causing a rather dramatic change in our care.dramatic change in our care.

In addition to clinical assessment of the In addition to clinical assessment of the presence and significance of jaundice, presence and significance of jaundice, laboratory evaluation is suggested as a laboratory evaluation is suggested as a possible routine tool.possible routine tool.

Transcutaneous bilirubinometers are Transcutaneous bilirubinometers are mentioned as useful devices.mentioned as useful devices.

Primary PreventionPrimary Prevention

Mothers should be advised to nurse their Mothers should be advised to nurse their newborns at least 8-12 times per day for the first newborns at least 8-12 times per day for the first several days.several days.22

The AAP recommends against routine The AAP recommends against routine supplementation of nondehydrated breastfed supplementation of nondehydrated breastfed infants with water or dextrose water.infants with water or dextrose water.

2.2. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, Guidelines for Perinatal American Academy of Pediatrics, American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care. 5th edition. Elk Grove Village, IL: American Academy of Pediatrics; 2002:220-224.Care. 5th edition. Elk Grove Village, IL: American Academy of Pediatrics; 2002:220-224.

Secondary PreventionSecondary Prevention

Clinicians should perform ongoing systematic Clinicians should perform ongoing systematic assessments during the neonatal period for the assessments during the neonatal period for the risk of an infant developing severe risk of an infant developing severe hyperbilirubinemia.hyperbilirubinemia.

Risk factors can be broken into major and minor Risk factors can be broken into major and minor categories, with an approximate order of categories, with an approximate order of importance.importance.

Major Risk FactorsMajor Risk Factors

Total bilirubin or transcutaneous bilirubin in the Total bilirubin or transcutaneous bilirubin in the high-risk zone.high-risk zone.3 3

Jaundice observed in the first 24 hours.Jaundice observed in the first 24 hours.4 4

Blood group incompatibility with positive direct Blood group incompatibility with positive direct antiglobulin test, other known hemolytic disease, antiglobulin test, other known hemolytic disease, or elevated end-tidal COor elevated end-tidal CO22..

3.3. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103:6-14.for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103:6-14.

4.4. Newman Liljestrand P, Escobar GJ. Jaundice noted in the first 24 hours after birth in a managed care organization. Newman Liljestrand P, Escobar GJ. Jaundice noted in the first 24 hours after birth in a managed care organization. Arch Pediatr Adolesc Med. 2002;156:1244-1250.Arch Pediatr Adolesc Med. 2002;156:1244-1250.

Major Risk Factors (cont.)Major Risk Factors (cont.)

Gestational age 35-36 weeks.Gestational age 35-36 weeks.55

Previous sibling received phototherapy.Previous sibling received phototherapy.66

Cephalohematoma or significant bruising.Cephalohematoma or significant bruising.77

5.5. Maisels MJ, Kring EA. Length of stay , jaundice, and hospital readmission. Pediatrics. 1998;101:995-998.Maisels MJ, Kring EA. Length of stay , jaundice, and hospital readmission. Pediatrics. 1998;101:995-998.

6.6. Ref. Gale R, Seidman DS, Dollberg S, Stevenson DK. Epidemiology of neonatal jaundice in the Jerusalem Ref. Gale R, Seidman DS, Dollberg S, Stevenson DK. Epidemiology of neonatal jaundice in the Jerusalem population. J Pediatr Gastroenterol Nutr. 1990;10:82-86.population. J Pediatr Gastroenterol Nutr. 1990;10:82-86.

7.7. Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000:154:1140-hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000:154:1140-11471147

Major risk factors (cont.)Major risk factors (cont.)

Exclusive breastfeeding, particularly if nursing is Exclusive breastfeeding, particularly if nursing is not going well and weight loss is excessive.not going well and weight loss is excessive.88

East Asian race.East Asian race.99

8.8. Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995-998.Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995-998.

9.9. Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140-hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140-1147.1147.

Minor risk factorsMinor risk factors Predischarge total serum bilirubin or Predischarge total serum bilirubin or

transcutaneous bilirubin in the high-intermediate transcutaneous bilirubin in the high-intermediate risk zone.risk zone.1010

Gestational age 37-38 weeks.Gestational age 37-38 weeks.1111

Jaundice observed before discharge.Jaundice observed before discharge.1111

Previous sibling with jaundice.Previous sibling with jaundice.1111

10.10. Bhutani, Gourley GR, Adler S, Kreamer B, Dalman C, Johnson LH. Noninvasive measurement of total serum Bhutani, Gourley GR, Adler S, Kreamer B, Dalman C, Johnson LH. Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. 2000:106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e17.2000:106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e17.

11. Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995-998.11. Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995-998.

Minor risk factors (cont.)Minor risk factors (cont.)

Macrosomic infant of a diabetic mother.Macrosomic infant of a diabetic mother.1212

Maternal age greater than or equal to 25 years.Maternal age greater than or equal to 25 years.1313

Male gender.Male gender.1313

12.12. Berk MA, Mimouni F, Miodovnik M, Hertzberg V, Valuck J. Macrosomia in infants of insulin-dependent diabetic mothers. Pediatrics. Berk MA, Mimouni F, Miodovnik M, Hertzberg V, Valuck J. Macrosomia in infants of insulin-dependent diabetic mothers. Pediatrics. 1989;83:1029-1034.1989;83:1029-1034.

13.13. Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140-1147.maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140-1147.

Decreased riskDecreased risk Total serum bilirubin or transcutaneous bilirubin in Total serum bilirubin or transcutaneous bilirubin in

the low-risk zone.the low-risk zone.1414

Gestational age greater than or equal to 41 Gestational age greater than or equal to 41 weeks.weeks.1515

Exclusive bottle feeding.Exclusive bottle feeding.1515

14.14. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103:6-14.significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103:6-14.

15.15. Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal hyperbilirubinemia Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140-1147.in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140-1147.

Decreased risk (cont.)Decreased risk (cont.)

Black race.Black race.1616

Discharge from hospital after 72 hours of age.Discharge from hospital after 72 hours of age.1717

16.16. Stevenson DK, Fanaroff AA, Maisels MJ, et al. Prediction of hyperbilirubinemia in near-term and term infants. Stevenson DK, Fanaroff AA, Maisels MJ, et al. Prediction of hyperbilirubinemia in near-term and term infants. Pediatrics. 2001;108:31-39.Pediatrics. 2001;108:31-39.

17.17. Soskolne EL, Schumacher R, Fyock C, Young ML, Schork A. The effect of early discharge and other factors on Soskolne EL, Schumacher R, Fyock C, Young ML, Schork A. The effect of early discharge and other factors on readmission rates of newborns. Arch Pediatr Adolesc Med. 1996;150:373-379.readmission rates of newborns. Arch Pediatr Adolesc Med. 1996;150:373-379.

Secondary PreventionSecondary Prevention All pregnant women should be tested for ABO and All pregnant women should be tested for ABO and

Rh (D) blood types and have a serum screen for Rh (D) blood types and have a serum screen for unusual isoimmune antibodies.unusual isoimmune antibodies.

If the mother was not screened or is Rh-negative, a If the mother was not screened or is Rh-negative, a direct antibody test, blood type, and an Rh type on direct antibody test, blood type, and an Rh type on the infant’s blood is strongly recommended.the infant’s blood is strongly recommended.

If the mother is 0-positive, it is an option to test the If the mother is 0-positive, it is an option to test the baby’s type and direct antibody test, but not baby’s type and direct antibody test, but not required if there is good surveillance, risk required if there is good surveillance, risk assessment before discharge, and follow-up.assessment before discharge, and follow-up.

Secondary Prevention (cont.)Secondary Prevention (cont.)

Newborns should be routinely monitored for Newborns should be routinely monitored for jaundice and nurseries should have established jaundice and nurseries should have established protocols for jaundice assessment.protocols for jaundice assessment.

Jaundice assessment protocols should include the Jaundice assessment protocols should include the conditions under which a nurse can obtain a total conditions under which a nurse can obtain a total serum bilirubin or transcutaneous bilirubin level.serum bilirubin or transcutaneous bilirubin level.

Laboratory EvaluationLaboratory Evaluation

A bilirubin measurement should be done on any A bilirubin measurement should be done on any baby less than 24 hours old who is jaundiced.baby less than 24 hours old who is jaundiced.

The need and timing of another bilirubin test The need and timing of another bilirubin test depends on the risk zone into which the bilirubin depends on the risk zone into which the bilirubin falls, the age of the infant, and the evolution of the falls, the age of the infant, and the evolution of the hyperbilirubinemia.hyperbilirubinemia.

A suggested approach to laboratory evaluation is A suggested approach to laboratory evaluation is presented in Table 1.presented in Table 1.

Laboratory Evaluation (cont.)Laboratory Evaluation (cont.)

Bilirubin should be measured if the jaundice Bilirubin should be measured if the jaundice appears excessive for the infant’s age.appears excessive for the infant’s age.

If there is any doubt about the degree of jaundice, If there is any doubt about the degree of jaundice, measure the bilirubin.measure the bilirubin.

All bilirubin levels should be interpreted according All bilirubin levels should be interpreted according to the baby’s age in hours.to the baby’s age in hours.

Cause of JaundiceCause of Jaundice The cause of jaundice should be sought in any child The cause of jaundice should be sought in any child

receiving phototherapy or whose bilirubin is rising receiving phototherapy or whose bilirubin is rising rapidly (crossing percentiles) and is not explained by rapidly (crossing percentiles) and is not explained by the H & P.the H & P.

Infants with an elevated direct or conjugated bilirubin Infants with an elevated direct or conjugated bilirubin should have a UA and culture.should have a UA and culture.

Sick infants, or those jaundice at 3 weeks of age or Sick infants, or those jaundice at 3 weeks of age or later, should have a total and direct bilirubin measured later, should have a total and direct bilirubin measured to identify cholestasis, as well as having their newborn to identify cholestasis, as well as having their newborn thyroid and galactosemia screen results verified.thyroid and galactosemia screen results verified.

Cause of Jaundice (cont.)Cause of Jaundice (cont.)

If the direct bilirubin is high, look for the cause of If the direct bilirubin is high, look for the cause of cholestasis.cholestasis.

Check infant’s G6PD level in infants getting Check infant’s G6PD level in infants getting phototherapy whose family, ethnic, or geographic phototherapy whose family, ethnic, or geographic origin suggests an increased chance of G6PD origin suggests an increased chance of G6PD deficiency, or in an infant whose response to deficiency, or in an infant whose response to phototherapy is poorphototherapy is poor..

Risk Assessment Before DischargeRisk Assessment Before Discharge

Two options, used individually or in combination. Two options, used individually or in combination.

Predischarge measurement of the bilirubin level Predischarge measurement of the bilirubin level either by total serum bilirubin or transcutaneous either by total serum bilirubin or transcutaneous measurement and/or assessment of clinical risk measurement and/or assessment of clinical risk factors.factors.

Regardless of whether either or both options is Regardless of whether either or both options is used, appropriate follow-up after discharge is used, appropriate follow-up after discharge is essential.essential.

Hospital Policies and ProceduresHospital Policies and Procedures

Hospitals should provide written and verbal Hospitals should provide written and verbal information for parents at the time of discharge, information for parents at the time of discharge, explaining jaundice, the need to monitor for it, and explaining jaundice, the need to monitor for it, and how to monitor.how to monitor.

Parent information handouts are available at Parent information handouts are available at www.aap.org/family/jaundicefaq.htmwww.aap.org/family/jaundicefaq.htm, both in , both in English and Spanish.English and Spanish.

Timing of Follow-upTiming of Follow-up

Infants discharged before 24 hours of age should Infants discharged before 24 hours of age should be seen by age 72 hours.be seen by age 72 hours.

Discharge between 24-47.9 hours should be seen Discharge between 24-47.9 hours should be seen by age 96 hours.by age 96 hours.

Discharge between 48 and 72 hours should be Discharge between 48 and 72 hours should be seen by age 120 hours.seen by age 120 hours.

Timing of Follow-up (cont.)Timing of Follow-up (cont.)

If follow-up cannot be ensured in the If follow-up cannot be ensured in the presence of increased risk for developing presence of increased risk for developing severe hyperbilirubinemia, it may be severe hyperbilirubinemia, it may be necessary to delay discharge until follow-up necessary to delay discharge until follow-up can be ensured or the time of greatest risk can be ensured or the time of greatest risk (72-96 hours of age) has passed.(72-96 hours of age) has passed.

Follow-up AssessmentFollow-up Assessment

Should include the baby’s weight and percent Should include the baby’s weight and percent change from birth, adequacy of intake, pattern of change from birth, adequacy of intake, pattern of voiding and stooling, and the presence or voiding and stooling, and the presence or absence of jaundice.absence of jaundice.

Clinical judgment should guide the need for a Clinical judgment should guide the need for a repeat bilirubin.repeat bilirubin.

If there is any doubt about the degree of jaundice, If there is any doubt about the degree of jaundice, measure the bilirubin.measure the bilirubin.

TreatmentTreatment

Treatment recommendations for phototherapy and Treatment recommendations for phototherapy and exchange transfusion are found in figures 3 and 4. exchange transfusion are found in figures 3 and 4. The direct bilirubin should not be subtracted from The direct bilirubin should not be subtracted from the total bilirubin.the total bilirubin.

If the bilirubin does not fall or continues to rise If the bilirubin does not fall or continues to rise despite intensive phototherapy, hemolysis is likely despite intensive phototherapy, hemolysis is likely occurring.occurring.

Treatment (cont.)Treatment (cont.)

If the bilirubin is at an exchange level or is 25 or If the bilirubin is at an exchange level or is 25 or more, do not send the baby to the ER. Rather, more, do not send the baby to the ER. Rather, directly admit the infant and begin intensive directly admit the infant and begin intensive phototherapy while awaiting the exchange phototherapy while awaiting the exchange transfusion to be organized and done.transfusion to be organized and done.

Treatment (cont.)Treatment (cont.)

Immediate exchange transfusion is recommended Immediate exchange transfusion is recommended in any jaundiced baby who shows the signs of in any jaundiced baby who shows the signs of intermediate to advanced stages of acute bilirubin intermediate to advanced stages of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) even if the opisthotonos, fever, high-pitched cry) even if the bilirubin is falling.bilirubin is falling.

Table 1. Laboratory Evaluation of the Jaundiced Infant of 35 or More Weeks’ GestationTable 1. Laboratory Evaluation of the Jaundiced Infant of 35 or More Weeks’ Gestation

IndicationsIndications AssessmentsAssessments

Jaundice in first 24 hJaundice in first 24 hJaundice appears excessive for infant’s ageJaundice appears excessive for infant’s ageInfant receiving phototherapy or TSB risingInfant receiving phototherapy or TSB rising rapidly (ie, crossing percentiles [Fig 2]) rapidly (ie, crossing percentiles [Fig 2]) and unexplained by history and physicaland unexplained by history and physical examinationexamination

TSB concentration approaching exchange levelsTSB concentration approaching exchange levels or not responding to phototherapyor not responding to phototherapyElevated direct (or conjugated) bilirubin levelElevated direct (or conjugated) bilirubin level

Jaundice present at or beyond age 3 wk, orJaundice present at or beyond age 3 wk, or sick infantsick infant

Measure TcB and/or TSBMeasure TcB and/or TSBMeasure TCB and/or TSBMeasure TCB and/or TSBBlood type and Coombs’ test, if not obtained withBlood type and Coombs’ test, if not obtained with cord bloodcord bloodComplete blood count and smearComplete blood count and smearMeasure direct or conjugated bilirubinMeasure direct or conjugated bilirubinIt is an option to perform reticulocyte count,It is an option to perform reticulocyte count,

G6PD, and ETCOG6PD, and ETCOcc, if available, if availableRepeat TSB in 4-24 h depending on infant’s ageRepeat TSB in 4-24 h depending on infant’s age and TSB leveland TSB levelPerform reticulocyte count, G6PD, albumin,Perform reticulocyte count, G6PD, albumin,

ETCOETCOcc, if available, if availableDo urinalysis and urine culture. Evaluate for Do urinalysis and urine culture. Evaluate for sepsis if indicated by history and physicalsepsis if indicated by history and physical examination examinationTotal and direct (or conjugated) bilirubin levelTotal and direct (or conjugated) bilirubin levelIf direct bilirubin elevated, evaluate for causes ofIf direct bilirubin elevated, evaluate for causes of cholestasischolestasisCheck results of newborn thyroid andCheck results of newborn thyroid and galactosemia screen, and evaluate infantgalactosemia screen, and evaluate infant for signs or symptoms of hypothyroidismfor signs or symptoms of hypothyroidism

Table 4. Risk Zone as a Predictor of HyperbilirubinemiaTable 4. Risk Zone as a Predictor of Hyperbilirubinemia3939

TSB Before DischargeTSB Before Discharge NewbornsNewborns(Total = 2840),(Total = 2840),

n n (%)(%)

Newborns Who Subsequently Newborns Who Subsequently Developed a TSB Level >95Developed a TSB Level >95thth

Percentile, Percentile,

nn (%) (%)

High-risk zone (>95High-risk zone (>95thth percentile) percentile)

High Intermediate-risk zoneHigh Intermediate-risk zone

Low intermediate-risk zoneLow intermediate-risk zone

Low-risk zoneLow-risk zone

172 (6.0)172 (6.0)

356 (12.5)356 (12.5)

556 (19.6)556 (19.6)

1756 (61.8)1756 (61.8)

68 (39.5)68 (39.5)

46 (12.9)46 (12.9)

12 (2.26)12 (2.26)

00